RU2607593C1 - Method for prevention of postoperative complications accompanying surgical management of patients with congenital malformations of external and middle ear - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology, and can be used for prevention of postoperative complications accompanying surgical management of patients with congenital malformations of external and middle ear. For this purpose, during the early postoperative period the ear is being cleaned, and the external acoustic meatus is being washed with an octenisept solution diluted in distilled water 1:5. Then, a session of endaural electrophoresis is performed with the Longidaza solution for 10–30 minutes. After the session of electrophoresis, a turunda impregnated with a mixture of preparations "Longidaza" and "Fermenkol" gel, 0.5 ml of each is being introduced into the external acoustic meatus. Turunda is being introduced 3 times a day for 10–15 days.

EFFECT: invention enables reducing the treating period and preventing commissure formation in the external acoustic meatus.

1 cl, 2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used in reconstructive plastic surgery of the craniofacial area and for otoplasty.

Reconstruction of the outer and middle ear is one of the most difficult problems in reconstructive surgery of the head and neck.

A significant number of methods for the surgical treatment of congenital malformations of the external and middle ear are known. After reconstructive surgery, as a rule, the epithelization of the tympanal flap completely ends by the 14-23 day, and the epidermisation of the walls of the trephine cavity is completed by the 31-40 day. However, after reconstruction of the ear, complications can continue to be observed, for example, such as “flap disease”, which can develop on the 30-35th day after the operation and manifests itself as a sharp swelling of the skin flap, its hyperemia, severe inflammation, significant narrowing of the newly created external auditory canal as a result of which secondary atresia of the external auditory meatus can occur. Particular attention is required when managing the patient at the indicated time of the postoperative period, since even an increase in the healing time can be considered as a complication that occurs both in the early and in the long term.

The group of complications of the late period after 1-2 years includes epidermitis of the meatal flap, incomplete epidermis and epithelization of the tympanic flap, which adversely affect the auditory function. Epidermitis of the meatal flap is clinically manifested by superficial desquamation (dry form) or by wetting areas (skin maceration) of this zone, purulent inflammation, tearing of the flap from the bone wall, while the auditory function changes.

These complications are caused by the peculiarities of the reparative process in patients, the level of the immunological status of the body, the state of soft tissues and circulatory disorders in the pathological area, as well as due to such genetic characteristics as the state of the fibroblastic sprout, the activity of the adrenal glands, the level of concentration of hormones in the blood, and much more.

There are many ways to treat these complications, for example:

1. Introduction to the auditory canal of drugs on turunda or in the form of candles.

2. Insufflation of fine powder into the external auditory meatus (V. T. Palchun. Diseases of the ear, throat, nose. - Moscow, "Medicine", 2000).

3. Repeated meatotympanoplasty using a free split skin flap taken from the anterior surface of the thigh (Lapchenko C.H. Congenital malformations of the outer and middle ear and their surgical treatment: dis .... Doctor of medical sciences. - M., 1972).

However, these methods have their drawbacks. So, the outflow of secretions can be impaired and the natural aeration of the ear cavities is hampered, the intensity of the inflammatory process in the area of the newly created eardrum and tympanomeatal flap can affect the effect of the drugs used.

The closest analogue of the present invention is a method for the prevention of complications in the postoperative period in the treatment of patients with ear defects, described in patent RU 2255678 (29.12.2003), which consists in the fact that after reconstructive surgery, tamponade of the ear canal with drainage and bandage with actovegin are applied . The disadvantages of this method is the lack of a complex effect both on the healing and regeneration course, and on the prevention of cicatricial processes.

To eliminate these drawbacks, we propose a method for the prevention of complications in the postoperative period in the treatment of patients with congenital malformations of the outer and middle ear by conducting sessions of endoural (intrauterine) Longidase electrophoresis followed by the introduction of Turund into the external auditory canal, impregnated with a mixture of Longidase enzymatic preparations and gel "Fermenkol".

The technical result of the present invention is the selection of such a form of drugs and such a method of its introduction into the middle ear cavity, which would ensure a high concentration of enzymatic preparations in the inflammatory focus for a long time, without complicating the outflow of the discharge and aeration of the middle ear cavity, enhancing the processes of epithelization and epidermization, and would reduce the treatment time and prevent complications arising after ear reconstruction in patients with congenital malformations of the ear, namely: stems external auditory canal stenosis, epidermitis meatalnogo flap, the rapid growth of granulation, incomplete epithelialization tympanic flap and scarring, which adversely affect the auditory function and reduce the quality of life of the patient. This is achieved by using both the combined effect of several drugs that hydrolyze excess collagen and polysaccharides to a large extent, preventing the abundant growth of granulations and accelerating the process of epithelization and epidermization of the tympanal flap, as well as our proposed method for their delivery to the site of exposure.

The method is carried out in the early postoperative period as follows: first, an ear toilet is performed, where the newly created external auditory canal is drained, which is cleaned of mucopurulent discharge. Then, the external auditory canal is washed with an attic cannula with a syringe with a solution of octenisept (diluted with distilled water 1: 5). This drug belongs to the class of surface-active substances, has a pronounced spectrum of antimicrobial activity, is effective against aerobic-anaerobic and gram-positive and gram-negative bacteria, chlamydia, mycoplasmas, fungi, as well as viruses, has a disinfectant effect, enhances local protective reactions, regenerative processes, including does not cause allergies.

After this, endaural electrophoresis with “Longidase” is carried out, the Potok-1 apparatus is used for this, the anode is the treatment electrode. The flux density is not more than 0.05 mA / cm2. The current strength increases smoothly by turning the knob of the potentiometer. The duration of the procedure is from 10 to 30 minutes, gradually increasing by the 5th procedure, a course of 10-15 procedures carried out every other day or 4 times a week.

After electrophoresis, a tamponade of the newly formed external auditory canal is carried out with cotton turundas soaked with Longidaza preparation in the form of a solution for injection of 3000 ME and Fermenkol gel, the ratio of 0.5 ml each for 20 minutes 3 times a day, course up to 10-15 sessions.

Clinical example No. 1: Patient K., 11 years old, medical history No. 26873, was in the Children's Clinical Hospital G.N. Speransky since 1.06.13. on 06/10/13, I complained of pain in the right ear, hearing loss in the right ear, congestion of the right ear, mucopurulent discharge from the ear, discharge from the nasal passages. When examining the right ear: the shape of the outer ear is changed, as a result of the operation to create 2/3 of the auricle (ascending curl and lobe), palpation and percussion of the behind-the-ear area are moderately painful. A yellowish viscous discharge was detected in the external auditory meatus. After the toilet of the ear, perforation was visualized in the central part of the tympanic membrane, epidermitis of the meatal flap with moist areas (maceration of the skin). Upon receipt in bacteriological analysis from 1.06.13, Staphylococcus aureus was seeded.

Diagnosis: "Right-sided congenital malformation of the outer and middle ear. Condition after auriculomeatotympanoplasty. Exacerbation of right purulent otitis media. Epidermitis of the meatal flap. Acute rhinitis. " A toilet of the external auditory canal of the ear, irrigation of the tympanic cavity with octenisept solution, 10 sessions of electrophoresis with "Longidase" of the newly formed external auditory canal and mucous membrane of the nasal cavity with an exposure of 0 minutes for 10 days, followed by tamponade with turundas soaked with Longidaza daily, were performed daily. "3000 ME and Fermenkol gel 3 times a day for 10 days.

The effect of the treatment occurred on the 8th day from the start of treatment, perforation of the tympanic membrane was closed, epidermitis of the meatal flap was eliminated, no flora growth was detected in the control smear from 10.06.13.

Clinical example No. 2 of a patient with a mild degree of hypogenesis.

Patient T., 4 years old, 1 month, (medical history No. 24141) with a diagnosis of I-II gill arch syndrome. Bilateral congenital malformation of the outer and middle ear. Bilateral conductive hearing loss III-IV degree.

The condition of the child is satisfactory. Complaints of a congenital cosmetic defect in both auricles, a sharp decrease in hearing in both ears.

The right physique. The skin is clean. Heart and lungs without features. The abdomen is soft, painless on palpation. Stool and diuresis are normal. Blood and urine tests are normal. ENT organs. The nose is of the correct form, the nasal septum is in the midline, the mucous membrane of the nasal cavity is pink, moist. Nasal breathing is free. Oropharynx: the mucous membrane is moist, pink. Palatine tonsils of medium size, without pathological contents. Nasopharynx: the arch is free, the mucous membrane is moist, pink, the choana are free, the mouths of the auditory tubes are differentiated. Ears: the right auricle is presented in the form of a skin-cartilaginous roller, the external auditory meatus is absent. The left auricle is rudimentary, also in the form of a skin-cartilaginous roller, atresia of the external auditory meatus. Audiogram: bilateral conductive hearing loss of the III degree. On a computer tomogram of the temporal bones, a tympanic cavity of normal sizes on both sides is determined, fragments of the auditory ossicles, mastoid processes are pneumatized.

These results of LDF were taken into account and an operation was performed taking them into account. Under endotracheal anesthesia, the skin was cut around the rudiment of the auricle, and a platform of the mastoid was exposed with a raspator. In the area of the site behind the rudimentary auricle, a skin tongue-like flap was cut about 8 cm long, about 1 cm wide on the vascular pedicle, while maintaining the perforated capillary network. In the projection of the Shipo triangle, an antrum was opened with access to the tympanic cavity of the middle ear, an anvil and stapes were found, no malleus. A titanium nickelide plate is laid on the anvil body, and a periosteal flap is placed on top. The bone part of the external auditory meatus was simultaneously formed. The auricle rudiment was mobilized and transferred back to the physiological position. Bone grafting of the external auditory meatus was performed with a skin graft cut in the behind-the-ear region, which was moved forward of the rudiment and laid in a spiral to the tympanum. Between the two formed parts of the auditory meatus, sutures were made along the line of contact of the skin-cartilaginous flaps. We performed a tamponade of the auditory meatus with drainage. The wound was sutured with polyglycolide 4.0, an aseptic dressing with Actovegin ointment.

The first dressing on the 2nd day, by this time the flaps are already firmly fixed to the bone. In the following days, the toilet of the external auditory canal was treated with vasoactive ointment "Actovegin". In the postoperative period, magnetotherapy No. 5 for the postoperative area was also carried out from 2 days after the operation. The use of elastic or rigid-elastic dilatation of the lumen of the external auditory meatus was refused, because any mechanical injury only leads to more severe scarring. Sutures were removed on the 8th day after surgery. Primary healing. The patient was discharged in satisfactory condition on day 10 with epithelialization phenomena. The effect of treatment occurred on the 8th day from the start of treatment - perforation of the tympanic membrane was closed, epidermitis of the meatal flap was eliminated, no flora growth was detected in the control smear from 1.10.10.

Despite the fact that according to the LDF study, the patient was assigned to the group with a possible unfavorable outcome of surgical treatment, thanks to the chosen tactics and early prescription of anti-scarring therapy, the results of the operation were regarded by us as good. Only marginal necrosis of the flap was noted, the phenomena of which were leveled at the time of discharge.

However, after 2 years, as a result of insufficient observation and treatment, a yellowish discharge appeared in the external auditory canal. After the toilet of the ear, perforation was visualized in the central part of the tympanic membrane, epidermitis of the meatal flap with moist areas (maceration of the skin). Upon receipt in bacteriological analysis from 1.06.12, Staphylococcus aureus was seeded. The toilet of the external auditory canal of the ear was daily conducted, irrigation of the tympanic cavity with 0.01% miramistin solution. Fifteen sessions of electrophoresis with "Longidase" of the newly formed external auditory meatus with an exposure time of 10 to 30 minutes were prescribed, followed by tamponade with turundas soaked in solution for 15 days with Longidase 3000 ME and Fermenkol gel 3 times a day. The effect of treatment occurred on the 15th day from the start of treatment - perforation of the tympanic membrane was closed, epidermitis of the meatal flap was eliminated, no flora growth was detected in the control smear from 06.15.12.

The proposed method was treated 11 patients after surgery to restore the outer and middle ear. When implementing this method, a good therapeutic effect was obtained in patients: a decrease in the severity of inflammation, inhibition of the development of a progressive inflammatory process, a decrease in the formation of adhesions, and the normalization of immunological parameters. These measures led to the elimination of inflammatory changes in the skin of the meatal flap by 6-7 days. The proposed method allows to achieve complete epidermization of the meatal flap, epithelialization of the tympanal flap and tympanic cavity. It was possible to achieve a recovery of 100% of patients. In all patients treated with the proposed method, relapse was not observed, and the period of remission lasts from 3 to 6 months.

Claims (2)

1. A method for the prevention of complications in the postoperative period in the treatment of patients with congenital malformations of the external and middle ear, in which an ear toilet is made in the early postoperative period, then the external auditory canal is washed with a solution of octenisept diluted with distilled water 1: 5, and then a session endoural electrophoresis with a solution of Longidase lasting from 10 to 30 minutes, followed by the introduction of an electrophoresis into the external auditory canal of turunda, impregnated with a mixture I take preparations of "Longidaza" and gel "Fermenkol" 0.5 ml each. 2. The method according to p. 1, characterized in that the introduction of turundum is carried out 3 times a day, the course of treatment is 10-15 days.