RU2447840C1 - Method for vocal fold medialisation in treating patients with laryngeal hemiplegia - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine, namely otorhinolaryngology, may be used for surgical management of the patients with laryngeal hemiplegia. A method involves introducing an implant in a paralysed vocal fold with regard to the dominant antropometric parameters and the vocal fold size. The preoperative measurement of height, acromial diameter, chest circumference, front neck length and circumference. The given antropometric parameters are placed in formulas of the presented multiple regression equations to calculate horizontal and vertical ellipsoid diameters (Dh and Dv) of the introduced implant. A transnasal fibrolaryngoscopy technique is used to display a distance of a vocal process of arytenoid cartilage (AC) of a healthy fold to a mean line (L). The derived values (Dh, Dv and L) in millimeters are placed in formula to determine a volume of the introduced implant: V=0.00052DvDhL. During the operation, the calculated implant volume is introduced in an upper surface of the paralysed vocal fold at the depth of 3-4 mm anteriad from the attachment of the vocal process of AC with pushing a vestibular fold aside. The use of the given invention enables eliminating additional introduction of the implant in the vocal cord, as well as preventing developing laryngostenosis. ^ EFFECT: pre-determined implant volume with regard to the antropometric parameters and the evidences of transnasal fibrolaryngoscopy enables reduced rate of surgical interventions and higher percentage of rehabilitation cases.

Description

The invention relates to medicine, more specifically to otorhinolaryngology, can be used in the surgical treatment of patients with unilateral paralysis of the larynx.

Ivanchenko G.F., Novitskaya N.V. (2004) developed the “Method for voice recovery in unilateral laryngeal paralysis using the Argiform biopolymer” (Application No. 2004107437). The essence of the method lies in the fact that in order to achieve the greatest functional effect, implants of various consistencies close to the density of the surrounding tissues and not violating their mechanical properties are introduced into the paretic HS in layers. Teflon paste (in the volume of 0.5 ml) is introduced into the deep layers of the muscle, and into the surface closer to the free edge into the Reinke-Argyform space (in the volume of 0.5 ml). The volume and vibratory function is established upon contact with the patient during laryngostroboscopy and phonation of vowels “e” or “and” with video documentation (Russian otorhinolaryngology. - 2008.- Appendix No. 3. - S.436-441).

A complication of implantation with a close injection to the free edge of the HS is the submucosal granuloma, which violates the vibratory function and the tone of the HS, leading to persistent hoarseness. Due to the risk of overdose of the implant and the development of stenosis of the larynx, video laryngostroboscopic control or indirect microlaryngoscopy under local anesthesia is necessary.

The closest is the method Vasilenko Yu.S., in which the implant is inserted anterior to the attachment of the vocal process (the injection site is selected depending on the shape and position of fixation of the GS) lateral to the vocal muscle, pushing the vestibular fold to a depth of several mm in a volume of 0.1-0 , 6 mm (“The Voice.” - M.: Energoizdat. 2000, p. 255). The volume of the implant is taken approximately under the control of vision.

The disadvantage of this method is the need for repeated injections due to inaccurate determination of the volume of the implant, which creates additional trauma to the HS. The risk of developing laryngeal stenosis due to an overdose of the implant is not excluded.

We first proposed a method for preoperative determination of the implant volume during vocal fold mediation in patients with unilateral laryngeal paralysis, taking into account dominant anthropometric parameters - neck length and circumference, body length, acromial diameter, chest circumference - and glottis size.

We first found correlation dependencies between anthropometric parameters and dimensional characteristics of larynx structures. According to the results of measurements of the Cartesian coordinates of 98 anatomical points of 100 preparations of the larynxes, statistical material was obtained and processed, which is a set of basic distances characterizing the size of the larynx in adults of various sexes and physiques. The measurements were carried out using a laryngostereotometer developed by the author (Pat. No. 48738 of the Russian Federation). The regression equations for the mutual determination of the size of the anatomical formations of the larynx are compiled from anthropometric data. The statistical reliability of these regression equations is at least 95%.

This method makes it possible for the first time to preoperatively calculate the inserted implant anterior to the attachment of the vocal process of the arytenoid cartilage (CX), pushing the vestibular fold to a depth of 3-4 mm, which corresponds approximately to the internal perichondrium of the thyroid cartilage plate (CX) lateral to the thyroid and corpuscular process of the CX. In Fig. 1 (view of the larynx in the frontal plane), Fig. 2 (view of the larynx in the horizontal plane) shows the introduction of the implant into the described space, where 1 is the anterior commissure, 2 is the voice process of the chch, 3 is the middle of the plate of the thyroid gland at an average level, 4 - the middle of the plate of the thyroid gland at the lower level, 5 - the implant, 6 - the thyroid muscle.

An implant behaving like a drop of liquid, flowing, but retaining its integrity and volume, takes one form or another, depending on the resistance of the surrounding tissues. Since the fabric has different elasticities in different directions (anisotropic), in a first approximation we can assume that the drop will take the form of a triaxial ellipsoid with diameters in three mutually perpendicular planes. The implantable jelly-like mass should optimally fill the space between the internal perichondrium of the thyroid gland plate and the thyroid and corpuscular muscle, spreading horizontally from the anterior commissure of the glottis to the vocal process of the thyroid gland (Dh) and vertically from the middle to the lower edge of the thyroid gland plate at the middle level (Dv). This space is determined by stereotopometrically studied anatomical points of 100 preparations of the larynx. The dependences of the named laryngometric distances (Dh and Dv) on anthropometric data are reflected further in the regression equations, according to which the individual norm Dh and Dv is calculated in millimeters for each patient:

- Dv - the vertical diameter of the ellipsoid - the distance over which the implant spreads from top to bottom - half the height of the SchK plate at an average level

for men: Dv = 13.255-0.06 · X1-0.025 · X2 + 0.04 · X3 + 0.62 · X4 + 0.035 · X5

for women: Dv = -0.675 + 0.055 · Xl + 0.02 · X2-0.025 · X3 + 0.07 · X4 + 0.12 · X5,

- Dh - horizontal diameter of the ellipsoid - the distance over which the implant spreads from front to back - from the anterior commissure to the apex of the vocal process of the CC.

For men: Dh = 12.18-0.045; X1-0.13; X2 + 0.1; X3 + 0.475; X4 + 0.04; X5

For women: Dh = 0.1l + 0.03 · X1 + 0.115 · X2 + 0.025 · X3 + 0.04 · X4-0.075 · X5,

where x ₁ is the length of the body; x ₂ - acromial diameter; x ₃ - chest circumference; x _{4 is the} length of the necks in front; x ₅ - neck circumference.

The volume of the implant inserted is calculated using the regression equations Dv, Dh obtained and measured at phonation, the missing distance from the voice process of the healthy complex fold to the midline (L). The amount of non-closure of the GS during phonation (L) - the required implant thickness (ellipsoid diameter from left to right) - is determined by transnasal laryngoscopy on the screen or using a graduated laryngeal mirror with indirect laryngoscopy.

мм³ _. Volume of a triaxial ellipsoid with diameters 2a, 2b and 2c:

mm ³ _.

мл, в нашем случае роль 2а выполняет Dv, 2b-Dh, 2 с - L.Since 1 ml = 1 cm ³ = 1000 mm ³ and the measurement of volumes in ml is more familiar, the finally proposed geometric formula

ml, in our case, the role of 2a is played by Dv, 2b-Dh, 2 s - L.

The values of Dv, Dh and L introduced into the formula for determining the volume of the implant must be specified in mm: V = 0052 · Dv · Dh · L _(ml).

The method is as follows. Before surgery, the patient measures body length (xl), acromial diameter (x2), chest circumference (x3), front neck length (x4), neck circumference (x5). Depending on the patient’s gender, these anthropometric parameters are put into the formulas of the above multiple regression equations and the horizontal and vertical diameters of the ellipsoid Dh and Dv are calculated.

Next, transnasal fibrolaryngoscopy is performed and the distance between the vocal process of the healthy part of the healthy fold to the midline (L) is determined by phonation on the TV screen. The obtained values (Dh, Dv and L) in millimeters are inserted into the formula to determine the volume of the implant inserted in milliliters:

V = 0.00052DvDh-L

Using the Brunings syringe, the calculated implant volume is introduced into the region of the upper surface of the paralyzed vocal fold by the direct microlaryngoscopy method to a depth of 3-4 mm anterior to the attachment of the vocal process of the CC, displacing the vestibular fold.

The proposed method to date, the clinic has operated on 6 patients with good results. Operated according to the method described above, the patients were divided as follows: 4 women and 1 man belonged to mesomorphs with an intermediate version of the neck, 1 man - a brachimorph with a short and thick neck. All patients were admitted with a diagnosis of Unilateral laryngeal paralysis. Condition after hemithyroidectomy ”with a complaint of hoarseness. Based on anthropometric parameters, the method of multiple linear regression for each patient calculated the basic distances and the missing volume of the implant for the medialization of a paralyzed vocal fold. During the operation, the calculated implant volume (Noltrex or Argiform) was injected using a direct microlaryngoscopy using a Brunings syringe. In the postoperative period, additional administration of the implant into the vocal fold was not required, an overdose of the administered substance with the phenomena of laryngeal stenosis was not noted. After the reactive phenomena subsided, correctional work was carried out aimed at the formation of a new stereotype of voice formation: breathing and voice exercises. Patients were discharged 10 days after surgery with an improvement in voice volume from 46 to 80 dB. In the distant postoperative period (after 1-1.5 years), the inter-fold lumen did not change, during phonation complete closure and synchronous vibration of the GS were noted, and the voice volume did not deteriorate.

Example of a patient: Patient V., 42 years old, was admitted to the otorhinolaryngology clinic of the SSMU on 04/16/08 with a diagnosis of “Right-sided laryngeal paralysis. Condition after hemithyroidectomy. Dysphonia". History - September 15, 07, hemithyroidectomy for toxic nodular goiter. On admission with indirect laryngoscopy, the laryngeal mucosa is pink, the vocal folds are white, the right one is motionless, located median, the glottis with unforced breathing in the posterior sections is 7-8 mm. The volume of the voice is 48 dB. Before the operation, an anthropometric examination was performed: height 174 cm (xl), acromial diameter 56 cm (x2), chest circumference 104 cm (x3), front neck length 10.3 cm (x4), neck circumference 45 cm (x5). The above parameters were introduced into multiple regression formulas, and the vertical (half the height of the thyroid gland plate at the average level - Dv) and horizontal (from the anterior commissure to the apex of the vocal process - Dh) diameters of the ellipsoid of the inserted implant were calculated.

Dv = 13.255-0.06 · 174-0.025 · 56 + 0.04 · 104 + 0.62 · 10.3 + 0.035 · 45 = 13.5 mm

Dh = 12.18-0.045 · 174-0.13 · 56 + 0, l · 104 + 0.475 · 10.3 + 0.04 · 45 = 14.4 mm

A transnasal laryngoscopy was performed and the distance between the vocal process of the CH of the healthy fold to the midline was determined on phonation: L = 3.5 mm.

The obtained values (Dh, Dv and L) in millimeters are entered into the above formula and the volume of the implant is determined for the medialization of a paralyzed HS.

V = 0.0005213.514.4.3.5 = 0.35 ml.

Using a direct microlaryngoscopy, Brunings’s syringe introduced 0.35 ml of an implant (“Argiform”) into the area of the upper surface of the right vocal fold to a depth of 3-4 mm - the tip of the needle as far from the free edge of the GS as lateral as it displaces the vestibular.

The postoperative period proceeded without pronounced local inflammatory phenomena and signs of stenosis of the larynx. On the 10th day the patient was discharged, learning a new stereotype of voice formation under the supervision and corrective treatment of a phoniatrist and phonologist. At discharge, the mucosa of the right GS is pink, the interfold space in the posterior part of the glottis with unforced breathing of 5-6 mm. 1.5 months after implantation, the right GS - without inflammation; during phonation - the closure of the GS in the front two-thirds is complete, the vibration is synchronous, the voice volume is 80 dB. After 10 months, the loudness of the voice and laryngoscopic picture did not change.

As can be seen from the description of our proposed method for mediating HS in the treatment of patients with unilateral paralysis of the larynx in comparison with those proposed earlier, it has a number of significant advantages, the main of which are:

- less traumatic due to the lack of the need to re-insert the implant;

- reducing the likelihood of formation of submucosal granulomas of the HS due to a single injection of the implant;

- no risk of developing laryngeal stenosis due to overdose of the implant;

- determination of the volume of the implant is carried out before the operation;

- does not require preliminary expensive methods for the study of CT, MRI; the introduction of the implant under local anesthesia by indirect microlaryngoscopy;

- convenience and simplicity of preoperative anthropometric examination of the patient;

- accurate calculation of the implant volume with a probability of 95%.

A preliminary calculated volume of the implant, taking into account the somatotype and transnasal laryngoscopy data, allows us to achieve a reduction in the frequency of surgical interventions and increases the percentage of patient rehabilitation. The clinical application of the proposed method for determining the volume of the implant in the medialization of HS in patients with unilateral paralysis of the larynx confirmed its effectiveness and allows recommending it for implementation in clinical practice.

Claims (1)

The method of medialization of the vocal fold in the treatment of patients with unilateral paralysis of the larynx, including the introduction of an implant anterior to the attachment of the vocal process of the arytenoid cartilage to a depth of 3-4 mm, displacing the vestibular fold laterally to the thyroids, characterized in that the neck length and circumference are previously measured in the patient before surgery , body length, acromial diameter, chest circumference, calculate the vertical and horizontal implant diameters according to the formulas
for men, Dv = 13.255-0.06 · X1-0.025 · X2 + 0.04 · X3 + 0.62 · X4 + 0.035 · X5,
Dh = 12.18-0.045 · X1-0.13 · X2 + 0.1 · X3 + 0.475 · X4 + 0.04 · X5,
and for women, Dv = -0.675 + 0.055 · X1 + 0.02 · X2-0.025 · X3 + 0.07 · X4 + 0.12 · X5,
Dh = 0.11 + 0.03 · X1 + 0.115 · X2 + 0.025 · X3 + 0.04 · X4-0.075 · X5,
where Dv is the vertical diameter of the implant, Dh is the horizontal diameter
implant, X1 - body length, X2 - acromial diameter, X3 - chest circumference, X4 - neck length in front, X5 - neck circumference,
measure the lumen of the glottis at the phonation and determine the volume of the inserted implant according to the formula
V = 0.00052 · Dv · Dh · L, where
L - the distance between the vocal process of the arytenoid cartilage of a healthy fold to the midline that is missing on phonation

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