RU2552097C1 - Method for surgical management of dacryocystitis in adults with implanting lachrymal surgical drain tube - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: lower lachrymal point is expanded. A probe is projected along a lower lachrymal duct all the way to the bone. A light guide is delivered through the expanded lower lachrymal duct all the way to the bone and fixed manually. A nasal cavity is visualised with an endoscope. Bone tissue of a lateral wall of the nasal cavity is burned through with endoscopically controlled laser light until the laser light appears in the nasal cavity. That implies using a diode laser at wave length 970 nm, emission power 6-7 Wt, in the continuous mode. An endoscopically controlled drain tube is inserted into the formed fistula through the nasal cavity by means of a plastic injector 10.01 mm long, 2 mm in diameter. The drain tube is 8.4 mm long. An external diameter of the cylindrical portion is 3 mm, whereas an internal diameter is 2 mm with the length of 6 mm. For the purpose of fixation in the lachrymal sac, an implanted end of the drain tube has deformable fletching elements 5 mm in diameter, 1 mm wide from each side, and 3.2-3.5 mm in flexion diameter. At the opposite side of the drain tube, there is a pad 5 mm in diameter fixed in the nasal cavity. Along the entire drain tube, there are grooves 0.25 mm wide, 8-8.1 mm long for additional outflow of the lachrymal fluid.

EFFECT: method enables preventing recurrent atresias of the formed fistulas between the lachrymal sac and nasal cavity by long-term postoperative drainage of the formed fistula.

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Description

The invention relates to medicine, in particular to ophthalmic surgery and otorhinolaryngology, can be used for transcanalicular laser endoscopic dacryocystorhinostomy in patients with chronic, acute, purulent or recurrent dacryocystitis.

Dacryocystitis in adults continues to be one of the urgent problems of modern medicine, often being one of the reasons for long-term disability and disability of the population, make up 2-73.5% of the total ophthalmopathology. At the same time, existing methods of treatment do not always allow to avoid relapses of the disease, manifested in the form of scarring, infection of the lacrimal-nasal anastomosis in the postoperative period.

A known method of treating dacryocystitis (classical external dacryocystorhinostomy), in which an anastomosis is formed between the lacrimal sac and the nasal cavity by operative external access. An incision is made in the skin and soft tissues up to 3 cm long, which begin 2-3 mm above the inner ligament of the eyelids and lead downward, slightly bending around the lower orbital margin. Superconductors are superimposed. Soft tissues stupidly exfoliate to visualize the inner ligament of the eyelids. The periosteum is cut and separated outside 0.5-1 cm medial to the internal ligament. With the help of a chisel and a hammer, a bone window is formed with a size of (1.5-2) × (1.2-1.5) cm. Within the hole, the inner wall of the lacrimal sac and the nasal mucosa are longitudinally cut. Flaps of the wall of the bag and nasal mucosa are sutured with catgut, forming the front and back lips of the formed stoma. Skin and soft tissue are sutured in layers [Cherkunov B.F. Diseases of the lacrimal organs, Samara, 2001, p. 219-220].

Among the disadvantages of this method, one can note a high invasiveness, a long duration of the operation, the presence of a skin scar, frequent complications (including infection of the formed stoma).

A known method of treating dacryocystitis with an endonasal approach (internal dacryocystorhinostomy). In the nasal cavity, in front of the middle conch, the mucous flap is cut and removed according to the projection of the lacrimal fossa. An anterior U-shaped flap of the nasal mucosa is formed anterior to the defect. A bone window is formed with a chisel or boron. An incision is made in the lacrimal sac and its inner wall is removed. The U-shaped flap is returned to the place. The operation is completed with anterior nasal tamponade [Cherkunov B.F. Diseases of the lacrimal organs, Samara, 2001, p. 272].

The use of this method can be limited by the physiological or pathological narrowness of the nasal passage, as well as by the presence of pathology in the proximal sections of the tear ducts. It should be noted that with the endonasal approach, the duration of the operation may increase due to intraoperative bleeding.

The closest analogue of the invention is a method for treating dacryocystitis using a solid state Nd YAG laser, which has two uses. In the first, the lacrimal opening is carried out, the probe passes through the lower lacrimal canaliculus as far as it will go into the bone, the laser is guided through the expanded lower lacrimal canaliculi into the bone, the nasal cavity is visualized with an endoscope, and the light guide is located through diaphanoscopic transmission through the bone. Burning of bone tissue of the lateral wall of the nasal cavity is carried out using laser radiation with the formation of an anastomosis between the lacrimal sac and the nasal cavity to visualize the fiber in the nasal passage. In this case, the lateral wall of the nasal cavity is burned by a solid-state Nd YAG laser with a wavelength of 1.44 μm, with a pulse energy of 300-440 mJ, a pulse frequency of 10-20 Hz, and a pulse duration of 50-150 μs. Bone exposure time is 0.4-4 minutes. The formed anastomosis is intubated through the lower lacrimal opening with a drainage of silicone drainage into the nasal cavity in the form of a hollow tube. In the second, visualization of the nasal cavity by an endoscope and burning of bone tissue of the lateral wall of the nasal cavity with laser radiation are performed. In this case, the fiber of the fiber is produced from the nasal cavity. Bone tissue of the lateral wall of the nasal cavity is burned by contact 3 mm anterior to the middle nasal concha in the projection of the lacrimal fossa with a solid-state Nd YAG laser with a wavelength of 1.44 μm with a pulse energy of 300-350 mJ, a pulse frequency of 10-12 Hz, and a pulse duration of 50 -150 μs. Bone exposure time 0.4-1 min. Then, they pass through the acute path through the lower lacrimal tubule until a probe appears in the formed anastomosis. After that, the formed anastomosis is intubated through the lower lacrimal opening with the drainage of silicone in the form of a hollow tube into the nasal cavity [patent RU 2254843, 2005].

Despite the effectiveness of this method, it should be noted that intubation of the formed anastomosis with the help of silicone drainage through the lower lacrimal opening with its outlet into the nasal cavity partially obstructs the duct of the lower lacrimal canaliculus, which further requires the removal of silicone drainage. This can lead to scarring and subsequent infection of the formed anastomosis in the long-term postoperative period, thereby provoking the risk of recurrence of dacryocystitis.

The technical problem solved by the invention is to achieve patency of the tear ducts with dacryocystitis by diode laser radiation and prosthetics of the formed anastomosis (dacryostomy) using the Dacryostream drainage for lacrima surgery, which helps prevent its infestation, while maintaining normal tear outflow through the tear ducts.

The technical result of the invention is to reduce the duration and morbidity of the method, to prevent relapse of the overgrowth of the formed anastomosis between the lacrimal sac and the nasal cavity in the postoperative period due to long-term or permanent drainage in the postoperative period of the formed anastomosis between the lacrimal sac and the nasal cavity.

The proposed method for the treatment of dacryocystitis is as follows. They carry out the expansion of the lacrimal opening, along the enlarged lower lacrimal canaliculi, the fiber of the diode laser is drawn all the way to the bone and manually fix it. Visualize the nasal cavity with an endoscope with an optical tip of 0 degrees. Bone tissue of the lateral wall of the nasal cavity is burned by laser radiation under endoscopic control until the laser fiber appears in the nasal cavity. The radiation parameters of the diode laser were: wavelength 970 nm, radiation power 6-7 W, continuous operation. Formed dacryocystorhinostoma is washed with a 3% solution of collargol. In the formed anastomosis through the nasal cavity under the control of an endoscope using a plastic injector 10-12 cm long, having a tip bent by 45 degrees 10.01 mm long, 2 mm in diameter, hollow silicone drainage for lacrima surgery "DACRIOSTRIM" with a total length of 8.4 is introduced mm having a cylindrical part with an outer diameter of 3 mm, an inner diameter of 2 mm, and a length of 6 mm. For fixation in the cavity of the lacrimal sac, the implantable end of the drainage is equipped with deformable elements of the “plumage of the arrow” type with a diameter of 5 mm, a width of 1 mm on each side, a diameter of 3.2-3.5 mm when bent, and a 5 mm diameter pad was made at the opposite end of the drainage for fixation in the nasal cavity, and along the entire drainage there are grooves 0.25 mm wide and 8-8.1 mm long for additional outflow of tear fluid.

This method allows to achieve patency of the tear ducts due to the effective controlled burning of bone tissue with a diode laser with the proposed characteristics. Unlike all existing methods, this technique allows you to use the approach through the lacrimal tubule and through the nasal cavity. Significantly reduced the duration and morbidity of the intervention and, accordingly, the likelihood of postoperative complications. The size of the light guides allows radiation to be produced through natural paths. The absence or significant reduction in the recurrence rate for inflorescence of the anastomosis is achieved by introducing the DACRIOSTRIM silicone drainage into the formed anastomosis using an injector. Drainage is intended for long-term drainage of the dacryostomy, which provides lacrimation throughout the postoperative period.

The characteristics proposed in the invention provide long-term drainage of the formed dacryostomy using the proposed drainage "DACRIOSTRIM", which helps to prevent or significantly reduce the recurrence rate of this disease.

The invention is illustrated by the following clinical examples.

Example No. 1. Patient S., 63 years old. Medical card number 60168. I complained of constant lacrimation from both eyes for 2 years. From the anamnesis it is known that over the past 2 years he was operated twice for chronic dacryocystitis, OD - transcanalicular laser endoscopic dacryocystorhinostomy in 2012;

OS - transcanalicular laser endoscopic dacryocystorhinostomy with temporary intubation of a silicone stent in 2012. Examination: lacrimal passages on both sides are not passable. According to x-ray contrast studies of the lacrimal passages, mechanical obstruction at the level of the lacrimal sac is detected on both sides. On the right is the lacrimal sac 10.0 × 3.0 mm in size, on the left is the contrast in the lacrimal tubules, dimming of the maxillary sinus.

Diagnosed with: OU - Chronic recurrent dacryocystitis. Mild myopia.

Considering the medical history and examination data, the patient was recommended dacryocystorhinostomy with the formation of an anastomosis between the lacrimal sac and nasal passage with the introduction of DACRIOSTRIM silicone drainage in the right eye.

Processing of the surgical field with 70% ethyl alcohol is carried out twice. An Inocaine solution of 0.4% was instilled epibulbarly, conductive anesthesia of the lacrimal sac area was performed with a solution of lidocaine 2% - 2.0, 10% lidocaine spray intranasally. During the operation, after the expansion of the lower lacrimal opening and the passage of the probe to the nasal cavity through the lower lacrimal tubule under the manual (through the skin) and endoscopic (from the side of the nasal cavity) control, an optical fiber with a diameter of 0.6 mm to the bone was inserted. An artificial anastomosis between the lacrimal sac and the nasal cavity is formed by laser radiation under the control of the endoscope from the side of the nasal cavity. The radiation parameters of the diode laser were: wavelength 970 nm, radiation power 6-7 W, continuous operation. In the formed anastomosis through the nasal cavity under the control of an endoscope, silicone drainage “DACRIOSTRIM” was introduced using an injector. Lacrimal ducts were rinsed with Collargor 3% solution, patency through the DACRIOSTRIM drainage was free. Installation in the conjunctival cavity of a solution of chloramphenicol 0.3% and in the nose a solution of 2% adrenaline. The duration of the intervention is 10-15 minutes.

The following postoperative appointments are recommended: to bury in the right eye:

1) a solution of Levofloxacin 0.3% 6 times a day for 3-4 days, 4 times a day - 10 days;

2) a solution of Dexamethasone 0.4% - 2 times a day - 1 week, 1 time per day -1 week;

3) Drops in the nose: Polymyxin + Neomycin + Dexamethasone 4 times a day - 2 weeks;

4) Lavage of the lacrimal passages within 5 days after surgery.

When you are discharged 5 days after surgery for outpatient treatment, the tear ducts on the right are passable, outflow through the DACRIOSTRIM drainage is carried out. At the control examination after 3 months, the tear ducts are passable on the right. Dacryostream drainage is functioning, its position is unchanged.

Example No. 2. Patient X., 52 years old. He complained of constant lacrimation from the left eye during the year. From the anamnesis it is known that over the past year I went to the clinic at the place of residence twice, where a course of conservative therapy was prescribed, which did not lead to a positive result. During the examination: tear ducts on the left are not passable. According to the X-ray contrast study of the lacrimal passages, mechanical obstruction at the level of the lacrimal sac is revealed on the left side. On the left is a lacrimal sac 11 × 3 mm in size.

Diagnosed with OS - Chronic recurrent dacryocystitis. OD - Healthy.

Given the history and examination data, the patient was recommended dacryocystorhinostomy with the formation of an anastomosis between the lacrimal sac and the nasal passage with the introduction of DACRIOSTRIM silicone drainage on the left eye.

Processing the surgical field with 70% ethyl alcohol twice. An Inocaine solution of 0.4% was instilled epibulbarly, conductive anesthesia of the lacrimal sac area was performed with a solution of lidocaine 2% - 2.0, a solution of lidocaine 2% - 2.0 was endonasally injected. During the operation, after the expansion of the lower lacrimal opening and the passage of the probe to the nasal cavity through the lower lacrimal tubule under the manual (through the skin) and endoscopic (from the side of the nasal cavity) control, an optical fiber with a diameter of 0.6 mm to the bone was inserted. An artificial anastomosis between the lacrimal sac and the nasal cavity is formed by laser radiation under the control of the endoscope from the side of the nasal cavity. The radiation parameters of the diode laser were: wavelength 970 nm, radiation power 6-7 W, continuous operation. In the formed anastomosis through the nasal cavity under the control of an endoscope, silicone drainage “DACRIOSTRIM” was introduced using an injector. Lacrimal ducts were rinsed with Collargol solution 3%, patency through the DACRIOSTRIM drainage was free. Installation in the conjunctival cavity of a solution of chloramphenicol 0.3% and in the nose a solution of 2% adrenaline. The duration of the intervention is 10-15 minutes. The following postoperative appointments are recommended: to bury in the left eye:

1) Levofloxacin solution 0.3% 6 times a day for 3-4 days, 4 times a day for 10 days;

2) a solution of Dexamethasone 0.4% - 2 times a day - 1 week, 1 time per day - 1 week;

3) Drops in the nose: Polymyxin + Neomycin + Dexamethasone 4 times a day for 2 weeks;

4) Lavage of the lacrimal ducts for 5 days after surgery.

When discharged 5 days after surgery for outpatient treatment, the lacrimal passages on the left are passable, outflow through the DACRIOSTRIM drainage is carried out. At the control examination after 3 months, the tear ducts on the left are passable. Dacryostream drainage is functioning, its position is unchanged.

Claims (1)

A method for surgical treatment of dacryocystitis, including the expansion of the lower lacrimal opening, the probe passing through the lower lacrimal tubule all the way to the bone, passing the laser fiber through the expanded lower lacrimal tubule all the way to the bone, visualizing the nasal cavity with an endoscope, laser radiation burning under the endoscopic control of the bone tissue of the lateral wall the nasal cavity with the formation of an anastomosis between the lacrimal sac and the nasal cavity until a laser fiber appears in the nasal cavity, the introduction of drainage into the formed anastomosis and h silicone in the form of a hollow tube, characterized in that the radiation used is a diode laser with a wavelength of 970 nm, a radiation power of 6-7 W, continuous operation, and as a drainage through the nasal cavity using a plastic injector 10-12 cm long having a tip bent by 45 degrees with a length of 10.01 mm, diameter 2 mm, drainage is introduced with a total length of 8.4 mm, having a cylindrical part with an outer diameter of 3 mm, an inner diameter of 2 mm, and a length of 6 mm, for fixation in the lacrimal cavity bag implantable end of the drainage is equipped with defo with recessing elements of the “plumage of an arrow” type with a diameter of 5 mm, a width of 1 mm on each side, and a diameter of 3.2-3.5 mm when bent, at the opposite end of the drainage a platform with a diameter of 5 mm was made for fixation in the nasal cavity, and along the entire drainage placed grooves 0.25 mm wide, 8-8.1 mm long for additional outflow of tear fluid.