RU2518679C1 - Method of treating middle laryngostenosis of paralytic ethiology - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: glottal aperture is sized. That is exposed to a CO₂ laser of 1-1.5 Wt in a continuous mode without forming a tracheostoma. If observing the degree I stenosis with the glottal aperture 6-7 mm wide, and the degree II stenosis with the glottal aperture 4-5 mm wide, a posterior one-third of the vocal cord is incised with the CO₂ laser from one side with a vocal process of arytenoid cartilage resected on the same side. At the degree II stenosis with the glottal aperture 2-3 mm wide, the posterior one-third of the glottal aperture is incised with the CO₂ laser from both sides with the vocal processes of arytenoid cartilage resected.

EFFECT: method enables enlarging the glottal aperture lumen with maintaining the separating function of the larynx providing free respiration and satisfactory voice quality.

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Description

The invention relates to medicine, in particular to otorhinolaryngology, and can be used to treat median stenosis of the larynx with maximum breath retention and good voice quality.

Currently, in otorhinolaryngology, various methods of treating patients associated with diseases of the vocal apparatus of paralytic genesis are known and widely used. Restoration of the lumen of the larynx and, accordingly, respiratory function in patients with laryngeal paralysis is possible by fundamentally different methods:

1. Outside access:

1.1 Laryngoplasty with dissection of the thyroid cartilage in the midline.

1.2 Latera fixation of the arytenoid cartilage by external access, without opening the lumen of the larynx.

2. Endoscopic methods:

2.1. Chorectomy

2.2. Chordarythenoidotomy.

2.33. Arithenoidectomy.

These methods are carried out, including using a laser. The prior art describes several methods of treating stenosis of the larynx:

1. The work (1) describes methods for diagnosing laryngeal stenosis and recommends various methods of surgical treatment (laryngiochio-, laryngoepigloto-, tracheopexy) [1].

2. Surgical treatment of laryngeal palsy is proposed by combining hemiaritenoidchordectomy using a contact Nd: YAG laser. Intervention is performed under endotracheal anesthesia through a tracheostomy followed by dilatation of the airway lumen [2].

3. Carry out the treatment of chronic stenosis of the larynx with the use of antibiotic and hormone therapy, the use of a balloon dilator and hyperbaric oxygenation [3].

4. Surgical treatment of paralytic stenosis of the larynx by using a contact NdiYAG laser and high-frequency ventilation of the lungs is proposed [4].

5. A method is proposed for performing laser chordectomy or simultaneous chordarythenoidectomy by vaporization using a CO ₂ laser conjugated with an operating microscope [5].

But, despite the proposed large number of methods, they have several disadvantages:

1. Violation of the dividing function of the larynx.

2. Violation of the voice function of the larynx

3. The formation of cicatricial stenosis.

4. Prolonged cannulation.

5. Multi-stage surgery.

6. The imposition of a tracheostomy.

7. The lack of differentiation in the tactics of treatment, in particular surgical, depending on the degree of stenosis of the larynx

Closest to our proposed method is a method of treating median stenosis of the larynx of paralytic etiology with the extra-laryngeal method, including front access to the plate of the thyroid cartilage, removal of the elastic cone with the vocal fold and fixing it on the surface of the thyroid cartilage plate, in which chondroperichondral flap is formed from the thyroid cartilage, most of the internal cricothyroid and thyroid muscles, the vocal process of the arytenoid cartilage is resected, the out nasal septum cartilage under the front third of the vocal cord and an autograft is applied to the outer plate of the thyroid cartilage and is fixed thereon sutures [6].

The disadvantages of this method are:

1. violation of the voice function of the larynx,

2. violation of the dividing function of the larynx,

3. cannulation

4. the lack of differentiation in the tactics of surgical treatment, depending on the degree of stenosis of the larynx,

5. extra-laryngeal access.

The technical problem that we solve is the development of a surgical method for the treatment of median stenosis of the larynx, carried out depending on the clinical picture of stenosis, in particular its degree.

The technical result of the proposed method is to achieve an increase in the lumen of the glottis with preservation of the voice due to the remaining front third of the vocal fold and satisfactory breathing, achieved both by using the parameters of the surgical CO ₂ laser and choosing the tactics of surgical treatment, depending on the degree of stenosis of the larynx .

To understand the essence of our proposed method, it is necessary to consider the following. Despite the fact that the diagnosis of anatomical and functional changes in stenosis of the larynx and trachea is quite clear, the classification of paralytic stenosis of the larynx has its own peculiarities associated with the difficulty in interpreting the clinical picture, assessed by the external manifestations of stenosis (hoarseness, etc.). Therefore, we used the magnitude of the opening of the glottis as a criterion for stenosis, which is consistent with the known approaches used to assess stenosis of the larynx [7].

The inventive method includes a visual assessment of the size of the glottis, and surgical treatment using a CO ₂ laser with a power of 1-1.5 W, in continuous mode, without applying a tracheostomy, while with grade I stenosis, which corresponds to the size of the glottis 6-7 mm and II extent when the size of the glottis 4-5 mm, is carried out posterior third excision vocal fold CO ₂ laser on one side with the resection process voice arytenoid cartilage on this side, the degree of stenosis III, which corresponds to the size voice of th slit of 2-3 mm, is carried out posterior third excision vocal fold CO ₂ laser on both sides with resection processes voice arytenoid cartilages.

The method is as follows.

To examine the larynx, pharyngeal anesthesia is performed with a 10% lidocaine solution, a laryngoscope is installed and a glottis is examined. If the size of the glottis is 6-7 mm or 4-5 mm, then I or II grade laryngeal stenosis is assigned, respectively. Stenosis of the III degree corresponds to the size of the glottis 2-3 mm.

Surgery is performed under general endotracheal anesthesia (propofol, fentanyl) with the use of muscle relaxants (nimbex). Through the lumen of the larynx, an endotracheal tube is inserted into the trachea for artificial respiration, which is protected against laser radiation (wet gauze).

Laser radiation is supplied using a ULTRA PULSE ENCORE Lumenis CO ₂ laser system through an Acuspot-712 nozzle under the control of an operating microscope.

With CO ₂ laser radiation with a power of 1-1.5 W, in continuous mode, the posterior third of the vocal fold is excised from one or both sides with resection of one or two vocal processes of the arytenoid cartilage. The volume of intervention depends on the degree of stenosis of the larynx: with stenosis of I and II degree, a unilateral chorectomy is performed, with stenosis of the III degree - bilateral.

From 2007 to 2011, we observed 33 patients with a diagnosis of bilateral peripheral laryngeal paralysis who underwent a stumectomy for various thyroid diseases. The terms after a stumectomy ranged from 6 months to 3 years. The main complaints of the patients were severe breathing difficulties and voice changes. Parts of patients in connection with decompensation of respiration previously had a tracheotomy. Depending on the results of the examination, the patients were divided into two groups - with stenosis of the I and II degree and stenosis of the III degree. Based on these parameters, patients underwent bilateral (for patients with stenosis of the III degree) or unilateral (for patients with stenosis of the I-II degree) posterior chorectomy. As a result of the operation, good results were achieved. The postoperative period was uneventful. During the follow-up examination: the condition of the patients is satisfactory, breathing through the natural airways is free. The phonation is satisfactory. Upon subsequent examination after 1-1.5 years, the condition of the patients is satisfactory, breathing through the natural airways is free. A moderate improvement in voice function was noted.

EXAMPLE 1

Patient L., 51 g, was admitted to the NCCO on 06/20/12 with complaints of shortness of breath, a feeling of lack of air with minimal physical exertion. From the anamnesis: in 2007, a stumectomy was performed for thyroid cancer. Currently hospitalized for surgical treatment. During endoscopic examination, bilateral abdominal laryngeal paralysis is determined, the lumen is narrowed to 4 mm, the folds are stationary during phonation. The degree of stenosis II. 06/22/12 the patient underwent surgery: Posterior chorectomy of the left vocal fold of the CO ₂ laser. A suspended laryngoscope was installed under general anesthesia, then a 1 W CO ₂ laser continuously excised the posterior third of the left vocal fold with resection of the vocal process of the arytenoid cartilage on the left. The postoperative period was uneventful. At the control examination: the patient's condition is satisfactory, breathing through the natural paths is free. The phonation is satisfactory.

Example 2

Patient P., 50 years old, was admitted to the NCCO on 11/14/11 with a diagnosis of Bilateral laryngeal peripheral paralysis. Condition after a stumectomy from 2008; Clinically stenosis of the II-III degree. Complaints about difficulty breathing, shortness of breath at rest, hoarseness. From the anamnesis - in July 2008 - a stumectomy. Currently admitted for surgical treatment. At endoscopic examination: bilateral abduction laryngeal paralysis, the lumen is narrowed to 2-3 mm, the vocal folds are stationary during phonation. 11.16.11 operation was performed: Bilateral posterior chorectomy using a CO ₂ laser. A suspended laryngoscope was installed under general anesthesia, followed by a 1.5 W CO ₂ laser, and the posterior thirds of both vocal folds were excised continuously with resection of the vocal processes of the arytenoid cartilage. The subsequent operational period was uneventful. At the control examination, the patient's condition is satisfactory, the glottis is wide, breathing through the natural airways is free, the phonation is satisfactory.

Literature

1. Folomeev V.N., Sotnikov V.N., Kirasirova E.A., Panferova A.V., Lafutkina N.V., Filipchenko E.E., Tarasenkova N.N. Diagnosis and treatment of patients with stenosis of the larynx of paralytic etiology. Materials of the Russian Scientific and Practical Conference "Modern problems of diseases of the upper respiratory tract and ear" November 19-20, 2002, Moscow, RAGS.

2. Romanova Zh.G., Chekan V.L. A combined method of treating median stenosis of the larynx. Materials of the Russian Scientific and Practical Conference "Modern problems of diseases of the upper respiratory tract and ear" November 19-20, 2002, Moscow, RAGS.

3. Romanova Zh.G., Chekan V.L. Algorithm for the treatment of chronic median stenosis of the larynx. Materials of the Russian Scientific and Practical Conference "Modern problems of diseases of the upper respiratory tract and ear" November 19-20, 2002, Moscow, RAGS.

4. Karpishchenko S.A. Laser surgery of paralytic stenosis of the larynx / S.A. Karpishchenko // News of otorhinolaryngology and logopathology. 2000. No3. S.130-136.

5. Pchelnikov Yu. N., Podmazov A.V. The use of surgical CO ₂ laser for bilateral abductor laryngeal paralysis. Conference "Modern problems of diseases of the upper respiratory tract and ear" Materials of the Russian Scientific and Practical Conference. Moscow, 2002

6. RF patent No. 2284773 from 10.10.2006.

7. N.N. Tarasenkova, E.A. Kirasirova, N.V. Lafutkina. The nature of respiratory and metabolic disorders in patients with stenosis of the larynx and trachea of various etiologies. Bulletin of Otorhinolaryngology, 4, 2007, p.26.

Claims (1)

A method for the treatment of median stenosis of the larynx of paralytic etiology includes assessing the size of the glottis and performing surgical treatment using a CO ₂ laser with a power of 1-1.5 W, in continuous mode, without applying a tracheostomy, while with grade I stenosis, which corresponds to the size of the glottis 6 7 mm and the II degree, which corresponds to the size of the glottis 4-5 mm, is carried out posterior third excision vocal fold CO ₂ laser on one side with the resection process voice arytenoid cartilage on this side, with steno e III extent which corresponds to the size of the glottis 2-3 mm, is carried out posterior third excision vocal fold CO ₂ laser on both sides with resection processes voice arytenoid cartilages.