RU2604940C1 - Method of surgical treatment of papillomatosis of vocal cords - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology, and can be used for treating papillomatosis of vocal cords. On the area of papillomatosis growths of vocal folds are exposed by semiconductor laser radiation with wavelength 960±30 nm, power 30±6 W, pulse duration 40-100 ms in the contact mode.

EFFECT: method allows to carry out removal of papillomatosis growths on the vocal cords without damaging the functionally important zones, controlling depth of influence, which improves vocal function, shortening the rehabilitation length.

1 cl, 1 tbl

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used in voice-saving laser surgery on the vocal folds, in particular, with a disease such as recurrent respiratory papillomatosis.

A known method for the surgical treatment of papillomatosis of vocal folds by irradiation of papillomatous growths with a CO2 laser with a wavelength of 10,600 nm in distant mode using special focusing nozzles for operating microscopes. The irradiation used a power of 2-3 W, a pulse duration of 1 sec, a spot diameter of 0.3 mm (Andrus JG, Shapshay SM Contemporary management of laryngeal papilloma in adults and children // Otolaryngologic Clinics of North America. - 2006. - T. 39 . - No. 1. - C. 135-158). Due to the absorption characteristics of the used wavelengths (they are well absorbed by water), the use of this laser allows one to obtain surface vaporization or ablation of tissues in the absence of damage to the underlying tissues. Thus, papilloma was removed in layers, allowing the surgical procedure to be controlled. Such features are convenient for obtaining predictable treatment results.

The disadvantages of this method are the extremely high price of the CO2 laser itself and its maintenance, the need for special focusing nozzles for the microscope, the need for special specialist training, the low prevalence of this type of laser in Russia.

The technical result achieved by the invention is to expand the arsenal of technical means for the surgical treatment of papillomatosis of the vocal folds.

The claimed technical result is achieved in a method of surgical treatment of papillomatosis of the vocal folds by exposing the region of papillomatous growths with laser radiation, in which the effect is carried out by radiation of a semiconductor laser with a wavelength of 960 ± 30 nm with a power of 30 ± 6 W pulses with a duration of 40-100 ms in contact mode.

Semiconductor lasers are used in contact modes in microendolaryngeal surgery, since their radiation is supplied to the irradiated tissues through special quartz optical fibers, most often they are exposed to constant radiation at powers up to 10 watts. The main mechanism of this effect after contact with biological tissue and the formation of carbon deposits around the end of the fiber in the first seconds is due to the absorption of most of the radiation by carbonizate and the transfer of heat to the tissues adjacent to the exposure zone. The exposure to a semiconductor laser in contact constant mode at the indicated powers does not allow to accurately determine the depth of damage, since the heat from the heated fiber and heated tissues spreads along the temperature gradient, which, when working on the vocal folds, can lead to damage to the Reinke space and further rough scarring of the functionally significant upper - the medial surface of the vocal folds.

The authors of the claimed invention experimentally selected exposure modes to avoid significant penetration of radiation into the underlying tissue and thus control the depth of damage.

The table shows the results of measurements of the zones of damage and coagulation of experimentally irradiated chicken muscle tissue at pulse durations of 40, 60, 80, and 100 ms with a semiconductor laser with a wavelength of 960 ± 30 nm at a power of 30 ± 6 W.

To preserve the vocal function when working on the vocal folds, it is important to preserve their histological structure as much as possible, work within the surface layer of the own mucous plate is permissible. Also, one of the important areas is the Reinke space, which ensures the mucous membrane glides on the free edge of the vocal fold during phonation. According to the literature, the thickness of the vocal fold epithelium together with the surface layer of the surface plate is about 400-600 microns (Matthew Reeve, ′ The Structure of the Vocal Folds ′, http://www.voicesource.co.uk/article/152, date of download May 13, 2014 (Milton Keynes: Voicesource Publishing, 2005). From the data in the table it follows that with a pulse duration of 40 ms, the maximum damage depth, which is the sum of the crater depth and the depth of the coagulation zone below it, is about 400 μm, with a pulse duration of 100 ms - about 800 microns.Thus, even when exposed to a maximum viewing with a pulse duration of 100 ms per region with a pathological thickening of the mucous membrane of the vocal fold characteristic of papillomatosis, the depth of damage in the affected area will not exceed the thickness of the tissue layer to functionally significant zones, i.e., Reinke space.

With contact exposure, we can assume that all the radiation emitted by the end of the fiber accounts for the area of the fabric equal to the diameter of the quartz fiber itself, that is, in our case, 400 microns. Thus, the power density on the surface is 19-29 kW / cm, which is much higher than under distant exposure. In the presence of carbon deposits at the fiber end, most of the radiation is absorbed precisely at the tip and, accordingly, thermal and mechanical energy are released here, due to which the surface defect is mainly formed. The radiation penetration depth and thermal effects in this case are reduced due to exposure to single pulses. Due to the formation of coagulate on the treated surface, the healing of the underlying tissues occurs under a scab of coagulated tissues, i.e. under conditionally sterile conditions, this significantly reduces the inflammatory response and the threat of scarring of tissues.

The claimed method is carried out, for example, as follows.

Before exposure, remove the polymer sheath from the end of the fiber and form a fresh chip, then a single impulse when in contact with the surface of a wooden medical spatula form a deposit at the end of the fiber. Exposure to papillomatous tissue is performed by a 960 ± 30 nm laser at a power of 30 ± 6 W, for example, Medical laser device LATUS-K, manufactured by ATKUS LLC, St. Petersburg, Russia, in contact, positioning the fiber at an angle as close as possible to 90 degrees, single pulses, while the pulse duration is selected from 40 to 100 ms depending on the required depth of damage, which prevents the accumulation of energy in tissues and thermal damage to tissues. After each pulse, the fiber is displaced and the next zone is exposed.

The method is illustrated by a clinical example.

Patient B., 27 years old, has been suffering from laryngeal papillomatosis since childhood (identified at 3 years old). At 3.5 years old, the removal of the larynx papillomas was first performed. In the long term, no dysphonia was noted. Currently an employee of the voice-speaking profession. Since 2012, hoarseness began to increase, turned to the ENT at the place of residence, and was sent for planned surgical treatment. On June 16, 2014, in the ENT clinic of PSPbGMU during telearingaring revealed: the anterior and middle third of the right vocal fold are covered with creeping (“surface”) classification Derkay C.S. (Derkay S.S. et al. A staging system for assessing severity of disease and response to therapy in recurrent respiratory papillomatosis // The Laryngoscope. - 1998. - T. 108. - No. 6. - C. 935-937) papillomatous growths, in the posterior third there is a flat papilloma (“raised”) according to the classification of Derkay CS, protruding into the lumen of the glottis by 2 mm. During the operation, the anterior and middle third of the right vocal fold are processed by a semiconductor laser with a wavelength of 960 ± 30 nm in contact mode at a power of 30 ± 6 W and pulses of 40 ms duration. The papilloma in the posterior third of the vocal fold is removed at the same power by pulses lasting 100 ms.

Acoustic parameters were evaluated using standard indicators Jitter, Shimmer, and HNR (Dejonckere P. N. et al. A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques // European Archives of Otorhinolaryngology. - 2001. - T. 258. - No. 2. - C. 77-82), which were determined in the pre- and postoperative period. A decrease in Jitter parameters from 3.011% to 0.939%, Shimmer from 19.646% to 4.494%, an increase in HNR from 4.599 to 18.562, indicating a decrease in dysphonia, i.e. improving voice function.

The postoperative endoscopic picture of the larynx testified to minor inflammatory phenomena and satisfactory healing of the wound surface without scarring.

According to the claimed method, papillomas were removed on the vocal folds in a group of patients, including 25 people: with juvenile (18 people) and adult (7 people) forms of papillomatosis; 15 women and 10 men aged 18 to 67 years. 35 interventions were performed - with relapse in individual patients, repeated removal of papillomas was performed. Microscopically, the pathological process on the vocal folds was represented by superficial and flat papillomas (“surface” and “raised lesion” according to the classification of Derkay C.S.) - 26 cases, with 9 surgical interventions, bulky lesion papillomas were identified and removed. During the examination in the pre- and postoperative period, a decrease in the inflammatory response of tissues to the intervention, shortening of the rehabilitation period was noted. All patients achieved improved voice function, as confirmed by computer voice analysis (Praat ver. 5.3.34 software).

Using the claimed method allows the removal of papillomatous growths on the vocal folds without damage to functionally significant areas, controlling the depth of exposure.

Claims (1)

A method for the surgical treatment of papillomatosis of the vocal folds by exposing the region of papillomatous growths to laser radiation, characterized in that the exposure is carried out by radiation of a semiconductor laser with a wavelength of 960 ± 30 nm, a power of 30 ± 6 W, pulses of 40-100 ms duration in contact mode.