RU2530755C1 - Method for surgical orbital decompression in patients with hormonal diseases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: endonasal approach is formed to create a window until the periorbit protrudes into the nasal cavity in the form of a dome. A surface of the domed periorbital protrusion is linearly dissected at a depth of 2-3 mm in an oval path along the protrusion border from a point of one pole to the opposite pole. That is followed by exposure to an alternating RF current of power 10-150 Wt and intermittency 10-50%. Fatty tissue is formed through the created window.

EFFECT: higher clinical effectiveness, reduced number of injuries, no aesthetic changes ensured by managing the penetration of a cutting instrument, eliminating the involvement of oculomotor muscles, providing reliable haemostasis, reducing a reactive response and an inflammatory reaction of the tissues surrounding the incisional wound.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used for surgical decompression of the orbit in patients with endocrine disorders.

There is a method of surgical treatment of patients with endocrine ophthalmopathy in the stage of decompensation and endocrine myopathy, when, for the purpose of decompression of the orbit, a single conjunctiva is cut in the outer or lower outer parts of the eyeball through which retrobulbar fatty tissue is removed, thereby reducing the pressure in Patent No. 21 , CL A61F 9/007, publ. 20.11.2002).

The disadvantage of this method is a significant wound lesion of the conjunctiva and the possibility of a pronounced inflammatory process, leading to decreased vision.

Closest to the proposed is a method of surgical decompression of the orbit in patients with endocrine disorders, including endonasal access with the formation of a domed swelling of the periorbit in the lumen of the nasal cavity, linear dissection of the dome surface using the working tip of the tool. As a working tool in this method using a scalpel. (P. A. Kochetkov, A. S. Lopatin, N. Yu. Sergienko. Endonasal endoscopic decompression of the orbit by transethmoid access. - Bulletin of Otorhinolaryngology, 2009, No. 4, pp. 23-26).

The disadvantage of this method is that the dissection of the periorbit with increased exposure to it with a scalpel can lead to excessively deep penetration of the instrument and damage to the medial rectus muscle of the eye, which in turn will lead to the development of strabismus.

The task of the invention is to remedy these disadvantages, increase the effectiveness of treatment, reduce the morbidity of surgery due to the quick atraumatic surgical intervention, which reduces the risk of intra- and postoperative complications.

This problem is solved by the fact that in the method of surgical decompression of the orbit in patients with endocrine disorders, including endonasal access with the formation of a window until a dome-shaped bulging of the periorbit in the lumen of the nasal cavity, linear dissection of the surface of the dome-shaped bulging of the periorbit, removal of fatty tissue through the formed window, it is proposed to cut periorbit carry out to a depth of 2-3 mm along an oval trajectory along the bulge border from the point of one pole to the opposite pole by applying alternating the electric current of the radio frequency range, power 10-150 W, duty cycle 10-50%.

The fact that the effect on the tissue is performed by means of alternating electric current eliminates the occurrence of bleeding, which increases the degree of visual control of the operation, reduces the reactive response in the field of surgical wounds and reduces the inflammatory response.

Figure 1 presents the working part of the tool; figure 2 is a tool for radiofrequency electrosurgery.

The method is as follows.

Under anesthesia, an endonasal exposure of periorbit is performed by excision of all layers of tissue covering it and the formation of a window through which the periorbite swells in the form of a dome. Under visual control, a tool 1 is brought to the surface of the latter, which, in addition to dissecting, allows simultaneous coagulation, which contains a metal rod in the form of a truncated cone covered with an electrically insulating material 2 that does not cover the proximal, thickened end 3 for fastening in the grip of the handle 4 and the distal thin end, on which has a working (cutting) part 5 in the form of a rod located perpendicular to the axis of the tool 1. The working part 5 is made of refractory material, such as frame with a cross-sectional diameter of mainly 0.1-0.3 mm The incision is carried out so that the working part of the tool 5 is perpendicular to the surface of the periorbit in its anteroposterior sector of the exposed area. After applying an alternating electric current from the power source 6, the working part 5 of the instrument is immersed in the periorbit tissue and with its help, the periorbit is cut along an oval path from the rear penetration point, then down and forward to the starting point. In this case, periorbit dissection is carried out to a depth of 2-3 mm along an oval path along the bulging border from the point of one of the poles to the opposite pole by exposure to tissue with an alternating electric current of the radio frequency range, with a power of 10-150 W, and a duty cycle of 10-50%.

The proposed method in comparison with the known has several advantages: a slightly injured intervention that does not cause cosmetic changes; controlled depth of penetration of the cutting tool; a reliable way to cut periorbit without damaging the oculomotor muscles; bloodless periorbit incision with a radio frequency current; reduction of operation time at the final stage due to the absence of hemostasis.

Example 1

Patient T., 54 years old. Diagnosis: Endocrine ophthalmopathy. The duration of the disease is 2 years. Before surgery, the patient received a full course of steroid pulse therapy (1000 mg IV metipred). Conservative treatment was ineffective, exophthalmos in both eyes increased in the patient, visual acuity sharply decreased. The patient was referred for surgical treatment - endonasal decompression of the orbits, in order to prevent the development of blindness in both eyes.

Under general anesthesia, the patient was alternately endonasal decompression of the orbits in two stages on the right and left. Initially, under the control of vision, by excision of the mucous membrane and periosteum, the bone plate dividing the nasal cavity and orbit was exposed. Then, the bone plate was excised over an area of 1.0-1.5 cm ² , with the formation of an oval window through which the periorbite swelled under pressure.

At the final stage of the operation, the periorbite was dissected bloodlessly using the above-described instrument, and the fatty tissue that fell through the incision was removed. Dissection was carried out to a depth of 2 mm by electric current with a frequency of 4.0 MHz, power 50 W, duty cycle 20%. This mode of exposure was selected according to the state of periorbit tissue in this patient, taking into account his age and the duration of the disease.

The operations went without complications. Immediately after surgery, the patient noted a decrease in exophthalmos and an improvement in visual acuity.

6 months after the operation, visual acuity was observed at the same (postoperative) level, i.e. decrease in visual acuity was stopped.

Example 2

Patient R., 47 years old, was in the ENT department of MONICA with a diagnosis of Endocrine ophthalmopathy, severe, in the stage of subsiding activity, complicated by optical neuropathy. Diffuse toxic goiter 0 tbsp. by WHO. Thyrotoxicosis, moderate, subcompensation. Upon admission, the patient complained of an increase in eyes, a feeling of “sand”, lacrimation, itching, periodic double vision when looking forward and upward. Considers herself a patient since September 2010, when complaints of redness of the conjunctiva, pain in the eyes, and lacrimation appeared. She was treated by an ophthalmologist at the place of residence for conjunctivitis without effect.

She was consulted by the MONICA endocrinologist, pulse therapy with solomedrol was performed, positive dynamics from the orbital symptoms were noted, however, taking into account the presence of optical neuropathy with a marked decrease in visual acuity in both eyes, bilateral bone orbit decompression was recommended. Visual acuity at the time of hospitalization: OD - 0.4, OS - 0.6. Gertel exophthalmometry: OD - 26 mm, OS - 22 mm.

In June 2012, a patient under general anesthesia underwent sequential endonasal decompression of the orbits using the final phase of the operation, i.e. at the stage of direct dissection of the periorbit, electrosurgical instrument 1: current frequency - 2.6 MHz, power - 65 W, duty cycle - 10%. The exposure regimen was selected taking into account the state of periorbit tissue during visual and tactile control. At the same time, the working part 5 of tool 1 (3.0 mm) was freely introduced into the periororbite and with its help an oval section of the periorbit was made to the left of the upper bulging (bulging) pole to the lower, and vice versa, from the bottom to the top, while removing fat fiber. Dissection of periorbit tissues was performed bloodless.

The postoperative period was uneventful. Gertel exophthalmometry: OD - 23 mm, OS - 22 mm.

After 6, 12 months after the operation, the preservation of visual acuity at the same level was noted.

The proposed method conducted 37 operations for patients aged 34 to 61 years. All operations led to the desired effect - at least stabilization, and in some cases, improved visual acuity. During operations, no bleeding was noted at the stage of periorbit dissection. In the postoperative period, no complications of any kind were noted.

The developed method is simple to execute, easy to replicate, i.e. in training specialists does not cause problems. The method allows to reduce the time and improve the quality of the rehabilitation period, which significantly affects the economic efficiency of the treatment of patients with this pathology.

Claims (1)

A method of surgical decompression of the orbit in patients with endocrine disorders, including endonasal access with the formation of a window until a dome-shaped bulging of the periorbit in the nasal cavity is obtained, linear dissection of the surface of the dome-shaped bulging of the periorbit, removal of fatty tissue through the formed window, characterized in that the periorbit is cut to a depth of 2 -3 mm along an oval path along the bulge border from the point of one pole to the opposite pole by exposure to tissue with an alternating element an insulating current radio frequency range of 50-70 watts, 10-50% duty cycle.

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