RU2727460C1 - Instrument - holmium fibre laser conductor for tissue vaporisation in area of natural anastomosis of maxillary sinus - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, particularly to otorhinolaryngology. Guide instrument for endoscopic laser rhinoantrostomy consists of a tube made of brass with a nickel coating, which has a straight working end 10 mm long and oriented at angle of 100°. End of the working end is made for bringing the light guide of the surgical laser to the area of the ostiomeatal complex, and the proximal end of the tube is fitted with a silicone perforated cap with a central hole of 1.0 mm diameter for fixation of laser fibre and holes with diameter of 0.8 mm with distance between holes of 2.5 mm for aspiration of smoke, which is formed during laser vaporization of tissue around natural junction of maxillary sinus. At that, aspiration of smoke is carried out by connection to vacuum nozzle of vacuum suction.EFFECT: application of this invention will allow delivering laser radiation to the region of natural junction of the maxillary sinus without damaging other structures.1 cl, 1 dwg, 1 ex

Description

The invention relates to medicine, in particular to otorhinolaryngology, and can be used in the treatment of patients with chronic maxillary sinusitis.

Chronic sinusitis is one of the most common chronic diseases in all age groups. Its estimated prevalence is more than 140 cases per 1000 population. At the same time, the incidence of chronic sinusitis increases from year to year, and the reasons for this trend have not been finally established. In the United States alone, the direct costs of treating chronic sinusitis (including chronic sinusitis) reach $ 3.4-5 billion per year. Chronic inflammation of the paranasal sinuses is the fifth most common reason for the prescription of antibiotics. All this indicates that the problem of treatment and prevention of acute and chronic inflammatory diseases of the paranasal sinuses remains relevant and needs to be improved in treatment tactics.

The osteomeatal complex has been identified as an important anatomical region in the pathogenesis of sinusitis. Understanding the importance of the ethmoid funnel in the etiology and pathogenesis of chronic sinusitis led to a fundamental change in the choice of surgical intervention: the main goal of any treatment should be to eliminate pathological changes in the mucous membrane in this area, which improves drainage and aeration of the affected sinus. In many cases, this goal is achieved with infuntibulotomy, using the Messerklinger technique (stepwise debridement of the ethmoid sinuses and key anatomical structures from front to back) or Wiegand (according to this technique, surgical treatment starts from the deep parts of the nasal cavity and moves from back to front). However, when using these methods of surgical treatment, the normal anatomical relations between the structures of the nasal cavity are disturbed, since it is carried out through the region of the middle nasal passage, which implies the complete or partial removal of the uncinate process, which is an important structure of the ostiomeatal complex. The disadvantage of this technique is that the intervention can lead to dysfunction of the uncinate process, which in turn disrupts normal (with uncomplicated cysts) ventilation and drainage of the paranasal sinuses, as a result of which there may be recurrences of maxillary sinusitis. Therefore, the use of these methods of treatment is significantly limited in isolated lesions of the nasal sinus.

In this regard, our goal was to develop a tool that would make it possible to bring the laser to the tissues around the natural anastomosis, perform surgical treatment without destroying the anatomical structures of the nasal cavity and blood loss.

Of the many lasers in otorhinolaryngology, CO ₂ (carbon dioxide), Nd: YAG (neodymium) and Ho: YAG (holmium) lasers are mainly used. The most gentle with respect to the tissues is the CO ₂ laser radiation, but it is currently not possible to make the CO ₂ laser beam at the impact point at an angle of 110 °, which makes it impossible to conduct its application rinoantrostomii. Holmium (Ho: YAG) laser rhinoanthrostomy is one of the most rational and reasonable methods of surgical treatment of chronic maxillary sinusitis.

In practical otorhinolaryngology, there are sinus catheters for the maxillary sinus along v. EICKEN with LUER lock, which is a cylindrical tube 9-15 cm long, one end of which is expanded in the form of a bell, and the other is bent at an angle of 140-150 ° and has the shape of a rounded beak. Catheters are available in different lumen widths from 1 to 3 mm and wall thicknesses from 0.5 to 1 mm [STORZ WORLD OF ENDOSCOPY. Endoscopes and ENT Instruments, Esophagoscopy - Bronchoscopy 9th Edition 2/2013. Section: Sinuscope, rhinoscopy, posterior rhinoscopy, FESS paranasal sinuses, base of the skull, p. 162]. This catheter could serve as a guide for a holmium laser light guide, but it cannot provide reliable fixation of the laser light guide and adequate smoke removal.

In this regard, we set the technical task of developing a tool - a guide for the holmium laser light guide, which allows endoscopic endonasal rhinoanthrostomy with fixation of the laser light guide and smoke removal.

To solve the problem, a tool is proposed - a conductor, which performs three functions: 1 - the function of a conductor; 2 - the function of a smoke aspirator, which is formed in the area of surgical intervention during laser vaporization of tissue; 3 - Ho: YAG laser fiber lock function. This possibility is due to the presence of a perforated silicone nozzle at the proximal end of the instrument with its attachment to the vacuum suction tube. Visual control of the surgical intervention is carried out by introducing an endoscope through the nasal cavity.

The achieved technical result of the claimed device is the ability to deliver laser radiation to the area of the natural anastomosis of the maxillary sinus without damaging other structures.

Brief description of the drawings.

Figure.

Figure A shows a guidewire for endoscopic laser rhinoanthrostomy:

1 - proximal end of the guideline instrument, outer diameter 6 mm, inner diameter 4 mm;

2 - silicone perforated nozzle,

3 - fiber Ho: YAG laser with a diameter of 1 mm,

- working part diameter 2.5 mm,

- total catheter length 125 mm,

- the length of the working part is 80 mm,

- length from distal end to bend 10 mm,

- bending angle 100 °.

Figure B shows a perforated silicone nozzle of a guidewire for endoscopic laser rhinoanthrostomy:

- the total diameter of the silicone tip is 9 mm, width is 4.5 mm,

- diameter of the smoke extraction holes 0.8 mm,

- distance between holes 2.5 mm,

- the central hole of the silicone nozzle with a diameter of 1.0 mm is intended for fixing the Ho: YAG laser fiber.

The guide instrument for endoscopic laser rhinoanthrostomy (Fig.) Is made in the form of a nickel-plated brass tube, which is bent at an angle of 100 ° and has a straight working end 10 mm long. The tip of the working end is designed to bring and position the Ho: YAG laser light guide to the area of the ostiomeatal complex.

The bending angle of the instrument - the guidewire was selected after studying a computed tomogram of the paranasal sinuses (CT) of 50 patients with diseases of the nose and SNP. The average indicator of the space between the uncinate process, the anterior wall of the ethmoid bulla and the paper plate is 18-22 °.

Endoscopic laser rhinoanthrostomy using a device developed by us is carried out as follows.

Operation progress:

1. Anesthesia

Местная анестезия (Sol. Lidocaini 10% - 1,0 ml - аппликационно на турундах до операции, Sol. Lidocaini 1% - 5,0 - инфильтрационно) - положение пациента сидя в кресле или лежа на операционном столе с приподнятым головным концом;

Local anesthesia (Sol. Lidocaini 10% - 1.0 ml - by application on turunda before surgery, Sol. Lidocaini 1% - 5.0 - by infiltration) - position of the patient sitting in a chair or lying on the operating table with a raised head end;

Комбинированный эндотрахеальный наркоз (КЭТН) + местная анестезия (Sol. Lidocaini 1% - 5,0 - инфильтрационно) - положение пациента лежа на операционном столе с приподнятым головным концом.

Combined endotracheal anesthesia (CETN) + local anesthesia (Sol. Lidocaini 1% - 5.0 - infiltration) - the position of the patient lying on the operating table with a raised head end.

2. Laser vaporization of tissues along the edge of the natural junction of the maxillary sinus.

Under the control of an endoscope, after medialization of the middle turbinate, the edge of the uncinate process is identified. Then, with the help of a bulbous probe, it is mobilized. The Ho: YAG laser fiber is passed through the instrument - a guide, the working end of which is oriented to its longitudinal axis and bent at an angle of 100 °, which allows the latter to be inserted beyond the hook-shaped process. Under control 45 gr. endoscopic optics, after fixation with a silicone nozzle, using a power of 0.8 W at a frequency of 16 Hz, the tissues are vaporized along the edge of the natural anastomosis of the maxillary sinus in the posterior-inferior direction to a size of 0.5 × 1 cm.During this surgical intervention, no bleeding was noted.

Further sanitation of the sinus can be carried out by instrumental means through the formed rhinoanthrostomy, under the control of endoscopes with viewing angles of 30, 45 or 70 degrees.

Clinical example.

The patient, 42 years old, was admitted to the otorhinolaryngology department of N.N. L.I. Sverzhevsky with a diagnosis of Chronic left-sided parietal-hyperplastic maxillary sinusitis.

Upon admission, she complained of discharge from the left half of the nasal cavity, discomfort in the projection area of the left maxillary sinus.

According to the patient, she has been suffering for 3 years, when, after hypothermia, she noted the above complaints. She was treated on an outpatient basis, took antibacterial drugs, washed her nose with saline solutions. After a while, the complaints recurred.

When viewed in the left half of the nasal cavity, there is scanty mucous discharge, the mucous membrane is edematous, hyperemic, the nasal septum is curved.

On a computed tomogram - parietal thickening of the left maxillary sinus with the presence of a persistent block of natural anastomosis.

The patient underwent surgical treatment, endonasal endoscopic rhinoanthrostomy using the Holmium laser.

Operation progress:

Under endotracheal anesthesia, with the control of an endoscope, after medialization of the middle turbinate, the edge of the uncinate process was identified, and its mobilization was carried out using a bulbous probe. The Ho: YAG laser fiber was passed through an instrument - a guide, the working end of which was oriented to its longitudinal axis and bent at an angle of 100 °, which made it possible to lead the latter behind the uncinate process. Parameters But: YAG radiation had the following values: power 0.8 W, pulse frequency 16.0 Hz. Under the control of 45 ° endoscopic optics, after fixing the Ho: YAG laser fiber, the tissues were vaporized along the edge of the natural anastomosis of the maxillary sinus in the posterior inferior direction to a size of 0.5 × 1 cm.During this surgical intervention, no bleeding was observed.

The patient was discharged from the hospital on the 2nd day. The effectiveness of this surgical method was evaluated at 3, 7, 10 days, 3 and 6 months. According to the endoscopic examination of the middle nasal passage and the area of the natural anastomosis, no pathological changes were recorded in these areas. According to CT data, SNP after 6 months had no recurrence of maxillary sinusitis.

Claims (2)

1. Instrument-guide for endoscopic laser rhinoanthrostomy, consisting of a tube made of nickel-plated brass, which has a straight working end 10 mm long, oriented at an angle of 100 °, the end of the working end is made to bring the surgical laser light guide to the ostiomeatal complex area, and on the proximal end of the tube, a silicone perforated nozzle with a central hole 1.0 mm in diameter for fixing the laser fiber and holes 0.8 mm in diameter with a distance of 2.5 mm between the holes for aspiration of smoke is put on, which is formed during laser vaporization of tissue around the natural junction of the maxillary sinuses, and smoke aspiration is carried out by attaching a vacuum suction to a silicone nozzle. 2. The tool-guide according to claim 1, characterized in that the end face of the working end with an outer diameter of 6 mm and an inner diameter of 4 mm is made to supply a fiber of a holmium Ho: YAG laser with a diameter of 1 mm.

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