RU2410033C2 - Method of treating middle laryngostenosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: larynx is dissected along a mid-line on an anterior and posterior wall; mobilised portions of the larynx are separated. A dilator tube fixed to skin is inserted into a laryngeal lumen. Then, the laryngeal portions are ligated to thyrohyals either from one or from both sides. Three weeks later, the dilator tube is removed.

EFFECT: extension of the laryngeal lumen, reduced number of intraoperative injures, reduced number of recurrences, shorter in-patient treatment.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and may find application in the treatment of laryngeal stenosis.

Median laryngeal stenosis most often develops after a stumectomy due to damage to the laryngeal nerves: during surgery (tension, nerve compression); after surgery in connection with inflammatory phenomena, edema and hematoma (in the first days after surgery); after surgery in connection with subsequent scarring (in the later stages).

Currently, generally accepted methods of treating this disease are operations, the essence of which is to remove the arytenoid cartilage or vocal folds or both at the same time (Kelly JD Arch Otolaryngol 1941; 33: 3: 293-298; Woodman DG Arch Otolaryngol 1946; 48: 1 : 63-65; Mareev OB, Starostina SV., Shuvalova LV Pat. No. 2284773 of the Russian Federation, MKI A61B 17/24. A method for the treatment of median stenosis of the larynx of paralytic etiology / (RF; GOU VPO “Saratov State Medical University” of Rosdrava) - No. 2005104919 / 14. Publish. 10.10.2006; Bull. No. 28, p.1-8). These methods can improve respiratory function in most cases, but lead to significant life-long voice impairment.

The closest analogue to the claimed invention is a method for surgical treatment of stenosis of the larynx, which consists in dissecting the plate of the thyroid cartilage anteriorly paramedially throughout; plates of the thyroid cartilage were bred apart, the late cricoid muscle was exfoliated from the inner perichondrium to the lateral edge of the arytenoid cartilage. The latter was captured and taken to the operational wound. The lateral posterior cricoid muscles, the transverse and oblique scyphoid muscles were dissected. Further, from front to back to the arytenoid cartilage, the external thyroid muscle was separated from the internal. The arytenoid cartilage was removed with a block of muscle, with the exception of the separated vocal process. Then, with the U-shaped sutures, the vocal muscle was fixed on the surface of the thyroid cartilage, the latter was sutured along the external perichondrium, an obturator roller was inserted over the tracheostomy. With a favorable course of healing of the postoperative wound for 8-9 days, the obturator roller was replaced with a T-shaped silicone endoprosthesis, with which the patient was discharged from the hospital (Lapchenko S.N., Gadzhiev R.Sh. Bulletin of Otorhinolaryngology 1987; 4: 44-48). Its disadvantage is the high morbidity due to the need to separate the mucous membrane of the larynx from the vocal processes of the arytenoid cartilage, the area of the cirrus joints. Removal of the arytenoid cartilage with a block of muscles may impair the protective function of the larynx (Mareev O.V., Starostina S.V. Vestnik of otorhinolaryngology 2007; 4: 52-55). The size of the section of the mucous membrane is very large, and most importantly, it is made in the unaffected area of the larynx, the wound surface as a result of these actions is extremely large, which causes mucosal disease, the duration of its engraftment, the reaction of the perichondria of the arytenoid and cricoid cartilage in the form of inflammation (perichondritis) and as a result, excessive growth of scar tissue, and, accordingly, relapse of the disease. This also contributes to the long-term presence of a T-shaped tube in the larynx cavity (3-4 months), the development of purulent necrotic complications around the obturator roller or endoprosthesis in the postoperative period is not ruled out. Practice has shown a lack of effectiveness of the prototype method.

The aim of the present invention is to develop a method of surgical treatment of median stenosis of the larynx, which allows to reduce the invasiveness of surgical treatment of stenosis and thereby increase the effectiveness of treatment, dramatically reduce relapse of the disease, reduce the duration of inpatient treatment.

The proposed method is as follows: the patient is laid on his back. The surgical field is treated with an antiseptic solution, delimited by sterile sheets. Under general anesthesia (anesthesia through the natural pathways), an incision is made in the soft tissues of the neck along the midline, from the level of the hyoid bone, to the level of the 3rd ring of the trachea. Soft tissues are spread apart, exposing the body of the hyoid bone, thyroid cartilage, the arch of the cricoid cartilage and the upper three rings of the trachea. An opening is established in the second ring of the trachea, a tracheostomy is formed, and the operation is continued with intubation through the tracheostomy. The thyroid cartilage is dissected in the midline, the lumen of the larynx is opened, then the signet of the cricoid cartilage is also dissected in the midline. The halves of the larynx mobilized in this way are pulled apart and a dilator tube is inserted into the lumen of the larynx. For additional and reliable fixation of the halves of the larynx in a given position, they are fixed by applying a ligature drawn through the upper edge of the thyroid cartilage to the large horn of the hyoid bone at a distance of 1 cm from the place of discharge of the small horn. Thus, the anteroposterior edge of the larynx is pulled to the place of application of the ligature. Similarly, the ligature is applied on the opposite side. As a result, the hyoid bone performs a peculiar role of the spacer between the diluted halves of the larynx. The time spent by the dilator tube in the lumen of the larynx in the time interval is shortened.

If in the usual method the dilator tube is in the lumen for 3-4 months, when using this method the dilator tube can be removed after 3 weeks. During this time, tissue interposition is formed between dissected halves of the larynx in the interchondral space, after removal of the dilatator tube, the diluted halves of the larynx remain in the specified position. In this case, additional fixation of the larynx to the hyoid bone and its use as a spacer shortens the time for finding the dilatator tube to 3 weeks and shortens the healing time. After removal of the dilator tube, the tracheostomy tube is removed and the patient goes to breathing through the natural paths. The method allows to reduce the morbidity of surgical treatment, reduce relapse of the disease and reduce the duration of inpatient treatment.

Example. Under observation were 15 patients (4 men and 11 women) who received surgical treatment for median stenosis of the larynx. Of these, in 14 patients, laryngeal stenosis occurred after surgery on the thyroid gland, in 1 - due to excessive alcohol consumption.

Surgical treatment consisted of dissection of the anterior and posterior walls of the larynx along the midline, dilution of the larynx halves to the sides, and fixation in this state using a dilatator tube fixed to the skin. The wound was sutured in layers. Breathing was carried out through a tracheostomy. After 1.5-2 months, the dilator tube was removed through the mouth using direct support microlaryngoscopy. At the same time, the granulations that appeared in the larynx due to prolonged wearing of the tube were also removed. At short periods of wearing the dilator tube, the treatment effect was unstable, half of the larynx approached each other and stenosis resumed. So in 3 patients after removal of the dilator tube 3 weeks after surgery, stenosis resumed within 6-8 months, about which they re-performed the operation.

In order to reliably fix the larynx halves in the expanded state and reduce the time of wearing the dilator tube, for 4 patients the above operation was supplemented by stitching the plates of the thyroid cartilage to the large horns of the hyoid bone in a stretching position. In all operated patients, breathing through the natural paths was restored, they are decanulated. The voice function, as expected, has worsened.

In the case of an operation with fixation of the plates of the thyroid cartilage to the large horns of the hyoid bone, the dilatator tube was removed after 3 weeks and the lumen of the larynx was widened.

Information sources

1. Lapchenko S.N., Gadzhiev R.Sh. Bulletin of Otorhinolaryngology 1987; 4: 44-48.

2. Mareev OV, Starostina S.V. Bulletin of Otorhinolaryngology 2007; 4: 52-55.

3. Mareev OV, Starostina SV, Shuvalova LV Pat. No. 2284773 of the Russian Federation, MKI A61B 17/24. A method for the treatment of median stenosis of the larynx of paralytic etiology / (RF; GOU VPO “Saratov State Medical University” of Rosdrava). - No. 2005104919/14. Publ. 10.10.2006; Bull. No. 28, C.1-8).

4. Kelly J.D. Arch Otolaryngol 1941; 33: 3: 293-298.

5. Woodman D.G. Arch Otolaryngol 1946; 48: 1: 63-65.

Claims (1)

A method for treating median stenosis of the larynx, including expanding the lumen of the larynx, characterized in that the larynx is dissected along the midline along the front and back walls, the mobilized halves of the larynx are pulled apart, the dilatator tube fixed to the skin is inserted into the lumen of the larynx, then the larynx is fixed with ligatures to the large horns of the hyoid bone on one or both sides, the dilator tube is removed after 3 weeks.