RU2479276C1 - Ossiculoplasty technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology, and may be applicable for surgical management of the patients with an ossicular chain pathology. For this purpose, an ossiculoplasty involves graft fixation by a platelet enriched autoblood plasma bunch taken immediately before the operation That is followed by laser coagulation of the bunch.

EFFECT: technique provides improved functional effect and simplified ossiculoplasty, eliminated allergic reactions, eliminated risk of graft rejection, reduced recurrences due to fixation of the repaired elements, reduced risk of dislocation thereof up to formation of the physiological fixation ensured by middle ear soft tissues regeneration.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used to fix the auditory ossicles or prostheses installed instead of them in the surgical treatment of middle ear pathology.

Despite significant successes in the surgical treatment of patients with pathology of sound-conducting structures, from 10 to 25% of patients in the long term report unsatisfactory functional results. The latter are often associated with a displacement of the sound-conducting structures of the middle ear after their reconstruction.

The reason for this shift is, on the one hand, the instability of several elements movably interconnected, replacing the missing auditory ossicles or their damaged parts, on the other hand, the difficulty in holding (fixing) these elements of sound conduction in the right position in the first days after reconstruction. An equally important reason for the displacement of the reconstructed parts of the sound-conducting apparatus is the postoperative deterioration of the function of the auditory tube due to tissue edema, as well as an increased “load” on it, associated with the need to release the tympanic cavity from blood and wound discharge.

The above processes can lead to an unsatisfactory functional result requiring repeated surgical intervention.

There is a method of surgical treatment of patients with pathology of the auditory ossicle chain, during which bioglue is used to fasten the elements of the sound-conducting system of the middle ear [Mirko Tos, Guide to Surgery of the Middle Ear, 2004, volume 1, p.243].

The disadvantage of this method is the existing risk of infection with HIV, hepatitis, the high cost of glue, etc. After using bio-glue, it is possible to develop an inflammatory process in the tissues of the middle ear and allergic reactions associated with the body's reaction to its constituent components.

There is a method of ossiculoplasty, during which various prostheses with fixing mechanisms are installed, for example, the Sheehy prosthesis replacing the anvil is fixed with a wire to the handle of the malleus [Mirko Tos, Middle Ear Surgery Manual, 2004, vol. 1, p. 376].

The disadvantage of this method is the difficulty of installing the prosthesis and the risk of rejection, as well as the absence in most cases of auditory ossicles, to which such a prosthesis can be fixed.

Use a fixing wire together with ionomercement [Mirko Tos, Guidelines for the surgery of the middle ear, 2004, volume 1, p. 318].

The disadvantage is the difficulty of fixing and the risk of rejection of the material used.

The closest analogue is the method of fixation of auditory ossicles using a Gel foam sponge. When performing the reconstruction of the auditory ossicle chain after the completion of the sanitizing stage of the operation and preparing the bed for laying the non-otimal transplant, the reconstructed sound-conducting structures are fixed using the Gel foam sponge, which is placed around the auditory ossicle chain, filling the tympanic cavity [Mirko Tos, Middle Ear Surgery Manual, 2004, Volume 1, pp. 380-381].

The disadvantage of this method is the poor resorption of the material with the formation of scars and adhesions. Sponge Gel foam can cause adhesive processes in the tympanic cavity, which also disrupts the mobility of sound-conducting structures. The possible risk of developing an allergic reaction to the material used should be taken into account.

Tasks

Improving the functional results of ossiculoplasty, eliminating allergic reactions, simplifying the method of ossiculoplasty, eliminating the risk of transplant rejection.

The essence of the method is the use of a transplant of a sound-conducting circuit and its fixation. The method is characterized in that the transplant is fixed with a clot of platelet-rich plasma from autologous blood taken from a patient immediately before surgery, followed by coagulation of the clot with a laser beam.

The technical result of the proposed method is laying around a sound-conducting chain of platelet-rich plasma, followed by heating it with a laser beam, which leads to a condensation of the clot by coagulation of its constituent blood proteins. The tight-elastic consistency of the OTP clot prevents the displacement of the sound-conducting chain during surgery and in the postoperative period. The elements included in the clot of OTP are exposed in the postoperative period of biodegradation (dissolve), like the blood itself.

The method was tested on 65 patients suffering from chronic otitis media with impaired sound conduction. There were 40 men, 25 women aged 25 to 53 years. All patients underwent a sanitization operation of a closed or open type with one or another type of tympanoplasty. The operations were carried out by one surgeon to exclude the influence of surgical technique features on the outcome of the intervention. The main group consisted of 35 people who used OTP as their sound-conducting chain fixing material, followed by its coagulation with a laser beam. In the control group of 30 people, operations were performed without using plasma.

The method is as follows. Immediately before the operation, the patient is taken blood from the cubital vein to obtain OTP. There are several methods for obtaining OTP. For example, blood is placed in a special Vacuette tube containing SiO coagulation activator on the walls. The tube is placed in a laboratory programmable centrifuge and centrifuged at a speed of 2800 rpm for 9 minutes. In this case, the whole blood is divided into three fractions: platelet-poor plasma, OTP and erythrocyte mass. After separation, three fractions are formed in the tube. Top - platelet-poor plasma, then - platelet-rich plasma along with leukocytes in the form of an activated clot and erythrocyte mass.

The platelet-rich plasma clot is removed from the test tube with sterile forceps and placed in a Petri dish, where the pieces of OTP 2-3 mm in size are separated with a scalpel. After the completion of the sanitation phase of the operation, a bed is prepared for the placement of a nonimplantal graft. In patients with chronic purulent otitis media, in violation of the integrity or absence of the auditory ossicle chain, prostheses of the TORP or PORP type are made of biological tissues (cartilage, bone) or synthetic materials (titanium, teflon).

To obtain reliable fixation of the prosthesis in the desired position, pieces of OTP are tightly packed around it. After this, the OTP is heated with a laser beam until there are signs of coagulation (whitening of the surface of a plasma clot). Use laser radiation with parameters (exposure and power) that are safe in relation to the structures of the inner ear [Ryabova MA The role of studying the effects of laser radiation on biological tissue in the development of laser surgery methods in otorhinolaryngology. - Bulletin of otorhinolaryngology. - 2008. - No. 4. - 24-27; Semenov F.V. Laser surgery of the middle ear. Krasnodar. - “Soviet Kuban”. - 2005. - 80 s .; Semenov F.V. The use of surgical lasers to treat middle ear diseases. Materials of the XVII Congress of Otorhinolaryngologists of Russia (Abstracts). St. Petersburg - 2006. - S.138-139]. Heating of OTP clots is accompanied by the effect of the so-called laser welding of biological tissues and provides reliable fixation of prostheses in a given position. After this, the eardrum graft is placed (usually autophasia of the temporal muscle or thinned tragus cartilage).

The functional results of the operation were evaluated after 1, 3, and 12 months. Functional results were evaluated using tonal threshold audiometry. The average value of the bone-air interval in the area of speech frequencies was determined.

The indicators of audiometric studies were as follows. In the main group, where laser coagulation of OTP was used to fix the reconstructed sound-conducting system, the value of the bone-air interval after 1 month was 25 ± 3 dB, after three months - 15 ± 4 dB, and after 12 months - 10 ± 3 dB. Cases of violation of the sound conduction function have not been established.

In the control group, 24 out of 30 patients, one month after surgery, the bone-air interval corresponded to 25 ± 3 dB, after three months - 15 ± 4 dB, after 12 months - 10 ± 3 dB. In the remaining 6 patients of the control group who underwent a sanitizing operation, the bone-air interval at all observation periods was 35 ± 3 dB. The latter indicates a displacement of the restored sound-conducting structures of the middle ear.

Example. Patient X., 52 g., Was admitted to the hospital GUZ KB No. 3 with a diagnosis of Right-sided chronic purulent otitis media. Whispering speech on the right ear - 1.5 m, on the left ear - 6.0 m. When conducting otomicroscopy, perforation was revealed in the upper sections of the tympanic membrane. On the audiogram, indicators of the study of the right ear: a bone-air gap of 35 dB in the area of speech frequencies. Immediately before the operation, the patient was taken blood from the cubital vein and placed in a tube containing a clot activator specially designed for receiving OTP. In vitro blood was centrifuged until an OTP was obtained. The platelet-rich plasma clot was removed from the tube using sterile forceps and placed in a Petri dish, where the pieces of OTP were separated with a scalpel.

The patient underwent a sanitizing operation of the open type with tympanoplasty according to type 3 with a titanium prosthesis of the TORP type. The carious mallet is removed. A defect in the body of the anvil and stapes legs, which are also removed, was revealed. A titanium prosthesis is installed on the base of the stapes, the base of the prosthesis is lined with pieces of platelet-rich plasma. After this, plasma coagulation was performed with 4 pulses of a holmium laser with a duration of 1 s at a power of 2 W.

A month later, when performing an audiometric study, the bone-air interval in the area of speech frequencies was 35 dB, the perception of whispering speech was 0.5 m.

Three months later, on the audiogram, the bone-air interval in the zone of speech frequencies was 15 dB, the whisper speech was 4 m.

Twelve months later, on the audiogram, the bone-air interval in the area of speech frequencies was 10 dB, whisper speech was 4.5 m.

This example confirms the efficiency of using platelet-rich plasma with its subsequent coagulation with a laser beam as a way of fixing sound-conducting structures when performing ossiculoplasty.

Thus, the use of platelet-rich plasma with its subsequent coagulation with a laser beam as a method of fixing sound-conducting structures when performing ossiculoplasty facilitates the fixation of prosthetic elements, reduces the risk of their displacement in the postoperative period until physiological fixation occurs due to the regeneration of soft tissues of the middle ear. All this allows us to improve the functional result of the treatment and reduce the percentage of relapses associated with the instability of the restored sound-conducting system.

Claims (1)

The method of ossiculoplasty, including the use of the graft and its fixation, characterized in that the fixation of the graft is carried out by a clot of platelet-rich plasma from autologous blood taken from a patient immediately before surgery, followed by coagulation of the clot with a laser beam.