RU2769917C1 - Method for surgical management of middle ear masses - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otiatrics. Infrared laser with wavelength of 1.47 mcm, or 1.56 mcm, or 1.94 mcm, laser radiation power of 10–15 W in pulsed mode with pulse duration of 5–30 ms and pauses between pulses of 1–2 s.

EFFECT: method enables to reduce the damaging effect of the laser, reduce the number of postoperative complications, use a single laser exposure protocol for the reduction of volumetric formations of the middle ear, improving reproducibility of the technique, its safety and controllability, reducing the length of hospital stay and reducing material costs.

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Description

The invention relates to medicine, namely to otiatry, and can be used for surgical treatment of space-occupying formations of the middle ear.

Middle ear masses can include soft tissue masses of the tympanic cavity of the following type: middle ear polyp, glomus tumor type A (FischU., MattoxD. Microsurgeryoftheskullbase. New York Stuttgart: Thieme, 1988. - P. 149-153), cholesteatoma and granulation tissue. A feature of the surgery of these formations is their high bleeding, therefore, preference is given to the use of "hot" instruments for coagulation, reduction of intraoperative bleeding and maintenance of a dry surgical field, which is extremely important due to the close location of important anatomical structures and the need to identify them to prevent iatrogenic damage. One of these techniques is laser exposure. However, laser energy can potentially cause thermal damage to underlying structures, such as the basal whorl of the cochlea, namely the neurosensory epithelium of the inner ear and the facial nerve, leading to a violation of their function and the development of complications - in the form of paresis and paralysis of the facial nerve, hearing loss and impaired vestibular functions.

Currently, the literature describes methods of using lasers for surgery of soft tissue formations of the outer and middle ear with different wavelengths:

-Nd: YAG laser (P J Robinson, H R Grant, S G Bown. NdYAG laser treatment of a glomus tympanicum tumour. J Laryngol Otol. 1993 Mar; 107(3):236-7);

- KTP laser (Kouzaki H, Fukui J, Shimizu T Management of a catecholamine-secreting tympanicum glomus tumour: case report The Journal of Laryngology & Otology (2008), 122, 1377-1380);

- diode laser with a wavelength of 0.81 microns

Despite the prevalence and relatively low cost of lasers with a wavelength (1.47 µm, 1.56 µm, 1.94 µm) in the near infrared spectrum, we did not find data on their use in surgery for volumetric soft tissue formations of the middle ear.

A known method of surgical treatment of mass formations of the middle ear using a KTP laser with a wavelength of 0.532 μm, which corresponds to one of the hemoglobin absorption peaks and, therefore, can provide coagulation of vascular structures. A continuous non-contact mode of operation at low power up to 5 W is used. This method was chosen as the closest analogue (VenkataS. P. Durvasula ⋅ RanitDe ⋅ DavidM. Baguley ⋅ DavidA. M off at Laser excision of glomustympanicumtumours: long-tennresults EurArch Otorhinolaryngol (2005) 262:325).

The disadvantage of this method lies in the absence of indications of the size of the distance between the end of the light guide and the surface of the formation, although the main parameter of laser exposure depends on it - the radiation power density, and hence its effect. In this case, the result of the applied exposure depends on the concentration of the chromophore in the tissues, which can vary greatly in various formations of the middle ear. A disadvantage of the Durvasula et al. is also the impossibility of developing a single exposure protocol.

The technical result of the invention is independence from the concentration of the chromophore in tissues, reducing the damaging effects of the laser and reducing the number of postoperative complications (thermal damage to the facial nerve and the development of sensorineural hearing loss and vestibular disorders in the postoperative period), the development of a single protocol for the mode and method of exposure to infrared lasers with a length waves 1.47; 1.56; 1.94 µm on middle ear masses, improving the reproducibility of the method.

The specified technical result is achieved in the method of surgical treatment of volumetric formations of the middle ear by laser exposure, in which contact exposure is carried out with a water-absorbing laser of the infrared spectrum with a laser radiation power of 10-15 W in a pulsed mode with a pulse duration of 5-30 ms and pauses between pulses of 1-2 seconds .

For near-infrared lasers, which include lasers with a wavelength of 1.47 µm, 1.56 µm, 1.94 µm, the main chromophore is water and the determining factor for the selected type of radiation is the water content, which is a more constant indicator for volumetric formations different nature, since water is contained not only in the bloodstream, but also in the interstitial tissues.

Thus, differences in the content of the chromophore (the level of vascularization of the formation) do not affect the volume of coagulation and the result of exposure does not depend on the concentration of the chromophore in tissues.

The flexible and thin laser fiber makes it convenient to work in the limited space of the middle ear in the vicinity of structures such as the facial nerve, the vestibule window and the cochlear window, and the basal cochlea.

The safest mode of laser exposure is provided by increasing the exposure power and simultaneously reducing the pulse duration.

The contact mode ensures the reproducibility of the technique, since the fixed diameter of the used quartz fiber (from 400-1000 μm) determines the radiation power density, and hence the energy density of the laser action.

The impact of water-absorbing lasers in these modes leads to coagulation of the tissue of the volumetric formation without burning and ablation, which means that the heating of the tissue does not exceed 100 °C.

Exposure in short-pulse mode significantly reduces heat transfer to surrounding tissues due to the presence of pauses for "cooling down" lasting more than 1 second. This significantly reduces the possibility of damage to underlying structures and the development of sensorineural hearing loss, vestibular disorders and dysfunction of the facial nerve in the postoperative period.

The method is confirmed by the following clinical examples.

Example 1. Patient K., aged 38, was admitted to the ENT clinic about a glomus tumor type A of the right tympanic cavity. Complained of discomfort in the right ear and constant low-frequency noise in the right ear. The above complaints have been disturbing for the past five years, but recently the patient has noted an increase in tinnitus.

Otoscopically: there is no pathological discharge in the right external auditory canal; the tympanic membrane is gray, the integrity is not broken; behind the tympanic membrane, a rounded red formation is visualized, pulsating, a symptom of the "rising sun". Hearing acuity for whispered speech 6.0 m, colloquial speech 6.0 m. Patency of the auditory tube I-II degree. MSCT of the temporal bones revealed no bone-destructive changes; a soft-tissue formation in the promontorium area, which does not involve the auditory ossicles, is visualized. According to MSCT angiography, there were no data for the presence of adducting (feeding) vessels associated with the main vessels. Rinne's experience was positive, lateralization of sound in Weber's experiment to the right, Jelly's experience was positive. According to the tone threshold audiometry, hearing loss was not detected.

The patient underwent a Rosen tympanotomy under conditions of local infiltration anesthesia, a tympano-meatal flap was formed, and a pulsating volumetric mass, abundantly vascularized, was visualized on the medial wall of the tympanic cavity. Interstitial photocoagulation of the formation was performed using a 1.56 μm laser in a pulsed mode of 10 ms and a power of 15 W. After laser exposure, the formation significantly decreased in volume and devascularized. The tympanomeatal flap is in place. Tamponade of the external auditory canal was performed with turundas moistened with an antibacterial solution.

In the postoperative period, the patient received antibiotic therapy for 7 days (Ceftriaxone 1000 mg once a day, im). The postoperative period proceeded without complications. The patient was discharged from the clinic on the 7th day, after removing the tampons from the external auditory canal, the hearing acuity for whispered speech was 6 m. On the 7th day, tone threshold audiometry was performed - without negative dynamics. In the long term (3 months) - during otoscopic examination, there are no data for the recurrence of a glomus tumor. No complaints about tinnitus. On the control MSCT of the temporal bones, there are no data for a soft tissue formation on the medial wall of the tympanic cavity.

Example 2. Patient P., aged 42, was admitted to the clinic of otorhinolaryngology for chronic purulent tubotympanic otitis media. Complained of discomfort in the left ear and constant low-frequency noise in the left ear. Periodically - suppuration, the last exacerbation about 2 years ago. The above complaints have been disturbing for the last ten years, but recently the patient has noted a decrease in hearing.

Otoscopically: there is no pathological discharge in the left external auditory canal; the tympanic membrane is gray, perforation is determined in the posterior sections, through which a rounded polypoid formation protrudes into the external auditory canal. Hearing acuity for whispering speech 4.0 m, colloquial speech 5.0 m. Permeability of the auditory tube I-II degree. MSCT of the temporal bones revealed no bone-destructive changes; a soft tissue formation in the epitympanum was visualized, not involving the auditory ossicles. Rinne's experience was positive, lateralization of sound in Weber's experiment to the left, Jelly's experience was positive. According to the tone threshold audiometry conductive hearing loss.

The patient underwent endaural tympanotomy according to Rosen, the edges of the tympanic membrane perforation were refreshed, a tympano-meatal flap was formed from 12 to 6 hours counterclockwise, and a large polypoid formation was visualized. The formation was photocoagulated using a 1.94 μm laser in a 5 ms pulsed mode and at a power of 10 W. After laser exposure, the formation significantly decreased in volume. The tympanomeatal flap is in place. The defect was closed with a fascial autograft of the underlay type, tamponade of the external auditory canal with turundas moistened with an antibacterial solution.

In the postoperative period, the patient received antibiotic therapy for 7 days (Ceftriaxone 1000 mg once a day, im). The postoperative period proceeded without complications. The patient was discharged from the clinic on the 7th day, after removing the tampons from the external auditory canal, the hearing acuity for whispered speech was 6 meters. In the long term (3 months) - during otoscopic examination, there are no data for perforation of the tympanic membrane and recurrence of a mass formation. No complaints about tinnitus. On the control MSCT of the temporal bones, there are no data for a soft tissue formation in the epitympanum of the tympanic cavity.

Example 3. Patient R., aged 63, was admitted to the clinic of otorhinolaryngology for chronic purulent tubotympanic otitis media. Complained of discomfort in the left ear, congestion of the left ear and hearing loss in the left ear. The above complaints have been disturbing for the past five years, but recently the patient has noted a decrease in hearing.

Otoscopically: there is no pathological discharge in the left external auditory canal; the tympanic membrane is gray, cicatricially changed, there is no perforation of the tympanic membrane. Hearing acuity for whispered speech 3.5 m, colloquial speech 4.5 m. Patency of the auditory tube I-II degree. Rinne's experience was positive, lateralization of sound in Weber's experiment to the left, Jelly's experience was positive. Conductive type hearing loss according to tone threshold audiometry.

The patient underwent an endaural tympanotomy according to Rosen, the edges of the perforation of the tympanic membrane were refreshed, a tympano-meatal flap was formed from 12 to 6 hours counterclockwise, scar and granulation tissue was visualized, enveloping the long process of the anvil and the stirrup, making it difficult to transmit vibrations to the oval window. Photocoagulation and dissection of the pathological tissue was performed using a 1.47 μm laser in a pulsed mode of 15 ms and a power of 15 W. The tympanomeatal flap is in place. The defect was closed with a fascial autograft of the underlay type, tamponade of the external auditory canal with turundas moistened with an antibacterial solution.

In the postoperative period, the patient received antibiotic therapy for 7 days (Ceftriaxone 1000 mg once a day, im). The postoperative period proceeded without complications. The patient was discharged from the clinic on the 7th day, after removing the tampons from the external auditory canal, the hearing acuity for whispered speech was 6 meters. On the 7th day performed tone threshold audiometry - complete closure of the air-bone interval. No complaints about tinnitus.

The inventive method was tested in 5 patients. The functional results are positive, which made it possible to remove volumetric formations in 100% of patients without signs of recurrence after 3 months. The evaluation of the results in the next (7th day after surgery) and separate periods (3 months after surgery) was performed using otomicroscopy.

EFFECT: method allows to reduce the damaging effect of the laser, reduce the number of postoperative complications, use a single protocol of laser exposure to reduce volumetric formations, increasing the reproducibility of the technique, its safety and controllability, reduce the time of hospitalization of patients and reduce material costs.

Claims (1)

Method for surgical treatment of space-occupying formations of the middle ear by laser exposure, characterized in that contact exposure is carried out with an infrared laser with a wavelength of 1.47 μm, or 1.56 μm, or 1.94 μm, with a laser radiation power of 10-15 W in a pulsed mode with a pulse duration of 5-30 ms and pauses between pulses of 1-2 s.