RU2636854C1 - Method for post-operative period management for patients with open injuries of nose skeleton - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: primary surgical treatment of wounds of the external nose and elimination of post-traumatic deformations of the osseous cartilaginous skeleton of the external nose and its cavity are performed. From the second day of the postoperative period, the wound area of the external nose is treated daily with Bepanten® plus cream, which is applied twice a day for 6-10 days before the onset of the stage of scar formation and reorganization. With the onset of this phase, laser cutting with Kontraktubeks gel is carried out for 7 days using a continuous technique in a continuous mode with a power of 10-15 mW in the area of cutaneous wounds. Exposure time is 1.5 min per point. Total exposure time is 4.5-6 min. From the fourth day of the postoperative period within 5 days, endonasal laser therapy is performed in the red range, in a pulse mode with a power of 5 W for 1.5 minutes in each half of the nasal cavity.

EFFECT: method reduces the frequency of scar deformations in the external nose due to prevention of excessive scarring, elimination of inflammation and stimulation of regeneration.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used for the postoperative period in patients with an open nasal skeleton injury.

Injuries to the nose make up a significant share in the structure of the population’s urgent care and may be accompanied by profuse nosebleeds, damage to vital facial structures, infection of wounds, which requires quick intervention by a specialist. The number of victims of nose injuries in modern conditions is not decreasing and this is most often associated with everyday situations and manifestations of increased aggressiveness of the population, road accidents, and accidents (Gorinov V.V., 2010). The outcome of traumatic injuries of the nose largely depends on the timely and proper organization of care for this group of victims, adherence to a rational algorithm for the diagnosis and treatment of specific traumatic injuries (Volkov A.G., Gyusan A.O., 2013; Volkov A.G., 2014). A particular problem is patients with open injuries of the nasal skeleton due to the presence of damage to the skin.

The healing of skin wounds is a complex multi-stage process, including physiological, biochemical and cellular reactions. An undoubted factor at the present time is that in the case of adequate local treatment, rough pathological scars do not form.

Among the drugs that are used to treat and prevent skin scarring, glucocorticoids, which are injected or physiotherapeutic methods, are widely used. Of this group of drugs, triamitionolone occupies a prominent place, which has poor solubility and, as a result, remains at the injection site for a long time. However, it was proved that its excessive and uneven administration leads to poor cosmetic results: the dermis is thinning.

Treatment aimed at removing excess extracellular matrix is carried out mainly by introducing a variety of enzymes into the tissues. The well-known “Method for the treatment and prevention of the development of hypertrophic and keloid scars” (A.S. RU 2220741; 2004), which consists in the fact that the patient is simultaneously administered lidase into the thickness of the scar or scar tissue in a therapeutic dose depending on size, depth and the duration of the lesion and collagenase by the method of electro- (phono-) phoresis on the scar area in the average therapeutic dose. The course of treatment is 10-15 daily procedures. However, the disadvantages of this method is the duration and low effectiveness of treatment due to the isolated effects on the elements of scar tissue, frequent relapses. In addition, this method uses an invasive technique for injecting the drug, which can additionally provoke the development of scar tissue.

A prototype is known - the method of using Kontraktubeks gel in the complex treatment of cicatricial deformations of the middle zone of the face (Gerasimenko M.Yu., Filatova E.V., Stuchilov V.A. et al. Laser phoresis with Kontraktubeks gel in the complex treatment of cicatricial deformities / Consilium medicum. Surgery. - 2008. - No. 1. - P. 82-85.) This technique involves the cutaneous application of laser phoresis with 10mW Contractractube gel at the output of the fiber, for 5 minutes, 5 daily procedures, and with the aim of a reflex increase in blood circulation in the orbit and central nervous system endonasal laser phoresis yes nny drug. However, the claimed prototype has a drawback, which is reported by the authors themselves, namely that the conduct of endonasal laser phoresis by Kontraktubeks gel in the acute period of trauma does not change the blood supply in the nasal cavity, which ultimately slows down the reparative process, and thereby prolongs the recovery time of the functional state nasal cavity. In addition, in the official annotation of the Kontraktubeks gel in the dosing section, it is indicated that to prevent the development of hypertrophic and keloid scars, it is necessary to use the phase after wound epithelialization (do not apply to granulation) (http://www.vidal.ru/drugs/contractubex_2260). Thus, the use of this drug in the first 7 days from the moment of injury is impossible.

The inventive method of introducing the postoperative period in patients with an open nasal skeleton injury is new and is not described in the literature.

The present invention aims to reduce the incidence of cicatricial deformities in the outer nose by preventing excessive scarring, eliminating inflammation and stimulating regeneration.

The specified technical result in the invention is achieved by the fact that from the second day of the postoperative period after the initial surgical treatment of the wounds of the external nose and the elimination of post-traumatic deformities of the osteo-cartilaginous skeleton of the external nose and its cavity, the Bepanten® plus cream is applied daily, which is applied twice per day for 6-10 days before the onset of the scar formation and reorganization phase, and laser phoresis with Kontraktubeks gel is carried out with the onset of this phase on the area of skin wounds for 7 days according to the distant method in a continuous mode with a capacity of 10-15 mW, the exposure time for one point is 1.5 minutes, the total exposure time is 4.5-6 minutes, and from the fourth day of the postoperative period within 5 days spend

endonasal laser therapy in the red range pulsed with a power of 5 W for 1.5 minutes in each half of the nasal cavity.

The developed method for managing the postoperative period in patients with an open nasal skeleton injury differs from the prototype in the following positions:

- laser phoresis with Kontraktubeks gel starts no earlier than 7 days after a nasal skeleton injury, which corresponds to the phase of scar formation and reorganization (Classification of the phases of the wound process according to M.I. Kuzin (1977)) taking into account the size of the wounds and structural features of the skin of the external nose;

- in order to eliminate inflammation and stimulate regeneration in the area of wounds of the external nose, from the second day after the injury, a daily double treatment of the wound area with Bepanten® plus cream is prescribed for 6-10 days. The processing time directly depends on the onset of the phase of formation and reorganization of the scar in a particular patient and, as a rule, is associated with the size of the wound and the regenerative capabilities of the epithelium of the victim;

- the developed method includes endonasal laser therapy in the red range, in a pulsed mode with a power of 5 W, given its proven effectiveness in the postoperative period in patients with injuries of ENT organs (Nasedkin A.N., Moskvin S.V. Laser therapy in otorhinolaryngology. - M. - Tver: LLC Triad Publishing House, 2011. - S. 162-164).

The choice of cream for external use Bepanten® plus is due to the fact that this drug has antimicrobial, anti-inflammatory and improves tissue regeneration action. The drug reduces pain due to the cooling effect. When applied to the surface of the wound, it protects against infection, promoting healing (http://www.vidal.ru/drugs/bepanthen_plus_6796).

The main active ingredient of Bepanten® Plus cream is dexpanthenol or provitamin B5, in the body it turns into pantothenic acid and participates in metabolic processes as a coenzyme. The mechanism of action of pantothenic acid is based on the normalization of metabolism in skin cells, which helps to increase the strength of collagen fibers. The result of improved metabolism is the stimulation of tissue repair. Bepanten® plus chlorhexidine dihydrochloride, which is part of the cream, is an antiseptic that has a bactericidal effect against gram-positive bacteria, especially sensitive strains of Staphylococcus aureus, that is, those microorganisms that are most often associated with skin infections due to traumatic injuries.

The duration of use of Bepanten® plus cream depends on the timing of the phase of tissue regeneration, which is associated with collagenization of the wound and the intensive growth of blood and lymph vessels with the formation of granulation tissue. As a rule, the regeneration phase in the area of the external nose proceeds within 6-10 days.

Laser phoresis and endonasal laser therapy can be performed in any physiotherapeutic department, which has a laser therapy apparatus that generates radiation from the red part of the optical spectrum in continuous and pulsed modes.

In our study, the treatment was carried out using the Matrix laser therapeutic device. For laser phoresis, the KLO3 emitting head was used, and for endonasal laser exposure, the KLO2 emitting head with the L-1-2 nasal nozzle was used.

The scheme of laser therapy (regimen, power, total exposure time, duration of treatment) is based on the optimization of laser therapy for diseases of the ear, nose and throat (Nasedkin A.N., Zenger V.G., 2000).

The exposure time per biological field is 1.5 minutes. This exposure duration was selected based on the work carried out by Professor A.N. Nasedkin. et al., who showed the leading role of calcium ions in triggering the primary mechanisms of therapeutic action of low-intensity laser radiation and the associated optimal exposure time intervals (Nasedkin AN, Moskvin SV Laser therapy in otorhinolaryngology. - M. - Tver: LLC "Publishing house" Triad ", 2011. - S. 175-176).

Endonasal laser therapy should be started from the fourth day after the surgical treatment due to the fact that in the first three days of the postoperative period, patients with septoplasty have gauze swabs or stents in the nose to stop nosebleeds and fix the nasal septum in the middle position, and also to prevent the formation of postoperative hematomas, as a result of which it is technically impossible to carry out any intranasal manipulations in the first three days. After stent removal (3 days postoperative period), any intranasal interventions are possible.

The proposed method for managing the postoperative period in patients with an open nasal skeleton injury has been used since May 2013 in the conditions of the Astrakhan branch of the Federal Scientific and Clinical Center for Otorhinolaryngology of the FMBA of Russia and the ENT department of the Alexander Mariinsky Regional Clinical Hospital in Astrakhan and was tested on 57 patients. It has been clinically proven that the proposed method allows to reduce the time of convalescence in patients with an open nasal skeleton injury by 5-8 days, as well as to reduce the incidence of cicatricial deformities in the outer nose by preventing excessive scarring, eliminating inflammation and stimulating regeneration.

Below are the results of testing.

Example No. 1.

Patient K., born in 1974, was admitted to the clinical department of the Astrakhan branch of the Scientific and Clinical Center of Otorhinolaryngology of the FMBA of Russia on September 17, 2014 with the diagnosis: “Open fracture of the nasal bones with displacement. Post-traumatic deformity of the nasal septum. " Complaints about the deformation of the external nose, the presence of a bleeding wound in the nose, difficulty in nasal breathing, a single nosebleed. He considers himself ill for about 3 hours, when he received a household injury while working on a garden plot. Objectively: the external nose is deformed due to rhinolordosis. Palpation in the nose is painful. The presence of crepitation of bone fragments is noted. On the back of the nose there is a bleeding laceration 3 cm long, its edges are uneven. The mucous membrane of the nasal cavity is edematous, hyperemic. In the nasal passages, a moderate amount of mucous-hemorrhagic discharge. The nasal septum is deflected to the left. Endoscopy of the nasal cavity - the mucous membrane is hyperemic, edematous. In the nasal passages, a moderate amount of mucous-hemorrhagic discharge. A sharp deviation of the cartilaginous and skeletal part of the nasal septum to the left was noted, in the anterior third its bone spike deforming the lower nasal concha. On a computed tomogram of the nasal bones dated September 17, 2014, a fracture of the nasal bones with a shift was noted. Other ENT organs without features.

After a clinical and laboratory examination on an emergency basis, on September 17, 2014, a patient undergoing local anesthesia underwent primary surgical treatment of the wound of the nose area with suturing, reposition of the nasal bones and septoplasty.

From the second day after the surgical allowance (September 18, 2014), the patient was subjected to daily double treatment of the wound area of the external nose with Bepanten® plus cream, followed by an aseptic dressing. On the third day after the operation (September 20, 2014), tamponade of the nasal cavity was removed. Objectively: the nasal septum in the middle position, in the nasal cavity pronounced swelling of the mucous membrane with a small amount of mucous-hemorrhagic discharge. From the fourth day after the surgical manual (09/21/2014), the patient received endonasal laser therapy in the red range for 5 days on a pulsed regime with a power of 5 W for 1, 5 minutes in each half of the nasal cavity every 5 days. It was noted that by the fourth procedure, swelling of the mucous membrane of the nasal cavity was significantly reduced, which was noted by the patient as a sharp improvement in nasal breathing.

On the 7th day after PHO, the wounds of the external nose, the sutures were removed. It was noted that the edges of the wound are dry, epithelized, with no signs of inflammation. In this connection, the treatment of the wound with Bepanten® plus cream was discontinued, and laser phoresis with Contractubex gel was started for 7 days using the distant technique in a continuous mode with a capacity of 10 mW, exposure time per point was 1.5 minutes, and the total exposure time was 4.5 minutes

The postoperative area was assessed daily. It was noted that already by the 5th laser phoresis procedure, complete epithelization of the edges of the wound of the external nose was objectively recorded, there were no signs of inflammation and pain symptom.

During dynamic observation of the patient for 1.5 years, it was noted that a normotrophic scar formed on the site of the existing external nose wound, which is invisible and does not rise above the surface of the skin, thereby not causing emotional discomfort for the victim.

Example No. 2.

Patient A., born in 1967, was admitted to the clinical department of the Astrakhan branch of the Scientific and Clinical Center of Otorhinolaryngology of the FMBA of Russia on March 9, 2015 with a diagnosis of “Open fracture of the nose with displacement. Post-traumatic deformity of the nasal septum. "

Complaints of deformation of the external nose, difficulty in nasal breathing, single nosebleed. He considers himself sick for about a day, when during a fight he received a blow to the nose. Objectively: the external nose is deformed due to rhinoscoliosis. Palpation in the nose is painful. The presence of crepitation of bone fragments is noted. On the right slope of the nose wing there is a laceration 4.5 cm long, covered with a dry hemorrhagic crust. The mucous membrane of the nasal cavity is edematous, hyperemic. In the nasal passages, a moderate amount of mucous-hemorrhagic discharge. The nasal septum is S-shaped. Endoscopy of the nasal cavity - the mucous membrane is hyperemic, edematous. In the nasal passages, a moderate amount of mucous-hemorrhagic discharge. A sharp S-shaped deviation of the cartilaginous and bone parts of the nasal septum was noted. On a computer tomogram of the nasal bones dated March 9, 2015, a broken nasal bone fracture was noted. Other ENT organs without features.

After a clinical and laboratory examination on an emergency basis, on 09.03.2015, the patient undergoing local anesthesia underwent primary surgical treatment of the wound of the nose area with suturing, reposition of the nasal bones and septoplasty.

Starting from the second day after the surgical manual (03/10/2015), the patient was treated twice daily with the Bepanten® Plus cream and the subsequent application of an aseptic dressing. On the third day after the operation (03/12/2015), tamponade of the nasal cavity was removed. Objectively: the nasal septum in the middle position, in the nasal cavity pronounced swelling of the mucous membrane with a small amount of mucous-hemorrhagic discharge. From the fourth day after the surgical manual (03/13/2015), the patient received endonasal laser therapy in the red range for 5 days with a pulse power of 5 W for 1, 5 minutes in each half of the nasal cavity daily for 5 days. It was noted that by the fifth procedure, swelling of the mucous membrane of the nasal cavity was significantly reduced, which was noted by the patient as a sharp improvement in nasal breathing.

On the 7th day after PHO, the wounds of the external nose, the sutures were removed. It was noted that the wound edges are dry, but somewhat hyperemic and edematous, and therefore the treatment of the wound with Bepanten® plus cream is continued for up to 10 days. On March 20, 2015, laser phoresis with Kontraktubeks gel was started within 7 days according to the distant technique in a continuous mode with a capacity of 15 mW, the exposure time per point was 1.5 minutes, and the total exposure time was 6 minutes.

The postoperative area was assessed daily. It was noted that already by the 5th laser phoresis procedure, complete epithelization of the edges of the wound of the external nose was objectively recorded, there were no signs of inflammation and pain symptom.

During dynamic observation of the patient for 1 year, it was noted that a normotrophic scar formed on the site of the existing external nose wound, which is invisible and does not rise above the surface of the skin, thereby not causing emotional discomfort for the victim.

The following positive result was achieved in both clinical observations: accelerated convalescence periods with restoration of the physiology of the nasal cavity compared with the control group of patients in which restoration of nasal breathing is achieved by 10-14 days after surgery. The absence of the formation of a pathological scar on the face of a patient with an open trauma to the skeleton of the nose led to a complete restoration of psychoemotional status.

Thus, the proposed method for managing the postoperative period in patients with an open nasal skeleton injury aims to reduce the incidence of cicatricial deformities in the outer nose by preventing excessive scarring, eliminating inflammation and stimulating regeneration. The present invention allows to reduce the time of convalescence in this group of patients by 5-8 days, which is accompanied by the restoration of the physiology of the nasal cavity in the shortest possible time.

The proposed method of treatment is easily reproducible, gives a pronounced clinical effect, can be used in any medical institution.

Claims (1)

A method for managing the postoperative period in patients with an open nasal skeleton injury, including laser phoresis with Kontraktubeks gel on the area of skin wounds after performing primary surgical treatment of wounds of the external nose and eliminating post-traumatic deformities of the bone-cartilaginous skeleton of the external nose and its cavity, characterized in that from the second day of the postoperative period, daily treatment of the wound area of the external nose with Bepanten® plus cream, which is applied twice a day for 6-10 days before phase of formation and reorganization of the scar, and laser phoresis with Kontraktubeks gel is performed with the onset of this phase on the area of skin wounds for 7 days according to the distant technique in a continuous mode with a capacity of 10-15 mW, exposure time per point 1.5 min, total exposure time 4 , 5-6 minutes, and from the fourth day of the postoperative period for 5 days spend endonasal laser therapy in the red range, in a pulsed mode with a power of 5 watts for 1, 5 minutes in each half of the nasal cavity.