RU2512953C1 - Method for conservative therapy of perforated nasal septum using silicone splints at preoperative stage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology, and may be used for the preoperative preparation of the patients suffering a perforated nasal septum. Intranasal silicone splints are placed 10 days before the operation. The splint is incised from one side within a perforation border. A 30° endoscope is used to assist a 7-day daily nasal perforation rinsing with chlorhexidine. A suction unit is used to evacuate mucosal secretion; synthomycin ointment is introduced through the incision in the silicone splint to the perforation region. The nasal cavity is irrigated daily with antiseptic and vasoconstrictive preparations. On the 7th day, the intranasal splints are removed.

EFFECT: method enables relieving the mucosal inflammation within the perforation, promotes the prolonged drug retention in the introduction place, ensures avoiding an overlay of a secondary infection, improves the functional state of ciliated epithelium.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used for conservative treatment (preoperative preparation) of patients with perforation of the nasal septum (PN) as preparation for surgical treatment to close the PN.

One of the urgent problems of modern otorhinolaryngology is the problem of treating patients with perforation of the nasal septum.

The occurrence of perforation of the nasal septum (PPN) may be due to the development of a wide variety of factors, such as traumatic (trauma to the facial skeleton or an isolated trauma to the nose in history); iatrogenic (submucosal resection of the nasal septum with removal of most of the quadrangular cartilage, rhinosurgical interventions in the external nose, prolonged transnasal intubation, repeated cryosurgery and cauterization of bleeding vessels in the Kisselbach plexus zone); inflammatory (transferred hematomas and abscesses of the nasal septum, chronic atrophic rhinitis), systemic diseases (Wegener's granulomatosis) or exposure to caustic substances (cocaine abuse) (R. Meyer, 1995, U. U.Umarov et al., 2005, S.Vignesetal. , 2002).

Since perforation of the nasal septum, especially located in the anterior sections, causes a change in the laminar flow of inhaled air to turbulent (P. Cole, 1992) and a deterioration in the normal physiological state of the ciliary epithelium of the nasal mucosa, chronic atrophic rhinitis will invariably be a mandatory concomitant diagnosis in such patients. In this case, further cilia are lost by epithelium, crusting, erosion, drying of the mucous membrane, degenerative changes, attachment of a secondary infection (R. Meyer, 1995). This can lead to chronic perichondritis and even greater cartilage necrosis, which means a further increase in perforation. The presence of perforation of the septum contributes to the drying of the mucous membrane, the development of atrophic rhinitis, the destruction of the bone-cartilage base of the septum.

Techniques for surgical correction of perforation of the nasal septum do not always give positive results due to improper care of the mucous membrane in the area of perforation of the nasal septum in the preoperative period. An essential part of treatment for PPN is preoperative assessment of the situation and preparation of the patient. Rarely, patients with a healthy mucous membrane and stable in size, not prone to increase PPN. More common are PPN with a large number of crusts, an unpleasant odor and an infectious inflammatory process. The mucous membrane, as a rule, is loose, bleeds easily and is in the stage of chronic inflammation. The restoration of the integrity of the PN should not begin until the cause of the perforation is clear and the main pathological process has been cured or it has not been transferred to the phase of prolonged remission. In the presence of infectious diseases, a course of antibacterial therapy is carried out. Granulating tissue may indicate a chronic inflammatory or neoplastic process. A biopsy and serological tests should be performed when there is a suspicion of the presence of systemic diseases or the presence of cancer. Inadequate diagnostics and preoperative treatment of the main pathological process can offset the results of successful PN recovery and delay the necessary treatment of the disease itself (S.Z. Piskunov, G.Z. Piskunov, 1991, JCChalaye, J.Levignac, 1985, IIDiamantopoulos, NSJones, 2001).

Some authors (S.Z. Piskunov, G.Z. Piskunov) in the preoperative period suggest appointing a regimen of intensive care for the nasal mucosa. The patient is informed that he performed the toilet of the nasal cavity 2-3 times a day with a sterile saline solution. Emollients such as liquid paraffin or Bactroban ointment can help reduce the amount of crust in the nasal cavity. The patient is supervised by the doctor every week, he undergoes a checkup and toilet of the nose. As soon as the infection is eliminated and good care of the nasal cavity is provided with epithelization and reduction of crusts, surgical treatment can begin.

The disadvantage of this method is:

- the impossibility of a long stay of the injected drug in the area of the defect in the nasal septum;

- contact of the inhaled and exhaled air with the mucous membrane of the perforation area, which prevents the full restoration of the mucous membrane.

There are many ways to keep the nasal septum in the middle position, one of which is the installation of intranasal tires, which due to their rigidity keep the nasal septum in the middle position, shielding the mucous membrane of the nasal septum from mechanical and chemical effects.

So, in particular, the intranasal tire is known, which contains a base of elastic material made in the form of a plate (patent of the Russian Federation No. 2121309, A61B 17/24, 1996), which is fixed on the nasal septum using a special clip.

This analogue provides that in the nasal cavity for the duration of treatment insert nasal "ring" tires with openings for free passage of air during breathing and the shape of a ring, half ring, oval, half shaft, truncated cone, half cone with one flat side surface, or insert tires - plates, or insert combinations of tire plates with "ring" tires.

The main disadvantages of this analogue are the complexity of the design, consisting of three elements, and the use of such a design requires special training from the doctor. The lack of clear sizes of structural elements associated with the anatomical formations of the nasal cavity greatly complicates the modeling of tires. In addition, the results of fixation by means of a tire of this design are often unsatisfactory due to the fact that the nasal cavity is covered with a mucous membrane that constantly produces mucus, and structural elements will constantly shift relative to the anatomical structures of the nasal cavity. The disadvantages of the analogue include the use of "ring" tires only for the correction of the nasal passages, moreover, their fixation in the nasal cavity is carried out due to local tissues, and at the same time the tire is installed as if opposed between the lateral wall of the nose and the nasal septum. The pressure exerted by the "ring" tires on the tissues of the nasal cavity, rich in nerve endings, gives the patient unpleasant sensations and discomfort. Also, the negative side of this fixation is that, against the background of the treatment, the inflammation subsides, characterized by a decrease in swelling of the nasal mucosa and an increase in the lumen of the nasal cavity, which in turn leads to flotation of the nasal splint and a high probability of aspiration into the upper respiratory tract. When modeling nasal tires according to the "shape and size of the general nasal passage", one of the boundaries of which are the nasal septum and the roof of the nasal cavity (the latter separates the cranial cavity), when installing tires of this form, the iatrogenic injury of the sieve plate is high, which leads to the development of rhinoliquorrhea and meningitis. The disadvantage of the plate-plate described in the analogue is that for its fixation on the nasal septum, a special clamp is required, the levers of which are located in the cavity of the common nasal passage, narrowing the lumen of the latter. The disadvantage of this mount is also that its levers, connecting near the nose (in front of the collume), in addition to the inconvenience to the patient, complicate the act of sweeping. Periodic adjustment of the compression force of the fixing clip is also necessary, which greatly complicates the work of the doctor. Due to the fact that the tire-plates are designed to “straighten” and “give the right shape” to the nasal septum, they are installed in a limited (curved) area. Thus, sections of the nasal septum that are not shielded by the tire remain.

The closest solution is the method of plasticity of perforation of the nasal septum 2.5 × 3.0 cm in size by an individually made silicone obturator (H.G. Kempf, H. Weber, 1991). After the imprint of the perforation of the PN is formed in a hollow plaster mold, an obturator is made. A polysiloxane with insignificant hydrophobic properties is used for the print, and silicone is used for the manufacture of the obturator. Due to the free edge in the form of a gutter, ointments can be applied to the edges of the perforation of the PN under the obturator. The presented silicone obturator should probably not be considered as a possible first choice. However, with large perforations, which are difficult to close by the surgical method, it can be used as a treatment option (H.G. Kempf, H. Weber, 1991). We take this method as a prototype. However, the above method has several disadvantages:

1 - difficulties in the manufacture of the obturator - first the formation of the imprint of the perforation of the PN, and only then its manufacture;

2 - this obturator does not provide complete isolation of the perforation of the nasal septum from the flow of inhaled and exhaled air;

3 - due to its unreliable fixation, flotation of the obturator in the nasal cavity is possible.

The purpose of the invention is the development of a conservative method for the treatment of patients with perforation of the nasal septum at the preoperative stage.

This goal is achieved by the fact that in patients with perforation of the nasal septum in the preoperative period, soft silicone tires are installed in the nasal cavity and drugs are introduced into the perforation area, which helps to eliminate inflammation of the mucous membrane in this area, and to keep the drug at the injection site for a long time . As a result, the prognosis and outcome of the subsequent operation (plastic defect) improves.

The technical result of this method is to increase the effectiveness of treatment and reduce the possibility of postoperative complications after plastic surgery of the perforation of the nasal septum. The installation of intranasal tires avoids contact of the inhaled and exhaled air with the mucous membrane of the area of perforation of the nasal septum, which improves the functional state of the ciliary epithelium of the mucous membrane, allows the formation of crusts, erosion in the area of perforation of the nasal septum, and degenerative changes. Also avoids joining a secondary infection; eliminate inflammation in the area of perforation.

The claimed method allows in the preoperative period (before plastic perforation) to conduct conservative treatment in order to combat signs of inflammation of the mucous membrane in the area of perforation of the nasal septum, which increases the effectiveness of surgical treatment and reduces the possibility of postoperative complications.

Description of the method - to patients with nasal septum perforation (sizes from 1 * 0.5 cm to 2 * 1.5 cm) as a preoperative preparation 10 days before the planned surgical treatment for plastic surgery of perforation of the nasal septum under local anesthesia (lidocaine 1% infiltration and lidocaine 10% application) in both halves of the nose lead along one tire with fixed threads at the choanal ends of the tire. The specified intranasal tire contains a silicone rubber base with shore hardness A-60, made in the form of a 1-2 mm thick plate of a heptagonal shape in plan (Russian Federation patent RU 2414180, 2011). A typical plate (suitable for most patients) has the following parameters: internal heptagon angles are: ∠A = 165 °, ∠B = 75 °, ∠B = 125 °, ∠Г = 163 °, ∠Д = 169 °, ∠E = 113 °, ∠Ж = 90 °, the points of convergence of the faces and the corners of the plate are blunt, mainly rounded, and the lengths of the sides are equal: AB = 15 mm, BV = 21 mm, VG = 17 mm, DG = 16 mm, DE = 32 mm, HF = 12 mm, JA = 50 mm. The tire in special cases of its implementation may have a hollow roll-like thickening on its surface, extending along the entire length of the intranasal tire at the level of the inferior nasal concha and oriented towards the side wall of the nasal cavity. This tire provides reliable fixation without the use of additional devices and preservation of nasal breathing in the patient due to the fact that the shape of the tire is in the form of a heptagonal plate and its dimensions are determined in accordance with the method described in this analogue. If necessary, if a tire with the typical dimensions indicated above is not suitable, it is possible to individually select the shape and dimensions of the intranasal tire according to the methodology described in the analogue for both children and the adult patient population.

Simultaneously with the establishment of the tires, the threads under endoscopic control are thrown through the opener to the opposite half of the nose and transseptally fixed through the tires in the front section, while the choanal end of the tire is set at the level of the distal edge of the nasal septum. An additional U-shaped seam is also imposed, fixing the tires in the front section and an incision is made in the tire on one side in the region of the perforation edge for subsequent drug administration. Thus, tight fixation of the intranasal splint is achieved along the entire length of the nasal septum. Tamponade of the nasal cavity after surgery is not performed. After the manipulation, every day for 7 days, successively through the incision area in the septal tire, under the control of an endoscope 30 °, the perforation area is washed with a chlorhexidine solution, the mucous discharge is removed by suction, the synthomycin ointment is introduced through an incision in the silicone tire to the perforation area. Also, daily, patients independently irrigate the nasal cavity with antiseptic and vasoconstrictor drugs. On day 7, the tires are removed.

An example of a specific implementation No. 1

Patient A., 18 years old, medical history number No. 0956, was admitted with a diagnosis of perforation of the nasal septum for planned surgical treatment, with complaints of obstructed nasal breathing, formation of crusts in the nose, and whistling when breathing.

From the anamnesis it is known that he considers himself a patient for 3 years, when the patient independently discovered perforation in the area of the septum of the nose and the above complaints appeared. Not treated.

During anterior rhinoscopy, perforation of the nasal septum 1.5 * 2.0 cm was visualized. In the area of the perforation edges, signs of inflammation, erosion, and crust were noted. In this connection, the intranasal tires were installed 10 days before the operation. An incision was made in the tire on one side in the region of the perforation edge. In the future, daily for 7 days, through the incision area in the septal splint under the control of an endoscope of 30 °, the perforation area was washed with a chlorhexidine solution. Using a suction, a daily toilet of the nasal cavity was performed, removing the mucous discharge. Through an incision in a silicone tire, synthomycin ointment was introduced to the perforation area. Daily nasal cavity was irrigated with antiseptic and vasoconstrictor drugs. On day 7, the tires were removed. Intranasal picture: the mucous membrane in the area of perforation without signs of inflammation, erosion is not visualized. 3 days after the removal of septal tires, the patient underwent surgical treatment - plastic surgery of the perforation of the nasal septum. The defect in the nasal septum was successfully closed with mucoperichondral flaps. The postoperative period was uneventful. On the 7th day after the operation, the patient was discharged from the hospital in satisfactory condition. In the distant postoperative period, the patient was observed for 3 months. With anterior rhinoscopy, the nasal mucosa is pink, moist, with no signs of inflammation. Nasal septum in midline without defect.

An example of a specific implementation No. 2

Patient K., 56 years old, medical history number 1238, was admitted with a diagnosis of perforation of the nasal septum for planned surgical treatment, with complaints of the formation of crusts in the nose, periodic nosebleeds.

From the anamnesis it is known that he considers himself a patient for a long time, when during a routine examination by an ENT doctor at the place of residence, perforation in the area of the nasal septum was revealed. A course of drug therapy was prescribed - irrigation of the nasal cavity with Aquamaris aerosol, oil drops in the nose. During anterior rhinoscopy, perforation of the nasal septum 2.0 * 1.5 cm was visualized. In the area of the perforation edges, signs of inflammation, erosion, and crust were noted. The patient was installed intranasal tires 10 days before the operation. An incision was made in the tire on one side in the region of the perforation edge. In the future, daily for 7 days, through the incision area in the septal splint under the control of an endoscope of 30 °, the perforation area was washed with a chlorhexidine solution. Using a suction, a daily toilet of the nasal cavity was performed, removing the mucous discharge. Through an incision in a silicone tire, synthomycin ointment was introduced to the perforation area. Daily nasal cavity was irrigated with antiseptic and vasoconstrictor drugs. On day 7, the tires were removed. Intranasal picture: the mucous membrane in the area of perforation without signs of inflammation, erosion is not visualized. 3 days after the removal of the septal tires, the patient underwent surgical treatment - plastic surgery of the perforation of the nasal septum. The defect in the nasal septum was successfully closed with mucoperichondrial flaps. The postoperative period was uneventful. On the 7th day after the operation, the patient was discharged from the hospital in satisfactory condition. In the distant postoperative period, the patient was observed for 5 months. With anterior rhinoscopy, the nasal mucosa is pink, moist, with no signs of inflammation. Nasal septum in midline without defect.

BIBLIOGRAPHY

1. Piskunov B.C. The value of endonasal anatomical structures in norm and pathology / B.C. Piskunov // Abstract. dis ... cand. honey. sciences. - SPb. - 2002 .-- 22.

2. Piskunov G.Z. Indications for operations on the nasal septum, when it should be performed / G.Z. Piskunov // 6th Congress of the otorhinolar. RSFSR. - Abstracts. September 19-21. - 1990. - Orenburg. - S.128-130.

3. Piskunov G.Z. The sequence of surgical intervention in violation of the respiratory and aesthetic functions of the nose and diseases of the paranasal sinuses / G.Z. Piskunov // Ros.rinologiya. - 2003. - No. 2. - S.93-94.

4. Piskunov G.Z. On the physiological role of the nasal septum / G.Z. Piskunov, S.Z. Piskunov // News, otorhinolaryngol. - 2000. - W 6. - P.57-58.

5. Piskunov G.Z. Clinical rhinology / G.Z. Piskunov, S.Z. Piskunov // Moscow. - 2002 .-- 392 p.

6. Piskunov S.Z. Diagnosis and treatment of inflammatory processes of the nasal mucosa and paranasal sinuses / S.Z. Piskunov, G.Z. Piskunov // Voronezh. - 1991 .-- 184 p.

7. Piskunov S.Z. Morphological and functional features of the nasal mucosa and paranasal sinuses. The principles of gentle endonasal surgery / S.Z. Piskunov, G.Z. Piskunov // Moscow. - 1991 .-- 48 p.

8. Molokov K.V. Perforation of the nasal septum - causes and methods of treatment / Moscow 2007 /.

9. Diamantopoulos I. L. The investigation of nasal septal perforations and ulcers / LL Diamantopoulos, N. S. Jones // J. Laryngol. Otol. - 2001 - Vol. 115. - Jf97. - P.541-544.

10. Dklewanger A. Plastik and Rekonstruktion des Nasenseptums / A. Dirlewanger, R. Meyer // Schweiz. ORL Congress - Delemont, 1968.122.

11. Hertig P. Closure of septal defects and septocolumellar reconstruction / P. Hertig, R. Meyer // Excerpta Medica, Int. Congr. Ser. No. 206, Oto-Rhino-Laryngology: Proceedings of the Ninth Intemation Congress, Mexico, August, 1969.

12. Kempf H.-G. Septumperforationsverschlufi durch emen individuellen Obturator / H.-G. Kempf, H. Weber // Laryngo. Rhino, aol. - 1991 .-- Bd. 70. - S. 436-437.

13. Kridel R.W.H. Septal perforation closure utilizing the external septorhinoplasty approach / R.W.H. Kridel, W. D. Appling, W.K. Wright // Arch. Otolaryngol. Head and Neck Surg. - 1986. - Vol. 112. - P. 168-172.

Claims (1)

A method of conservative treatment of nasal septum perforation using silicone tires at the preoperative stage by installing intranasal silicone tires, characterized in that intranasal tires are installed 10 days before surgery, an incision is made in the tire on one side in the region of the perforation edge, daily for 7 days in a row through the incision area in the septal tire under the control of an endoscope 30º, the perforation area is washed with a chlorhexidine solution, the mucous discharge is removed by suction, introducing sintomitsinovoy ointment through an incision in the silicone bus perforation area irrigated daily nasal cavity antiseptic and vasoconstrictive drugs on day 7 intranasal tire removed.