RU2632117C1 - Method for prevention of complications in postoperative period in case of nasal septum surgical treatment in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: for prevention of complications in the postoperative period in case of surgical treatment of nasal septum deformities in children, the cavity is washed with an octenicept solution diluted with distilled water in a volume ratio of 1:7. After this, endonasal ionophoresis is carried out using fermenkol. Then, tamponade of the reconstructed nasal cavity is performed by turundas impregnated with fermenkol-gel.

EFFECT: invention can reduce inflammation, prevent adhesions and scars formation in the nasal cavity, accelerate mucous membrane epithelialization.

5 cl, 3 ex

Description

The invention relates to medicine, namely to otorhinolaryngology and is intended for the prevention of complications in the postoperative period in the surgical treatment of deformation of the nasal septum in children.

Currently, the prevalence of abnormalities in the development of the nasal septum reaches 95% (B. Guyuron et al., 1999). According to the results of a study by R. Mladina (1997), pathological deformation of the nasal septum occurs in 68% of the adult population. The upward trend in this type of pathology is determined by an increase in the frequency of general injuries and, in particular, ENT organs. Up to 27% of all injuries of the maxillofacial region are injuries of the nasal bones; while 8% are isolated fractures, and in 18.8% of nose injuries combined with multiple fractures of the bones of the facial skeleton. About 54-59% of cases of nasal bone fracture in children are combined with a nasal septum fracture (Yunusov A.S. 2000; Rybalkin S.V., Maslov E.Yu., 2003; Artemyev M.E. et al., 2006; Eremina N.V. et al., 2006; Rusetskiy Yu.Yu. et al., 2006).

Various types of deformation of the nasal septum in children cause a prolonged violation of nasal breathing, which leads to a number of problems, including the development of various forms of chronic rhinitis, pathology of the paranasal sinuses, auditory tube and middle ear, inflammatory diseases of the pharynx, larynx, and also lower respiratory tract, adversely affects the functional state of the cardiovascular system, leads to a whole range of neurological disorders (Soldatov I.B. 1994).

Reconstruction and therapeutic treatment of curvature of the nasal septum is one of the most difficult problems in reconstructive surgery of the nose.

As a rule, by 14-23 days after surgery, the epithelization of the nasal mucosa should completely end, however, after nose reconstruction, complications such as the occurrence of synechia of the nasal cavity, cicatricial processes in the nasal cavity, which are accompanied by difficulty in nasal breathing, discharge from the nose, impaired sense of smell, headaches.

Particular attention is required in the management of the patient in this postoperative period, since if the recovery process lengthens, then this should be considered as a complication that occurs both in the early and in the long term.

These complications are caused by the peculiarities of the reparative process in patients, the peculiarities of the immunological and allergological status of the body, as well as the state of soft tissues and circulatory disorders in the pathological area, the presence of genetically determined features, such as the state of the fibroblastic sprout, the activity of the adrenal glands, and their concentration in the blood hormones and more.

There are many ways to treat these complications:

1. Introduction on turunda into the nasal passages of medicinal substances (MI Nikulin, VV Skorobogaty, 1993).

2. The introduction of medicinal gels to eliminate the phenomena that violate the outflow of secretions and impede the natural aeration of cavities (GI Markov, MG Markov, 1994).

3. Insufflation of fine powder into the nasal passages (V. T. Palchun, Diseases of the ear, throat, nose. - Moscow, "Medicine", 2000).

4. The use of “Plazon” in combination with ultrasonic irrigation of miramistin (V. M. Zaitsev 2004).

However, these methods have the following disadvantages: for example, the use of miramistin only gives removal of the inflammatory process, and when the powder is insufflated into the nasal passages, thick crusts are formed that prevent other portions of the wound surface from reaching. In addition, there are other disadvantages: 1. A burning sensation, soreness and dryness of the nasal mucosa. 2. From the side of the central nervous system rarely headaches. 3. From the side of the cardiovascular system, arrhythmia and an increase in blood pressure are extremely rare. 4. The lack of effectiveness of the final elimination of the process.

The closest solution to the technical solution is a method for the treatment of postoperative rhinitis with the use of antibiotic therapy, anti-inflammatory therapy, intranasal proteolysis (Kim I.A., Treatment of polypous rhinosinusitis in the postoperative period, abstract of diss. ... MD, St. Petersburg, 2009).

However, this method does not take into account the peculiarities of physiological processes in the postoperative period and, in particular, is not aimed at restoring microcirculation of the nasal mucosa, reducing edema and hyperemia of the mucous membrane, regenerating the epithelium of the mucous membrane of the nasal cavity, and at the possibility of removing granulation tissue residues, which leads to to relapse of the disease, the formation of scar tissue as a result of the operation.

In this regard, an important factor is the selection of such a form of drugs and such a method of its introduction into the nasal cavity, which would not depend on the magnitude of the inflammatory process in the nasal structures and would provide a high concentration of enzymatic preparations in the focus of inflammation for a long time, without complicating the outflow of the discharge and aeration of the nasal cavity and enhancing the processes of epithelization, as well as reducing the time of treatment.

The purpose of the invention is the prevention of complications arising after reconstruction of the nose in children with a curved nasal septum, namely: cicatricial stenosis of the nose, synechia, rapid growth of granulations that adversely affect important functions of the nose and the appearance of negative deviations in the quality of life of the patient.

The technical results of the invention are:

- providing a high concentration of drugs in the focus of inflammation for a long time, in the possibility of creating an unhindered outflow of detachable contents of the nose and aeration of the nasal cavity;

- elimination of pathological tissue changes by reducing the severity of inflammation, inhibition of the progressive sclerotic process with the prevention of adhesions, scar growth, (its bulk density and density decrease) in the nasal cavity;

- cessation of the abundant growth of granulations, acceleration of the process of epithelization of the mucous membrane of the nasal cavity.

We propose a method for the prevention of complications in the postoperative period in the surgical treatment of nasal septum deformity in children, in which the nose of the nasal cavity is produced in the postoperative period, then the cavity is rinsed with octenisept solution in dilution with distilled water in a volume ratio of 1: 7, after which endonasal iontophoresis is performed using fermencol, after iontophoresis, tamponade of the reconstructed nasal cavity is used with turundas soaked in fermencol gel.

The method is as follows: both in the early and late postoperative periods (1-3 days after the operation and four weeks after the operation, respectively), the first stage is the toilet of the nasal cavity, first, the nasal cavity is drained, it is cleaned of mucopurulent discharge, then washing is carried out using an attic cannula with a syringe with a solution of octenisept (diluted with distilled water 1: 7). This drug belongs to the class of surfactants, has a pronounced spectrum of antimicrobial activity, is effective against aerobic and anaerobic 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 that, in the second stage, endonasal iontophoresis is performed up to 14 procedures using fermencol (a collagenase complex that is a light yellow powder hygroscopic powder, 4 mg of active substance) using only the Potok-1 electrophoresis apparatus. Solactin was used to prepare the enzyme solution. included in the set for enzymatic correction of the drug fermencol. The concentration of the enzyme solution was 0.1-1.0 mg / ml. The drug was administered from the anode at a current strength of 0.05 to 0.15 mA / cm ² for 20-25 minutes.

The treatment was carried out in cycles of 5-7 procedures in 1-2 days, the interval between courses was 10-14 days.

After iontophoresis, the application or tamponade of the reconstructed nasal cavity with turundas soaked in fermencol gel is immediately applied (the transparent mass in 1 gram of gel contains 0.1 mg of the collagen complex) 3 times a day for 20 minutes.

The introduction of the drug does not require sterilization conditions and does not cause pain, since it itself reduces pain.

Contraindications to the iontophoresis procedure were: purulent-inflammatory processes, cardiovascular diseases, not perception by the body of a drug substance or galvanic current.

After the use of fermencol, there was a profound violation of tissue trophism in the area of interest in sick children with nasal septum contamination, it changes for the better, namely: adhesions and inflammation decrease, the scar tissue growth is suppressed when it is excessively formed, a significant part of trigger factors disappears the occurrence of synechia and cicatricial processes in the nasal cavity.

Thus, the method is based on the action of an enzymatic preparation, such as Fermenkol, from the dimexide medium, which includes digestive enzymes from the hepatopancreas of the king crab, in its collagenolytic activity significantly (from 3.9 to 7.6 times) exceeds the collagenases obtained from other sources, in addition, it dissolves and hydrolyzes the branched pathological collagen molecules with vortex and nodular folding of the extracellular matrix into individual amino acids and also exceeds these parameters t hyaluronidase, it also activates macrophages and fibroblasts, stimulate tissue regeneration. Fermencol is non-toxic, has a high selective activity. As a result of the destruction of excess collagen, the structure and water-electrolyte balance of scar tissue is restored.

Clinical example No. 1. Patient: Azimov T. Case history No. 648 \ 86. Date of birth: March 27, 2001 Date of receipt: 01/19/2016. Date of discharge: 01.25.2016.

Clinical diagnosis: Displaced nasal septum. The comb of the nasal septum on the right along the entire length with a violation of the function of the nose.

Concomitant diagnosis: Hypertrophy of the lower nasal concha. Left-sided sensorineural hearing loss of 4 degrees.

Complaints on admission to headache, difficulty in nasal breathing, constant nasal congestion, dependence on vasoconstrictive drops.

Anamnesis morbi: The child has been ill for several years. He received occasional treatment, with no visible effect.

Anamnesis vitae: a child from the first pregnancy, 1 urgent birth. Childbirth and pregnancy proceeded without features. It grows and develops according to age. Allergic history is not burdened. I didn’t have childhood infections. Viral hepatitis, tbc denies. It is registered with a pediatrician and an audiologist with a diagnosis of Chronic left-sided cochleoneuritis. Left-sided sensorineural hearing loss, IV degree.

Objective research data: the general condition of the child is satisfactory, clear consciousness, active position, sleep and appetite are preserved. Body temperature 36.6, height 170 cm, weight 51 kg. Consciousness is clear, conversational speech is saved. Moderate nutrition. The skin is clean. Peripheral lymph nodes are not enlarged. In the lungs, vesicular breathing, no wheezing. NPV = 20 in 1 min. Pulse = 86 in 1 min, satisfactory filling, rhythmic. The area of the heart is not visually changed. Heart sounds are clear, rhythmic. The tongue is wet, clean. The abdomen is soft, painless. The liver and spleen are not enlarged. Physiological administration is normal.

ENT status: Pharyngoscopy: Mucous pharynx pink, moist. Palatine tonsils are not enlarged, there are no pathological contents in the gaps, swallowing is painless, a small tongue along the midline.

Rhinoscopy: The outer nose is of the correct shape. The mucous membrane of the nose is pink, wet. The nasal septum is curved to the right, the crest of the nasal septum to the right throughout. The nasal concha are hypertrophied, after anemia they do not contract, there is no discharge in the nasal passages, breathing is difficult.

Otoscopy: AS AD-auricle of the correct form, the behind-the-ear region without features, in the NSP is dry, clean, MT is gray, the identification marks are clearly visible.

Examined: OAK dated 01/13/2016 St. Sukhorev St., Hb 136 g / l, Er 4.42 * 10 * 12, lake 6.8 * 10 * 9, trom 200 × 10 × 9, ESR 4 mm / h

OAM: from 01/13/2016: quantity, color - s / f, density - 1010, acidic reaction, protein-OTR, epithelium - units, white blood cells - 0.

Endoscopic examination of the nasopharynx 10/19/2016. Displaced nasal septum. Nasal septum crest on the right. Hypertrophy of the lower nasal concha.

Audiometry from 10/19/2016. Left-sided Senosoneural hearing loss of 4 degrees. There are no contraindications to the operation.

01/20/2016, Operation No. 39: Septoplasty. Under ETN + local anesthesia Sol. Ubestesini 4% N 2 at a dilution of 10.0 NaCl 0.9% - an incision was made at the anterior edge of the nasal septum on the left. Retreating 0.8 cm from the caudal region, the nasal septum is distinguished subperitoneally from the cartilage and subperiosteally from the inert skeleton on both sides. After detachment of the cartilage from mucoperichondria, in the caudal region, the vertical line of cartilage fracture with callous edges is clearly visible, which divided the quadrangular cartilage into two fragments, the cartilage is much larger than its bed, and does not fit between the sheets of mucoperichondria. The curved strip of cartilage in the lower part of the septum along the entire length was isolated and removed, remodulated. The wing of the bone crest of premaxilla is partially knocked down by a chisel. Remodulated cartilage in the lower section is laid in a bed. The leaves of mucoperichondria and mucoperioste are laid in place. Stitches on the wound. Front swab.

01/20/2016, Operation No. 40: Vasotomy of the lower nasal concha.

One day after the operation, anti-relapse treatment was carried out according to the claimed method.

During his stay in the hospital, his condition improved, nasal breathing restored, body temperature 36.6, no complaints. The postoperative period was uneventful.

Pharyngoscopy: The mucous pharynx is pink, wet. The palatine tonsils behind the palatine arches are not enlarged, there are no pathological contents in the gaps, swallowing is painless, a small tongue along the midline.

Rhinoscopy: The outer nose is of the correct form, the nasal mucosa is pink, moist. The nasal septum is in the midline, the nasal concha are reduced, the nasal passages are free, breathing is free, there is no discharge.

It is discharged in satisfactory condition.

Clinical example No. 2. Sick Dosanbekov Rakhat. The medical history No. 2010/276. Date of birth: September 6, 2001 Date of receipt: 02/23/2016. Date of discharge: 03/01/2016.

Clinical diagnosis: Displaced nasal septum. The nasal septum crest on the left with impaired nasal breathing. Concomitant diagnosis: Vasomotor rhinitis.

Complaints of admission to headache, difficulty in nasal breathing. Concerned about the constant congestion of the nose.

Anamnesis morbi: The child has been ill for several years. He received occasional treatment, with no visible effect. Anamnesis vitae: baby of 3 urgent births. Childbirth and pregnancy proceeded without features. It grows and develops according to age. Allergic history is not burdened. I didn’t have childhood infections. Viral hepatitis, tbc denies. Objective research data: the general condition of the child is satisfactory, clear consciousness, active position, sleep and appetite are preserved. Body temperature 36.6, height 190 cm, weight 58 kg. Consciousness is clear, conversational speech is saved. Moderate nutrition. The skin is clean. Peripheral lymph nodes are not enlarged. In the lungs, vesicular breathing, no wheezing. NPV = 19 in 1 min. Pulse = 85 in 1 min, satisfactory filling, rhythmic. The area of the heart is not visually changed. Heart sounds are clear, rhythmic. The tongue is wet, clean. The abdomen is soft, painless. The liver and spleen are not enlarged. Physiological administration is normal.

ENT status: Pharyngoscopy: Mucous pharynx pink, moist. Palatine tonsils are not enlarged, there are no pathological contents in the gaps, swallowing is painless, a small tongue along the midline.

Rhinoscopy: The outer nose is of the correct shape. The mucous membrane of the nose is pink, wet. The nasal septum is curved to the left due to the crest of the nasal septum on the left along the entire length in the bone section. The nasal concha are enlarged, do not contract after anemia, there is no discharge in the nasal passages, and breathing is difficult. Otoscopy of AS-AD the auricle of the correct form, the behind-the-ear region without features, in the NSP is dry, clean, MT is gray, the identification marks are clearly visible.

OAK surveyed on 02/18/2016 St. by Sukhorev, Hb 144 g / l, Er 5.16 * 10 * 12, lake 5.0 * 10 * 9, thromium 202 × 10 × 9, fallen, seg 60, eos, mon 7 , lymph 33, ESR 3 mm / h.

OAM: 02/18/2016: color - s / f, density - 1015, acidic reaction, protein - neg, epithelium - unit, white blood cells - 1-2.

LHC from 02/18/2016. Total protein 62.7 g / l, glucose m / mol, urea m / mol / l, ALT 20, ACT 31, creatinine, bilirubin total. - 20.9, straight 4.6, cholesterol, thymol sample units.

Coagulogram from 02/18/2016: Fibrinogen 3.1, prothrombin time 19.2, prothrombin index 91%, prothrombin ratio, ethanol test - neg, thrombin time 20.20, thrombotest V, APTT MHO 1.09, RFMK.

Surgical treatment recommended: septoplasty, vasotomy. There are no contraindications to the operation.

02/26/2016, Operation No. 175. Septoplasty: Under ETN + local Sol anesthesia. Ultracaini 2: 100000, N 10 an incision was made at the front edge of the nasal septum on the left. The nasal septum is exfoliated subperitoneally from the cartilage and oblique skeleton on both sides. The cartilage strip in the lower part of the septum was removed. The wing of the bone crest of premaxilla is partially hit by a chisel. The resected part of the septum is remodulated on a special fitting (crusher), laid in place. The leaves of mucoperichondria and mucoperioste are laid in place. Stitches on the wound. Front swab.

Operation No. 176: Vasotomy of the lower nasal concha.

One day after the operation, anti-relapse treatment was carried out according to the claimed method.

During his stay in the hospital, his condition improved, nasal breathing restored, body temperature 36.6, no complaints. The postoperative period was uneventful.

Rhinoscopy: The outer nose is of the correct form, the nasal mucosa is pink, moist. The nasal septum is in the midline, the nasal concha are reduced, the nasal passages are free, breathing is free, there is no discharge

It is discharged in satisfactory condition. Outcome: recovery.

Clinical example No. 3. Patient: Suvorov T. Case history No. 2619/384. Date of birth: born on April 6, 2000 Date of receipt: 03.16.2015. Date of discharge: 03/21/2015.

Clinical diagnosis: Post-traumatic deformity of the nasal septum. The nasal septum crest on the left along the entire length with impaired nasal function.

Concomitant diagnosis: Hypertrophy of the lower nasal concha.

Complaints upon receipt of a headache, difficulty in nasal breathing, are worried about the constant nasal congestion.

Anamnesis morbi: The child has been ill for several years. He received occasional treatment, with no visible effect.

Anamnesis vitae: a child from the first pregnancy, 1 urgent birth. Childbirth and pregnancy proceeded without features. It grows and develops according to age. Allergic history is not burdened. I didn’t have childhood infections. Botkin's disease, tbc denies. Objective research data: the general condition of the child is satisfactory, clear consciousness, active position, sleep and appetite are preserved. Body temperature 36.7, height 175 cm, weight 68 kg. Consciousness is clear, conversational speech is saved. Moderate nutrition. The skin is clean. Peripheral lymph nodes are not enlarged. In the lungs, vesicular breathing, no wheezing. NPV = 19 in 1 min. Pulse = 85 in 1 min, satisfactory filling, rhythmic. The area of the heart is not visually changed. Heart sounds are clear, rhythmic. The tongue is wet, clean. The abdomen is soft, painless. The liver and spleen are not enlarged. Physiological administration is normal.

ENT status: Pharyngoscopy: Mucous pharynx pink, moist. Palatine tonsils are not enlarged, there are no pathological contents in the gaps, swallowing is painless, a small tongue along the midline.

Rhinoscopy: The outer nose is of the correct shape. The mucous membrane of the nose is pink, wet. The nasal septum is curved to the left, the thorn of the nasal septum to the left, the dislocation of the quadrangular cartilage. The nasal concha are enlarged, after anemia they do not contract, the mucous membrane that is separated in the nasal passages, breathing are difficult.

Otoscopy_ AS - AD-auricle of the correct form, the behind-the-ear region without features, in the NSP is dry, clean, MT is gray, the identification marks are clearly visible.

OAK surveyed on March 12, 2015 St. Sukhorev (4.15), Hb 145 g / l, Er 4.6 * 10 * 12, lake 5.9 * 10 * 9, trom 324 × 10 × 9, pal 2, seg 50, eoz 1, mon 8, lymph 39, ESR 3 mm / h

OAM: dated 12.03.2015: amount 60.0, color s / f, density 1015, acidic reaction, protein otr, epithelium 0-1 units, white blood cells 2-3.

Endoscopic examination of the nasopharynx 01/22/2015. Displaced nasal septum. Nasal septum crest on the right. Hypertrophy of the lower nasal concha.

Recommended surgical treatment: septoplastic, vasotomy. There are no contraindications to the operation.

03/17/2015 g Operation No. 213 Septoplasty. Under ETN + local anesthesia Sol. Ubestesini 4% × N 5 at a dilution of 5.0 Na Cl 0.9% incision was made at the front edge of the nasal septum on the left. Retreating 1.0 cm from the caudal region, the nasal septum is distinguished subperitoneally from the cartilage and the bony skeleton on both sides. The curved strip of cartilage in the lower part of the septum along the entire length was isolated and removed, remodulated. The wing of the bone ridge is partially knocked down by a chisel. Remodulated cartilage in the lower section is laid in a bed. The leaves of mucoperichondria and mucoperioste are laid in place. Stitches on the wound. Front swab.

03/17/2015. Operation No. 214. Vasotomy of the lower nasal concha. Under ETN + local anesthesia of Sol. Ubestesini 4% × N 5 at a dilution of 5. With Na O 0.9% - ml, the anterior end of the inferior nasal turbinate was cut. Raspator produced detachment of the mucosa from the bone skeleton of the anterior tamponade.

One day after the operation, anti-relapse treatment was carried out according to the claimed method.

During his stay in the hospital, his condition improved, nasal breathing restored, body temperature 36.6, no complaints. The postoperative period was uneventful.

Rhinoscopy: The outer nose is of the correct form, the nasal mucosa is pink, moist. The nasal septum is in the midline, the nasal concha are reduced, the nasal passages are free, breathing is free, there is no discharge.

It is discharged in satisfactory condition.

The claimed method was treated 15 patients with deformation of the nasal septum. A good therapeutic effect was obtained: the degree of severity of the inflammatory process was reduced, the inhibition of the development of a progressive inflammatory process, the decrease in adhesions, the normalization of immunological parameters. These measures led to the elimination of inflammatory processes in the nasal cavity after surgery.

In all patients treated with the proposed method, complications were not observed.

Claims (5)

1. A method for the prevention of complications in the postoperative period during surgical treatment of deformation of the nasal septum in children, in which the toilet of the nasal cavity is produced in the postoperative period, then the cavity is rinsed with octenisept solution in dilution with distilled water in a volume ratio of 1: 7, after which endonasal iontophoresis is performed using fermencol, after iontophoresis, tamponade of the reconstructed nasal cavity is used with turundas soaked in fermencol gel. 2. The method according to p. 1, characterized in that the fermencol is diluted with solactin to a solution concentration of 0.1-1.0 mg / ml. 3. The method according to p. 2, characterized in that the solution is injected from the anode at a current strength of 0.05 to 0.15 mA / cm ² for 10-15 minutes. 4. The method according to p. 3, characterized in that the electrophoresis treatment is carried out in cycles of 5-7 procedures in 1-2 days, the interval between courses is 10-14 days. 5. The method according to p. 1, characterized in that the tamponade of the reconstructed nasal cavity with turundas soaked in fermencol gel is carried out for 20 minutes.