RU2632783C1 - Method for external nasal valve formation in children after cheil-urano plasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: hydro-preparation of mucoperichondrium and mucoperiost all the entire length using a proprietary technology, in 3 points. The first endonasal linear section of the cutaneous part of the nasal septum is made on the cleft side. An acute raspatory is used to cut off the mucoperichondrium and mucoperiost from both sides. The passage to the other side of the septum is carried out through its caudal section. A revision of the lower wall of the cartilaginous and bony parts of the nasal septum is performed. The quadrangular cartilage is completely isolated along its entire length, then resected. If there is a curvature of premaxilla and bony parts of the nasal septum, the curved structures are removed. The mucoperiost is separated according to the orientation of the anterior nasal spine. The removed quadrangular cartilage is mobilized, restored to the condition of a flat plate, perforated over the entire surface for additional fixation under the mucoperichondrium and mucoperiost and rigidity. Then the cartilage is reimplanted with chondroinverse of 180° to avoid repeated deformation due to the presence of the "cartilage memory" effect. From the quadrangular cartilage remains, after restoration, a column is formed, which is implanted into the caudal part of the septum between the medial legs of the lower lateral cartilages. The medial legs are aligned and fixed to the columnt with a suture. The mucosa is put in place and stitched. The surgery is terminated with nasal tamponade.

EFFECT: method allows to restore the nose valve, intranasal structures by endonasal access, which is a less traumatic operation and excludes postoperative complications in children.

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Description

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

Reconstruction of the external nose and intranasal structures is one of the most difficult problems in reconstructive surgery of the head and neck.

The treatment of children with congenital malformations of the maxillofacial region, namely cleft upper lip and cleft palate, is being improved and modified. It is known that in recent years, both domestic and foreign authors, in an effort to reduce the influence of factors that impede the harmonious and physiological development of the facial skeleton as a whole, tend to restore early the structure and functions of organs close to physiological. It is proved that the expectant tactics of reconstructive operations with cleft upper lip and palate leads to increased deformation of the middle zone of the face and affects the psychoemotional status of the child. The developed methods of surgical correction are aimed at eliminating the cleft lip, palate and much attention is paid to the correction of deformation of the nose. Although there is no consensus on the volume of surgical intervention and the timing of the operation. Most surgeons believe that correction should be carried out at the age of 3 months, some authors perform operations in the first days of a newborn’s life. Depending on the type of congenital clefts of the upper lip and palate (hidden, incomplete, complete), the volume of surgical intervention is divided into: cheiloplasty, rhinocheiloplasty, rhinocheilognoplasty. Cheiloplasty is performed with hidden and incomplete clefts, in this case, the deformation of the nasal valve is insignificant, the need for this operation to restore the circular muscle of the mouth, affecting the further formation of the middle part of the facial skeleton and nasal valve. Modern methods of surgical treatment include both simultaneous correction of crevices and interventions on the cartilaginous parts of the structures of the nose. A significant number of surgical interventions are known, but after reconstructive operations, complications can be observed in the future. For example, such as: flap insolvency, naso-oral fistulas, severe scarring, which often leads to deterioration of nasal breathing, insufficiently formed angle of the nose valve, lack of "height of the nose tip", lability of the lateral wall of the nose valve, leading to collapse. Of course, the management of such patients is very laborious and painstaking work, first of all it is associated with dysbiotic disorders in the first days of the birth of the child. Therefore, special attention is required when managing a child within the specified time period 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. It is also necessary to take into account: the volume of defects, the degree of violation of the functions of the nose, the level of the immunological status of the body, the condition of the soft tissues and circulatory disorders in the pathological area, the activity of the adrenal glands, the level of concentration of hormones in the blood, and much more.

There are many methods for surgical correction of the nasal valve in children with cleft lip and palate, for example:

1. K. Saiyer (1992, 2001), as well as H.K. MeComb and B.A. Coghlan (1996) A method for rhinocheyloplasty.

2. H.S. Byrd and J. Salomon (2000) a rhinoplasty technique.

3. V.A. Vissarionov (1989) a method of chelorinoplasty.

However, these methods have their drawbacks, since all these methods are produced by open access.

The closest analogue of the invention is the "Method of reconstructive rhinoplasty with congenital unilateral cleft of the upper lip" patent RU 2393795 12/03/2008. In this way, secondary rhinoplasty is performed in patients after treatment of congenital unilateral cleft of the upper lip, which require repeated corrective operations. The method consists in conducting open rhinoplasty. In this case, the lateral pedicle and arch of the large wing cartilage on the cleft side are mobilized. They mobilize the skin and mucous membrane anterior to the incision in the area of the arch of the nostrils and the edges of the crest-shaped folds, forming a mucocutaneous pocket. Align the position and length of the medial pedicle due to sequential fixation from the bottom up with the medial pedicle of the healthy side based on the supporting cartilage graft. The lateral leg of the large cartilage of the wing of the nose is moved to a position symmetrical with the opposite side in the formed skin-mucous pocket, after which it is fixed to the nasal lining. The disadvantages of this method is open rhinoplasty.

To address these shortcomings, we propose a method for forming the external nasal valve in children after cheylouranoplasty.

The technical result of the present invention is the use of less traumatic endonasal access for the formation of intranasal structures, the creation of a support frame for the nose tip, strengthening the lateral wall of the nasal valve, thereby restoring the correct anatomy of the nasal valve, and postoperative complications are eliminated, and a good aesthetic effect is also achieved.

The method is as follows.

The first stage is an infiltration anesthesia and simultaneous hydropreparation of mucoperichondria and mucoperioste throughout the nasal septum. The first injection of the anesthetic solution is done at the point of contact of the medial legs of the wing cartilage and the caudal part of the nasal septum, at the level of the lower third of the columella, for this we use a needle from a single-cube syringe. The anesthetic solution is distributed simultaneously in the mucoperioste of both halves of the nasal septum, while mucoperichondria is separated and the tip of the nose rises, which improves visual control in the nasal cavity, facilitating the further work of the surgeon. For infiltration anesthesia, we use a 0.5% solution of novocaine with the addition of 2-3 drops of adrenaline per 40 ml. Children over 4 years old also use articaine with adrenaline, calculating the dose of the solution depending on the age and body weight of the child. The first injection takes about 5 to 10 ml of the solution.

The second injection is done on the eve of the nose in the area of transition of the skin part of the nasal septum into the mucosa at the level of 1/3 of the height of the caudal part of the nasal septum from the cleft side, possibly moving deeper. Also leaves from 5 to 10 ml of solution.

The third injection is carried out similarly to the second, but on the opposite side of the nasal septum.

I would like to take into account several points: in a unilateral process on the cleft side, after uranoplasty, it is necessary to be careful to exclude perforation of the lower wall of the nasal cavity. In a one-way process, the vestibule of the bottom of the nasal cavity on the healthy side is used as the fourth injection point. the lower wall of the nasal cavity there is whole, "healthy".

The first endonasal linear vertical incision is made on the skin section of the nasal septum on the cleft side, the incision line begins at a level of 1-2 mm, departing from the upper part of the nasal septum to the lower edge of the nasal septum, not reaching the bottom of the nasal cavity. With a sharp raspator, mucoperichondria and mucoperiosts are separated throughout on both sides, with the transition to the other side of the nasal septum through its caudal section. It should be noted that the separation of the mucoperiost should be carried out according to the landmark of the anterior nasal spine. In this case, it is necessary to revise the lower wall and the presence of cartilage and bone of the nasal septum. A complete selection of the quadrangular cartilage is made throughout, then its resection. To eliminate the saddle deformation of the nose, a strip of cartilage is left in the upper section, parallel to the back of the nose, 2-5 mm in size. If there is a curvature of premaxilla and bone structures, then they are accurately knocked down with a hammer and chisel. In rare cases, there is a coulter deformity, in which it is resected along the lower edge, followed by passive redress, according to the anatomical and physiological characteristics of the child's body. The removed quadrangular cartilage is mobilized, restored to the state of a flat plate, perforated over the entire surface for additional fixation. Perforation is carried out using a cartilage graft perforator described, for example, in RF patent No. 2215490. Rigid cartilage is reimplanted under mucoperichondria and a mucoperiost with 180 ° chondroinversion to avoid re-deformation due to the presence of the "cartilage memory" effect. After restoration, a column is formed after restoration of the cartilage, which is implanted in the caudal section of the nasal septum between the medial legs of the wing cartilage. The length of the column corresponds to the length of the columella, a height of 3-4 mm and a width of 2-3 mm. If the width is not sufficient, then we thicken the column by connecting the two plates of the auto-cartilage using sutures. The medial legs are aligned and fixed to the column with a suture, proline 2/0, 3/0 thread is used. The mucosa is put in place. Sutures are made on the incision; for this, the vikril thread is used from 3/0 to 5/0, and the vikril rapid is 3/0.

The second linear incision is made at the level of the lower 1/3 of the lateral wall of the nasal valve between the cartilages, along the edge of the pear-shaped opening, thereby accessing the lateral leg of the wing cartilage. Before the incision, infiltration anesthesia is performed using the above solution at the site of the proposed incision. To strengthen and form the lateral wall of the nasal valve, another column is installed, in the formed bed below and medial to the lateral leg of the wing cartilage (Fig. 1). The shape of the column is modeled in accordance with the dimensions of the lateral pedicle of the wing cartilage of the opposite side. If there is a lack of auto-cartilage of the nasal septum, material is taken from the auricle or tragus. A seam is applied to the incision. Vicryl from 3/0 to 5/0, as well as vicryl rapid 3/0, are used as suture material. In both nasal passages latex glove tampons, lubricated with antiseptic ointment, are installed, while on the side where the nose valve was corrected, two tampons are installed (one in the middle nasal passage, the other short in the vestibule of the nose, to maintain the newly formed lateral wall of the nasal valve). Apply a splint on the nose, fasten with a sling bandage. On the second day, tampons change. On the 4th day after surgery, tampons are removed. A toilet of the nasal cavity is carried out.

Clinical example No. 1: Child G., 6 years old, was in DGKB them. G.N. Speransky from 06/03/14. on June 11, 2014, according to the mother: complaints of deformation of the external nose, constant difficulty in nasal breathing on the right, and lack of nasal breathing on the left, nasal, periodic hearing loss in both ears. Objectively: the shape of the external nose is changed due to the narrowing of the external nasal valve (scar tissue) with its lowering down and back, with retraction and displacement of the tip of the nose to the left. When rhinoscopy: on the left at the vestibule of the nose there is a postoperative scar. The mucous membrane of the nose is pink, a small amount of mucous discharge. The nasal septum is S-shaped. The nasal concha are enlarged, contracting well with anemia. To the right of the vestibule, the caudal part of the quadrangular cartilage (subluxation) is determined, which practically obstructs the lumen of the internal valve of the nose. The mucous membrane of the nose is pink, in the nasal passages there is a small amount of mucous discharge. Breathing is more difficult on the left.

Diagnosis: "Multiple malformations. Congenital deformation of the external nose and nasal septum, anomaly in the development of intranasal structures. Condition after chelorinoplasty from 2008, uranoplasty from 2009. " 06/04/2014 under ETN + TBVA performed: rhinoseptoplasty with simultaneous bilateral vasotomy. The formation of the left nasal valve according to the proposed method. No complications. Merocel swabs impregnated with synthomycin emulsion are installed on both sides. On the left under the lateral wall of the nasal valve is a latex, glove swab impregnated with a synthomycin emulsion. Tampons on the 2nd day are replaced. On day 4, tampons are removed. The child in satisfactory condition was discharged home. The child was performed: anterior active rhinomanometry, acoustic rhinometry before surgery, after surgery. The child was followed by follow-up after 3 months, six months, a year. The functional and aesthetic result has improved.

Clinical example No. 2 Child M. 11 Patient G. was in FGBU NUKTSO 1 children's department from 12/18/14. on 12.26.14. According to the guardian, complaints of nasal congestion, difficulty in nasal breathing, deformation of the external nose, and nasal nausea. Objectively: the shape of the external nose is changed due to a cicatricial change in the lower wall of the vestibule of the nose, with the retraction of the lateral wall of the valve of the nose on the left, deformation of the caudal region 4 of the coal cartilage on the left. With rhinoscopy: the nasal mucosa is pale pink. The nasal passages are narrowed, more to the left, due to a dislocation of the 4-sided cartilage that obstructs the common nasal passage. Mucous discharge in the nasal passages. The lower and middle nasal edema, with anemia, contract well. Their mucous membrane is pale pink. The nasal septum is curved in the form of a book, the crest is all the way to the right. The absence of cartilage and bone skeleton of the nasal septum. The area of the sinuses is not changed, percussion and palpation of the PPN projection is painless. Nasal breathing is difficult, more to the left.

Diagnosis: "Multiple malformations. Deformation of the external nose and nasal septum with a violation of the function of the nose, S-shaped curvature in the cartilage and bone. Crest all over to the right. Condition after rhinocheiloplasty from 2007, uranoplasty from 2008. ". 12/19/2014 under ETN + TVVA conducted: rinoseptoplasty. The formation of the left nasal valve according to the proposed method. No complications. Merocel swabs impregnated with synthomycin emulsion are installed on both sides. On the left under the lateral wall of the nasal valve is a latex, glove swab impregnated with a synthomycin emulsion. Tampons on the 2nd day are replaced. On day 4, tampons are removed. The child was performed: anterior active rhinomanometry, acoustic rhinometry before surgery, after surgery. The child in satisfactory condition was discharged home. The child was followed by follow-up after 3 months, six months, a year. The functional and aesthetic result has improved.

The proposed method was treated 26 patients after surgery to restore the external nose, nasal valve and nasal septum. When implementing this method, patients received a good functional and aesthetic effect: improved performance of the nose, namely nasal breathing, as a result of this, intranasal structures (nasal concha) were restored. When breathing, the lateral wall does not sink (collapse was excluded). Restored columella, gave the tip of the nose support. A positive aesthetic effect was also obtained (symmetrical external valve of the nose Fig. 2). The proposed method allows to restore the nasal valve, intranasal structures using endonasal access, which is a less traumatic operation and eliminates postoperative complications.

Claims (1)

A method of forming the external nasal valve in children after cheylouranoplasty, including performing infiltration anesthesia, the first injection of the anesthetic solution being made at the point of contact of the medial legs of the wing cartilage and the caudal part of the nasal septum, at the level of the lower third of the columella, the second injection is made in anticipation of the nose in the transition area the skin part of the nasal septum into the mucosa at the level of 1/3 of the height of the caudal part of the nasal septum from the cleft, possibly moving deeper, the third injection is carried out similarly to the second, but on the opposite side of the nasal septum, as the fourth injection point, the vestibule of the bottom of the nasal cavity is used on the healthy side, then the first endonasal linear vertical incision is made of the skin section of the nasal septum on the cleft side, the cut line starts at level 1-2 mm departing from the upper part of the nasal septum to the lower edge of the nasal septum, not reaching the bottom of the nasal cavity, the mucoperichondria and mucoperiost are separated with a raspator throughout sides, the transition to the other side of the nasal septum is carried out through its caudal section, the lower wall is revised and the presence of the cartilaginous and bone parts of the nasal septum is determined, the quadrangular cartilage is completely isolated throughout, then its resection, the removed quadrangular cartilage are mobilized, restored until the plate is flat, perforated over the entire surface and reimplanted under mucoperichondria and mucoperiost with 180 ° chondroinversion, from the remains of the quadrangular cartilage after restoration radios, form a column that is implanted in the caudal part of the nasal septum between the medial legs of the wing cartilage, the length of the column corresponds to the length of the columella, the medial legs are aligned and fixed to the column with a suture, the mucous membrane is laid in place, a second linear incision is made on the cleft side at the level of the lower 1 / 3 lateral wall of the valve of the nose between the cartilages, along the edge of the pear-shaped opening, thereby accessing the lateral leg of the wing cartilage, before the incision, an infiltration anesthesia is performed in m then the mucoperichondria are steeped and another column is inserted into the lateral wall of the nasal valve, into the formed bed below and medial to the lateral leg of the wing cartilage, the shape of the column is modeled in accordance with the dimensions of the lateral leg of the wing cartilage of the opposite side, stitch the cuts in both nasal passages are installed latex glove tampons, lubricated with antiseptic ointment, while on the side where the nose valve was corrected, two tampons are inserted, the mouth avlivayut splint, sling bandage applied to the bow, on the second day and change tampons were removed at 4 hours after the operation, after that carried toilet nasal course of 10 days.

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