RU2734627C1 - Method for surgical management of patients with chronic dacryocystitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmology and otorhinolaryngology. Anaesthesia, endonasal approach is performed, a bone window and a lachrymal sac and nasal cavity are formed. Elevator is used, consisting of handle, intermediate and working part, wherein handle is located relative to axis of intermediate part at angle of 160°, intermediate part with length of 80 mm and diameter of 4.5 mm changes into working part with length of 11 mm, with diameter of 2.5 mm, arc-bent with radius of 10 mm at angle of 110° to an intermediate portion and having a non-traumatic end rounded with 1.25 mm radius. Elevator is introduced through the vestibule of the nasal cavity under the lower nasal concha until its rounded atraumatic end reaches the lachrymal sac, which is determined by excrement from the lachrymal points exudate, and the beginning of bending of the working part does not rest against the attachment point of the inferior nasal concha. After that, the elevator is turned medially by the handle, forming its atraumatic end bone opening in the lower part of the lachrymal fissure. Elevator is removed. Mucous membrane projecting in the projection of the formed bone window is incised through the middle nasal passage with a scalpel, the bone fragments are removed, a medial flap of the lachrymal sac is placed in the nasal cavity and fixed.

EFFECT: method enables reducing the length of the operation, reducing the area of injuries, reducing the length of postoperative rehabilitation of the patients, reducing the number of recurrences.

1 cl, 1 ex

Description

The invention relates to medicine, namely to ophthalmology and otorhinolaryngology, and for the surgical treatment of patients with chronic dacryocystitis.

A known method for the treatment of dacryocystitis, in which an anastomosis is formed between the lacrimal sac and the nasal cavity with an external access. The periosteum is cut and separated outwards by 0.5-1 cm medial to the internal ligament. With the help of a chisel and a hammer, a bone window of 1.5-2 by 1.2-1.5 cm is formed. Within the opening, the inner wall of the lacrimal sac and the nasal mucosa are cut longitudinally. The flaps of the wall of the bag and nasal mucosa are sutured with catgut, forming the anterior and posterior lips of the formed stoma [1].

The disadvantage of this method is its high invasiveness, long duration of the operation, the presence of a skin scar, frequent complications, including infection of the formed stoma).

A known method of treating dacryocystitis with an endonasal approach. In the nasal cavity, in front of the middle shell, cut out and remove a mucosal flap along the projection of the lacrimal fossa. An U-shaped flap of the nasal mucosa is formed in front of the resulting defect. A bone window is formed with a chisel or bur. An incision is made in the lacrimal sac and its inner wall is removed. The U-shaped flap is returned to its place. The operation ends with an anterior nasal tamponade [1].

The application of the method is limited by the physiological or pathological narrowness of the nasal passage, the presence of pathology in the proximal parts of the lacrimal duct, the possibility of intraoperative bleeding and recurrence of the disease (infection of the formed stoma). We have taken this method as a prototype.

The purpose of the invention is to develop and apply a new method of surgical treatment of chronic dacryocystitis.

This goal is achieved by the fact that an elevator is introduced through the vestibule of the nasal cavity under the inferior turbinate until its rounded atraumatic end reaches the lacrimal sac, which is determined by the release of exudate from the lacrimal openings; and the beginning of the bending of the working part does not rest against the place of attachment of the inferior turbinate, after which the elevator is turned medially by the handle, forming its atraumatic end into a bone window in the lower part of the lacrimal fossa; the elevator is removed; through the middle nasal passage, the mucous membrane protruding in the projection of the formed bone window is incised with a scalpel, bone fragments are removed, the medial flap of the lacrimal sac is placed in the nasal cavity and it is fixed.

The elevator consists of a handle, intermediate and working parts. The handle is located relative to the axis of the intermediate part at an angle of 160 °. The intermediate part 80 mm long and 4.5 mm in diameter passes into the working part 11 mm long, 2.5 mm in diameter, bent by an arc with a radius of 10 mm at an angle of 110 ° to the intermediate part and having an atraumatic end rounded with a radius of 1.25 mm ( application for a utility model of the Russian Federation).

These dimensions of the instrument are due to the anatomical shape of the vestibule of the nasal cavity, the lower nasal passage, the location, direction and diameter of the nasolacrimal canal, lacrimal sac. The curvature of the parts of the instrument allows it to be freely deployed when the end of the working part of the lacrimal sac reaches. In this case, after turning the instrument medially, the end of the working part of the instrument abuts against the lower part of the lacrimal fossa, where the bone is thinnest, forming a bony window. The atraumatic rounded end of the instrument does not injure the mucous membrane of the lower nasal passage and the nasolacrimal duct, when carrying it out.

With other variants of endonasal dacryocystorhinostomy, it is the search and formation of the bone window that takes the most time. In this case, the maximum injury to the surrounding tissues is inflicted, which in turn leads to excessive scarring and relapses of the disease.

The simplicity of the operation, reduction of its time, reduction of the area of injury to the minimum required size of the bone window contributes to the reduction of the rehabilitation period for patients in the postoperative period, a significant decrease in the number of relapses of the disease in the absence of the need to use expensive equipment - boron machines, lasers.

The method is performed as follows. After application and infiltration anesthesia of the nasal mucosa in the area of surgical intervention (infiltrate the inferior turbinate, the nasal cavity floor, the side wall of the nose under the inferior turbinate and above it to the level of attachment of the middle turbinate), an elevator is introduced through the vestibule of the nasal cavity under the inferior turbinate , lowering its handle down and forward. The operator feels the passage of the working part of the instrument, but it can also be monitored visually using a straight or angled endoscope. The advancement of the instrument is continued until its rounded atraumatic end reaches the lacrimal sac, which is determined by the release of exudate from the lacrimal openings. In this case, the beginning of the bending of the working part of the instrument relative to its intermediate part abuts against the attachment point of the inferior turbinate.

After that, the elevator is turned medially by the handle. Due to the pressure when turning, the atraumatic end of the instrument "breaks out" the bone window in the lower part of the lacrimal fossa into the nasal cavity. The elevator is removed.

Through the middle nasal passage, the operator cuts the mucous membrane protruding in the projection of the formed bone window with a scalpel, removes bone fragments, lays out the medial flap of the lacrimal sac into the nasal cavity with its further fixation with a ligature or simply pressing the tampon. Lacrimal openings are washed with saline to remove pathological secretions and blood clots. Drainage of the received message between the lacrimal sac and the nasal cavity is not required.

The method is illustrated by a clinical example. Patient B., 45 years old. Diagnosis: Chronic dacryocystitis. Condition after a gunshot wound to the orbit area with violation of anatomical landmarks used for dacryocystorhinostomies. The operation was performed using the developed tool. There were no intraoperative complications. Simultaneously, when the instrument was turned, a bony window was formed in the lower part of the lacrimal fossa, and the formation of the communication between the lacrimal sac and the nasal cavity was completed. In the postoperative period, the patient was followed up for 5 months. The message is functional, the tear goes into the nasal cavity.

Thus, the method can be used in the surgical treatment of patients with chronic dacryocystitis in otorhinolaryngological and ophthalmic medical institutions.

SOURCES OF INFORMATION

1. Cherkunov B.F. "Diseases of the lacrimal organs", Samara, 2001, p. 219-220; from. 272.

Claims (1)

A method for the surgical treatment of patients with chronic dacryocystitis, including the implementation of anesthesia, endonasal access, the formation of a bone window and communication between the lacrimal sac and the nasal cavity, characterized in that an elevator is used, consisting of a handle, an intermediate and a working part, and the handle is located relative to the axis of the intermediate part under an angle of 160 °, the intermediate part 80 mm long and 4.5 mm in diameter passes into the working part 11 mm long, 2.5 mm in diameter, bent by an arc with a radius of 10 mm at an angle of 110 ° to the intermediate part and having a rounded one with a radius of 1.25 mm atraumatic end; the elevator is inserted through the vestibule of the nasal cavity under the inferior turbinate until its rounded atraumatic end reaches the lacrimal sac, which is determined by the release of exudate from the lacrimal openings, and the beginning of the bending of the working part does not rest against the attachment point of the inferior turbinate, after which the handle of the elevator is turned medially, forming a bony window in the lower part of the lacrimal fossa with its atraumatic end; the elevator is removed; through the middle nasal passage, the mucous membrane protruding in the projection of the formed bone window is incised with a scalpel, bone fragments are removed, the medial flap of the lacrimal sac is placed in the nasal cavity and it is fixed.