RU2732872C1 - Method of bougienage an auditory tube using an introducer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to otorhinolaryngology. A trans-meatal approach to the tympanic cavity is performed, and a revision of the tympanic orifice of the auditory tube is performed. An introducer with diameter of 1 mm is inserted into the tympanic orifice of the auditory tube; the end of the introducer is bent 30–40° down and medially. A flexible metal conductor with diameter of 0.64 mm and a button at the end, which is brought to the pharyngeal opening of the auditory tube, is passed through the introducer. An endoscopic visualization of the end of the conductor is performed through the nasal cavity. Then, the introducer is removed, and 0.81 mm-diameter catheter is put on the conductor along the entire length. Conductor is removed, auditory tube is sprayed with corticosteroid solution when catheter is removed from nasopharynx.

EFFECT: method allows facilitating bougienage of the auditory tube from the tympanum to the nasopharynx, reducing the risk of traumatization of the mucosa of the eustachian tube lumen.

3 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to otorhinolaryngology.

Problems with the patency of the auditory (Eustachian) tube are the reasons for the development of exudative otitis media or various forms of chronic otitis media. Allocate functional (temporary) and organic (permanent) obstruction of the auditory tube. The auditory tube provides drainage, ventilation, protective and resonator functions for the middle ear [Boboshko M.Yu., Lopotko A.I., 2003], therefore, any violation of its patency affects the functions of the middle ear. Its functional disorders are caused by acute pathology of the nasal cavity, nasopharynx, paranasal sinuses and middle ear, and organic - by trauma, deformation, formations along its lumen and in the surrounding tissues. The most complex pathology is made up of organic changes in the auditory tube, since they require invasive intervention to eliminate its obstruction.

One of the ways to restore the patency of the auditory tube is its bougienage, which is carried out for diagnostic and therapeutic purposes [Preobrazhensky NA, Goldman II, 1987]. Known methods of bougienage of the auditory tube from the tympanic mouth of the auditory tube to the nasopharynx for the purpose of diagnosis, treatment of mechanical obstruction of the auditory tube and to prevent fibrous obliteration of its lumen using a rubber catheter [Volstein H., 1972; Kruk M.B., 1988; Stratieva O.V., Arefieva N.A., 2000; Oh S. et al., 2015], the introduction of Teflon tubes [Shakhov V.Yu., 1990] and silicone splints [Kikuchi T. et al., 2016] into the bone segment of the auditory tube. Some authors for these purposes use transnasal and transoral introduction of catheters through the pharyngeal opening of the auditory tube [Yanov Yu.K. et al., 2003].

Closest to the invention is a method of bougienage of the auditory tube using a steel conical-oval probe from the tympanic mouth of the auditory tube to the nasopharynx [Vulshtein H., 1972; Sushko Yu.A., 1986].

A significant disadvantage of these methods is to conduct manipulations "blindly", without optical control, which reduces the possibility of their implementation and does not exclude damage to the canal of the internal carotid artery. In addition, the use of rigid materials creates the possibility of additional trauma to the mucous membrane and a real threat of future obliteration of the tubular lumen [Kruk MB, 1988; Krechetov GM, 1993].

The purpose of the invention is to improve the accuracy of bougienage of the bony part of the tympanic mouth of the auditory tube.

Patients with chronic perforated otitis media often have dysfunctions of the auditory tube, which maintain inflammation and affect the anatomical and morphological results of tympanoplasty. Overcoming the impairment of these functions is the main factor in improving the results of tympanoplasty. The scientific novelty of the method lies in the fact that after opening and revising the tympanic cavity using a microscope, the tympanic membrane is cut off from the handle of the malleus for better visualization of the tympanic mouth of the auditory tube, an introducer is installed into it, through which a flexible metal conductor with a diameter of 0.64 mm with a button is inserted at the end from the tympanic mouth of the auditory tube to the nasopharynx. After endoscopic visualization of the end of the guide wire (bougie) in the nasopharynx, a catheter is put on the guide wire along its entire length to flush the auditory tube with a corticosteroid solution.

The technical result, which is achieved when implementing the claimed method, is that with the help of the introducer, it is facilitated to conduct bougienage of the auditory tube from the tympanic opening to the nasopharynx, the procedure is carried out accurately and the risk of trauma to the mucous membrane of the lumen of the Eustachian tube is reduced.

Description of drawings.

Figure 1. Sheath for central venous catheterization (the end of the sheath is manually bent 30-40 °).

Figure 2. Scheme of introduction of the guidewire for bougienage of the auditory tube from the tympanic opening to the nasopharynx:

1 - metal flexible conductor;

2 - tympanic cavity;

3 - the pharyngeal opening of the auditory tube.

The method is carried out as follows.

Under general anesthesia, transmeatal access to the tympanic cavity is performed using a microscope in patients with chronic suppurative otitis media. All parts of the tympanic cavity are revised, the edges of the tympanic membrane defect are scarified and cut off from the hammer handle for better visualization of the tympanic mouth of the auditory tube. An introducer (Fig. 1) with a diameter of 1 mm from a set ES-04150 for catheterization of central veins from ARROW (USA) is installed into the tympanic opening of the auditory tube, the end of which is manually bent down and medially by 30-40 ° in relation to the medial wall of the tympanic cavity, and through it, a flexible metal conductor (Fig. 2) with a diameter of 0.64 mm with a button at the end from the tympanic to the pharyngeal opening of the auditory tube is introduced. For this purpose, a conductor from the above set is used. Endoscopic visualization of the end of the guidewire is carried out through the nasal cavity on the side of the affected ear or on the other side if there is a curvature of the nasal septum, which complicates this study. After that, the introducer is removed and a 0.81 mm catheter from the same set, made of thermoplastic polyurethane, and the distal part of which is protected by a soft atraumatic BlueFlexTip tip, is put on the guide wire along its entire length. Then the guidewire is removed, a syringe filled with a corticosteroid solution is inserted into the cannula of the catheter. When the catheter is removed from the auditory tube, its lumen is irrigated with a corticosteroid solution (in particular, dexamethasone). After bougienage and washing of the auditory tube, tympanoplasty is performed and the ear canal is lined with protectors and filled with tampons.

In cases of a subtotal defect of the tympanic membrane, cutting it off from the handle of the malleus is not required, since in this case it is possible to install an introducer with sufficient visualization of the tympanic opening of the auditory tube.

Facilitates the insertion of the introducer and the behind-the-ear approach in tympanoplasty, as it improves the visibility of this area.

The described method was used in 15 patients with chronic suppurative otitis media in the research department of ear microsurgery at the Research Clinical Institute of Otorhinolaryngology named after L.I. Sverzhevsky. There were no complications from the application of the technique.

An example of the effective application of the proposed technique is the case history of patient A., 38 years old, who was admitted for surgical treatment with a diagnosis of chronic left-sided perforated otitis media. From the anamnesis it is known that the patient has been suffering from this disease since childhood after suffering acute purulent otitis media. Otitis exacerbations are rare and are associated with colds. Turned to the otosurgeon NIKIO them. L.I. Sverzhevsky due to hearing loss in the left ear. On examination, according to otomicroscopy data, chronic left-sided perforated otitis media was revealed. There is a central defect in the posterior parts of the tympanic membrane with the preservation of the ossicular chain. The mucous membrane of the tympanic cavity on the left is moist, thickened. According to the tonal threshold audiometry, left-sided conductive hearing loss with a bone-air gap (CVI) of 30 dB was revealed at speaking frequencies. According to the X-ray data of the temporal bones according to Schüller and Mayer, signs of chronic otitis media were revealed, which are manifested by the sclerotic nature of the mastoid process on the left without signs of destruction. The auditory tube is passable only when blowing with a catheter (grade IY) on the left, on the right - according to Toynbee (I).

The patient underwent surgery under general anesthesia on the left ear: revision of the tympanic cavity, bougienage of the auditory tube and tympanoplasty with autofascia and type I cartilage (according to H. Wolstein). Using a microscope, the tympanic cavity was opened using an intrameatal approach after local infiltration anesthesia, scalping the edges of the perforation and cutting out a meatal flap. In the tympanic cavity, a thickened, moist mucous membrane of the medial wall was revealed. The ossicular chain is preserved and mobile. The windows of the labyrinth are free, we pass the aditus - washed. After cutting off the handle of the hammer from the remnants of the tympanic membrane, the entrance to the tympanic opening of the auditory tube was visualized, which was probed - no adhesions were found. An introducer with a diameter of 1 mm from the set ES-04150 for catheterization of central veins from ARROW (USA) is installed into the tympanic orifice, the end of which is bent 40 ° downward and medially, and a flexible metal guide with a diameter of 0.64 mm is inserted through it with a button at the end from tympanic to the pharyngeal orifice of the auditory tube (from the same set). After that, the introducer is removed and a 0.81 mm catheter from the same set is put on the guide wire. When the catheter was removed from the auditory tube in the opposite direction, a dexamethasone solution was injected into its lumen. After bougienage and washing of the auditory tube, tympanoplasty was performed and the auditory meatus was lined with protectors and filled with Merocel tampons. The patient was discharged 3-5 days after the operation, the tampons were removed from the ear canal after 3 weeks. When observing the patient after 3 months, the closure of the tympanic membrane perforation and a reduction in CVI by 20 dB were noted. In addition, there was an improvement in the ventilation function of the auditory tube on the left - it is blown through Valsalva (II degree).

Thus, the proposed method of bougienage of the auditory tube using an introducer from the tympanic to the pharyngeal orifice is safe and effective in the treatment of chronic perforated otitis media with impaired ventilation function of the auditory tube.

Bibliography:

1. Boboshko M.Yu., Lopotko A.I. Auditory tube. - SPb .: SpetsLit, 2003: 360 p.

2. Preobrazhensky N.A., Goldman I.I. Exudative otitis media. - M., Medicine, 1987: 147-151.

3. Wolstein H. Hearing-improving operations. - M., Medicine, 1972: 248-255.

4. Kruk MB Research methods of the functional states of the auditory tube. Journal. ear., nose. and throat. bol. - 1988. - No. 3: 71.

5. RF patent No. 2145203 dated 02/10/2000, OV Stratieva, NA Arefieva. The method of bougienage of the auditory tube.

6. Oh S., Lee I., Goh E., Kong S. Trans-tympanic catheter insertion for treatment of Patulous Eustachian tube. Am J Otolaryngol. 2015; 36 (6): 748-52. doi: 10.1016 / j.amjoto.2015.07.003

7. Shakhov V.Yu. On the issue of surgical restoration of the auditory tube lumen. Journal. ear., nose. and throat. bol. - 1990. - No.4: 13.

8. Kikuchi T., Ikeda R., Oshima H., Takata I., Kawasa T., Oshima T., Katori Y., Kobayashi T. Effectiveness of Kobayashi plug for 252 ears with chronic patulous eustachian tube. Acta Oto-Laryngol. 2017; 137 (3): 253-258. DOI: 10.1080 / 00016489.2016.1231420

9. Yanov Yu.K., Dvoryanchikov V.V., Zadorozhnikov G.K., Ivashin I.A. Treatment of acute otitis media by draining the auditory tube. Russian otorhinolaryngology. 2003; 4: 118-122.

10. Sushko Yu.A. Diagnostics and treatment of dysfunctions of the auditory tube. Method. decree. Research Institute of Ear, Throat, Nose them. Kolomiychenko. - Kiev, 1986: 23.

11. Krechetov G.M. Fibrosing otitis media: author. diss ... cand. honey. sciences. - M., 1993 .-- 27 p.

Claims (3)

1. The method of bougienage of the auditory tube, including transmeatal access to the tympanic cavity, revision of the tympanic mouth of the auditory tube, characterized in that an introducer with a diameter of 1 mm is installed into the tympanic opening of the auditory tube, the end of which is bent 30-40 ° downward and medially, then through it a flexible metal conductor with a diameter of 0.64 mm is carried out with a button at the end, which is brought to the pharyngeal opening of the auditory tube, endoscopic visualization of the end of the conductor is carried out through the nasal cavity, then the introducer is removed, a catheter with a diameter of 0.81 mm is put on the conductor along the entire length, the guide is removed , carry out irrigation of the auditory tube with a corticosteroid solution while removing the catheter from the nasopharynx. 2. The method according to claim 1, characterized in that the introducer is installed in the tympanic opening of the auditory tube, preliminarily cutting off the tympanic membrane from the handle of the malleus. 3. The method according to claim 1, characterized in that in cases of a subtotal defect of the tympanic membrane, the introducer is installed in the tympanic opening of the auditory tube without preliminary cutting off the tympanic membrane from the handle of the hammer.

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