RU2785495C1 - Method for surgical treatment of stenosis of the vocal larynx - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to otorhinolaryngology. An endolaryngeal submucosal chordaritenoidtomy is performed using a laser. Resection of the posterior third of the thyroarytenoid muscle, arytenoid cartilage, namely the vocal process, the anterior 2/3 of its body, apex, and muscular process is performed. In this case, a laser fiber with a diameter of 400 μm is used in an inert gas atmosphere in a pulsed mode: the wavelength is 445 nm, the laser radiation power is 7.0 W with a pulse duration of 15 ms and a pause between pulses of 120 ms. In the contact mode, an incision is made in the mucous membrane of the vocal fold along its upper surface from the border between the anterior and middle third of the vocal fold, continuing along the vestibular fold. Resection of the posterior portion of the vestibular fold is performed. Then the mucous membrane of the vocal fold is dissected under the vestibular fold. The upper and medial surfaces of the mucous membrane are separated from the thyroid-arytenoid muscle. The flap is folded back medially, submucosal chordaritenoidtomy is performed. Then interrupted sutures are placed endolaryngeally on the separated flap and on the wound in turn from the anterior corner of the wound. At the end of the operation, control of hemostasis and consistency of the sutures are carried out.

EFFECT: method makes it possible to form a stable laryngeal lumen, restore respiratory function, reduce the inflammatory response in the postoperative period, shorten the rehabilitation period, improve the quality of life of patients.

1 cl, 1 ex, 5 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used in the surgical treatment of chronic laryngeal stenosis of paralytic etiology by endoscopic means.

Chronic stenoses of the larynx account for 7.7% of the total number of all diseases of the ENT organs, and recently there has been a tendency to increase the number of patients with this pathology.

Narrowing of the larynx of neurogenic etiology - paralytic stenosis - a condition associated with bilateral damage to the recurrent laryngeal nerves in the vast majority of cases, has a traumatic iatrogenic etiology.

The number of this pathology is growing in proportion to the growth of diseases of the thyroid gland, mediastinal organs and related surgical interventions. The growth of traffic accidents, the criminal situation - all this leads to blunt and penetrating injuries of the neck organs, and, as a result, to an increase in chronic stenosis of the larynx.

The effectiveness of surgical treatment of stenosis of the larynx according to the results of literature reviews by different authors varies from 22 to 94%. An unsatisfactory result is associated with the development of a cicatricial process in the area of the surgical wound and recurrence of stenosis of the larynx.

To date, the use of lasers in the surgical treatment of chronic stenosis of the larynx has a number of undoubted advantages in comparison with "cold" methods. The laser incision is completely aseptic, when the tissues are cut, instant hemostasis of the vessels in the wound occurs, so the surgeon works on a relatively “dry” surgical field, which reduces the operation time.

By minimizing the surgical trauma, tissue repair and patient rehabilitation occur in a shorter time. These advantages make laser surgery the treatment of choice for chronic laryngeal stenoses.

A known method of surgical treatment of stenosis of the vocal larynx of neurogenic etiology, including the use of an Nd:YAG laser (see M.S. Pluzhnikov, M.A. Ryabova, S.A. Karpishchenko "Chronic stenosis of the larynx", Aesculapius, St. Petersburg, 2004, pp. 93-97).

When implementing this method, chordaritenoidotomy is performed using a Nd:YAG laser in contact mode. The contact mode of lasering increases the accuracy of microsurgical operations on the structures of the larynx. Possessing high hemostatic properties, the Nd:YAG laser helps to reduce the operation time, and therefore, to reduce the thermal effect on the tissues of the larynx.

The disadvantages of this method are:

1. Nd:YAG laser, due to its physical characteristics, has a high penetrating ability into biological tissues, with continuous lasering, the depth of thermal damage can reach 8-10 mm.

2. The technique for performing laser chordaritenoidotomy involves laser vaporization of the posterior third of the vocal muscle and vocal process of the arytenoid cartilage. As a result of the operation, an open wound surface is formed in the cavity of the larynx, the healing of which occurs by secondary intention for a long time. This process is always accompanied by a prolonged inflammatory reaction, and in some cases, the formation of connective and scar tissue, which cannot but have a negative impact on the results of surgical treatment.

The closest in technical essence to the claimed solution is a method of laser endoscopic submucosal chordaritenoidotomy, including endolaryngeal performance of submucosal chordaritenoidtomy using a laser, in the process of this, resection of the posterior third of the thyroid arytenoid muscle, arytenoid cartilage, namely the vocal process, anterior 2/3 of its body, apex , muscular process (see Krivopalov A.A., Podkopaeva Yu.Yu. “Laser endoscopic laryngoplasty in the treatment of chronic paralytic stenosis of the larynx”, Medical Council magazine, No. 8, Group Remedium LLC, 2015, p. 32- 35).

When implementing this method, a diode laser with a wavelength of 980 nm in a quasi-pulse mode is used.

The application of this method allows to reduce thermal damage.

However, the efficiency of the method is 83.4%. In other cases, there is a recurrence of stenosis due to insufficient resection of the tissues of the true vocal fold.

The technical result of the proposed solution is to improve the quality of life of the patient by restoring respiratory function due to the formation of a stable lumen of the larynx in combination with a decrease in the inflammatory response in the postoperative period and the rehabilitation of the patient in a shorter time.

To achieve this technical result in the method of surgical treatment of stenoses of the vocal larynx, including endolaryngeal performance of submucosal chordaritenoidtomy using a laser, in the process, resection of the posterior third of the thyroid arytenoid muscle, arytenoid cartilage, namely the vocal process, anterior 2/3 of its body, apex, muscle process, according to the invention, use a laser fiber with a diameter of 400 microns in an inert gas atmosphere in a pulsed mode: wavelength 445 nm, laser radiation power is 7.0 W with a pulse duration of 15 ms and a pause between pulses of 120 ms, while in contact mode an incision is made in the mucous membrane of the vocal fold along its upper surface from the border between the anterior and middle third of the vocal fold, continuing along the vestibular fold, the posterior portion of the vestibular fold is resected, then the mucous membrane of the vocal fold is dissected under the vestibular fold, in the upper and medial surfaces of the mucous membrane are separated from the thyroid-arytenoid muscle, the flap is folded medially, submucosal chordaritenoidtomy is performed, then interrupted sutures are applied endolaryngeally on the separated flap and on the wound endolaryngeally alternately from the anterior angle of the wound, at the end of the operation, hemostasis is controlled and the consistency of the sutures is performed.

The use of a semiconductor "blue" laser with a wavelength of 445 nm, which has photoangiolytic and good resection properties, can reduce the scarring process in the postoperative period compared to other lasers.

The depth of thermal damage to the surrounding tissues is minimal and does not exceed 1.0 mm around the underlying tissues.

The ability to work in an inert gas atmosphere (intraoperative helium supply) allows you to maintain excellent visualization of the surgical field, since the working area is freed from emerging smoke.

When working in an inert gas atmosphere, due to the lack of oxygen in the surgical field, there is no effect of combustion and carbonization of biological tissue, this reduces thermal damage to healthy tissues subject to the surgical field.

Performing laryngoplasty using the specified laser with a wavelength of 445 nm provides work in a "dry" surgical field, increases the accuracy of lasering, while achieving minimal thermal damage to surrounding tissues.

With this method of resection, the mucous membrane of the upper, medial and lower surface of the vocal fold is preserved. This volume of the mucous membrane is sufficient for the formation of a mucous flap and its subsequent fixation on the wound surface.

Wound healing under the mucosal flap occurs in a shorter time, scarring is reduced, and granulation formation is excluded by closing the site of resection of the arytenoid cartilage.

The absence of resection of the posterior third of the body of the arytenoid cartilage makes it possible to preserve the protective and supporting functions of the cartilage, and at the same time, aspiration into the respiratory tract does not occur when swallowing.

From the foregoing, it follows that the introduced distinctive features affect the specified technical result, are in a causal relationship with it.

The method is illustrated in the drawings, where: in Fig. 1 schematically shows a mucosal incision with a diode laser tip; in fig. 2 schematically shows the top view of the direction of separation of the mucosal flap; in fig. 3 schematically on the cut shows the separation of the mucous membrane; fig. 4 schematically shows a top view - the area of resection of the thyroid arytenoid muscle and arytenoid cartilage, the location of the mucous flap during resection; in fig. 5 schematically shows a top view - a method of fixing the mucous flap with interrupted sutures.

The following items are used in the drawings: 1 - laser fiber; 2 - cut line; 3 - border between the anterior and middle third of the vocal fold; 4 - vocal fold; 5 - vestibular fold; 6 - arytenoid cartilage; 7 - flap of the mucous membrane; 8 - thyroid arytenoid muscle; 9 - knotted seam.

The method is carried out as follows.

Under conditions of endotracheal anesthesia, a reference sliding laryngoscope of the WEERDA type and an operating microscope are installed.

Laser fiber 1 with a diameter of 400 μm is used in an atmosphere of inert gas (helium), using a pulsed mode: wavelength 445 nm, laser radiation power from 6.0 to 8.0 W with a long pulse from 10 to 20 ms and a pause between pulses from 100 up to 130 ms.

In the contact mode, laser fiber 1 cuts 2 along the upper surface from the border 3 between the anterior and middle third of the vocal fold 4, continuing along the vestibular fold 5, followed by resection of the free edge of the latter, to the top of the arytenoid cartilage (Fig. 1).

After resection of the free edge of the vestibular fold using laser fiber 1, the incision 2 is continued along the upper surface of the vocal fold 4 in the direction of the apex of the arytenoid cartilage 6.

From the incision line 2, the mucosal flap 7 is separated from the upper and medial surfaces of the thyroid arytenoid muscle 8, the mucosal flap 7 is folded medially (Fig. 2, 3).

Then, using a laser fiber 1, the posterior two thirds of the thyroid arytenoid muscle 8 are resected in the direction from the upper corner of the wound to the arytenoid cartilage 6.

After that, the arytenoid cartilage 6 (vocal process and 2/3 of the body) is isolated, the selected part of the arytenoid cartilage 6 is resected with cold instruments (endoscopic scissors), while only the back part of the body of the arytenoid cartilage 6 is left (Fig. 4).

Interrupted (Monocryl 6-0) sutures 9 are applied endolaryngeally to the separated mucosal flap 7 and to the wound using an endoscopic needle holder.

Interrupted sutures 9 are applied alternately from the anterior angle of the wound, in total from 2 to 4 sutures. At the end of the operation, hemostasis is monitored and the consistency of the sutures is performed (Fig. 5).

The method is illustrated by the following example.

Patient D., born in 1979, was admitted to the surgical department of the St. Petersburg Research Institute of Ear, Throat, Nose and Speech with a diagnosis of bilateral chronic paralytic stenosis of the larynx. Complaints of difficulty breathing with little physical exertion.

From the anamnesis it is known that in 2008 the patient underwent surgery for a multinodular goiter. In the intensive care unit after surgery, she noted difficulty in breathing, dysphonia. Against the background of conservative therapy, the voice was restored, difficulty breathing persisted, occurs with minor physical exertion.

On examination at the institute: sonorous voice, stridor breathing. The general condition is satisfactory. Associated diseases: no

ENT examination: rhinoscopy: the mucous membrane is pink, moist, shiny. The inferior turbinates are of normal size. The nasal septum is slightly curved. There is no pathological discharge from the nasal cavity. There is no difficulty in breathing through the nose. Pharyngoscopy: the mucous membrane is pink, moist, shiny. The soft palate is symmetrical, the movement is full. The palatine tonsils behind the palatine arches, lacunae are not expressed, free. The posterior wall of the pharynx without features. Otoscopy: AD/AS - external auditory canals are free, the skin is not changed. The tympanic membranes are gray in color, the contours are clear. Indirect laryngoscopy: the mucous membrane is pink, moist, shiny. The vocal folds are mother-of-pearl gray, are in the paramedian position, there is no movement, the width of the glottis is not more than 2.0 mm.

Videostroboscopy: the vocal folds are gray, without inflammation. The position of the vocal folds is parallel to each other, on inspiration the opening of the glottis is not more than 2.0 mm, the tone of the folds is reduced.

When examining the function of external respiration by spirometry, the following indicators were obtained: vital capacity of the lungs (hereinafter - VC) - 74.2% of the due values; forced vital capacity of the lungs (hereinafter - FVC) - 74.4%; forced expiratory volume at 1 second (hereinafter - FEV1) - 60.2%; the ratio of FEV1 to VC - 81.1%; peak volumetric expiratory flow rate (hereinafter - PIC) - 55.2; the maximum volumetric velocity during expiration of 50% (hereinafter - MOS 50) - 42.2%; the maximum volumetric velocity during exhalation of 75% (hereinafter - MOS 75) - 34.3%.

Diagnosis at admission: bilateral chronic paralytic stenosis of the larynx.

The patient underwent submucosal chordaritenoidotomy with direct support microlaryngoscopy using a laser.

Under conditions of endotracheal anesthesia, a reference sliding laryngoscope of the WEERDA type and an operating microscope are installed.

A laser fiber with a diameter of 400 μm is used in an atmosphere of inert gas (helium), using a pulsed mode: wavelength 445 nm, laser radiation power from 6.0 to 8.0 W with a long pulse from 10 to 20 ms and a pause between pulses from 100 to 130 ms.

In the contact mode, a laser fiber is used to cut the vocal fold along its upper surface from the border between the anterior and middle third of the vocal fold, continuing along the vestibular fold, followed by resection of the free edge of the latter, to the top of the arytenoid cartilage.

After resection of the free edge of the vestibular fold using a laser fiber, the incision is continued along the upper surface of the vocal fold in the direction of the apex of the arytenoid cartilage.

From the incision line, the mucosal flap is separated from the upper and medial surfaces of the thyroid arytenoid muscle, the flap is folded medially.

Then, using a laser fiber, the posterior two-thirds of the thyroid-arytenoid muscle are resected in the direction from the upper corner of the wound to the arytenoid cartilage.

After that, the arytenoid cartilage is isolated (vocal process and 2/3 of the body), the selected part of the arytenoid cartilage is resected with cold instruments (endoscopic scissors), while leaving only the back of the body of the arytenoid cartilage.

Catgut (Monocryl 6-0) sutures are applied endolaryngeally to the separated flap and to the wound using an endoscopic needle holder.

Interrupted sutures are applied alternately from the anterior angle of the wound, in total from 2 to 4 sutures. At the end of the operation, hemostasis is monitored and the consistency of the sutures is performed. The time of surgical intervention was 90 minutes.

After awakening, the patient was transferred to the intensive care unit. The endotracheal tube was removed after restoration of spontaneous breathing.

After 12 hours, videofibroscopy of the larynx was performed: swelling of the mucous membrane of the larynx, mucous membrane of the arytenoid cartilages is slightly pronounced, the sutures are consistent, the lumen of the larynx is sufficient for breathing.

Drug treatment: dexamethasone intravenously drip 24 mg intraoperatively; after surgery - 24 mg, 20 mg, 16 mg, 12 mg, 8 mg, 4 mg. Ceftriaxone intravenously drip on the day of surgery 2 g, after surgery 2 g per day for 5 days.

Daily in the hospital produced indirect laryngoscopy and inhalation through a nebulizer solution of dexamethasone 0.5 ml + 2 ml 2 times a day.

In the early postoperative period, the patient noted a significant improvement in breathing. Edema of the mucous membrane of the larynx quickly regressed.

Control video stroboscopy of the larynx was performed 10 days after the operation: the vocal fold on the right is gray, without inflammation. The left half of the mucous membrane of the larynx was slightly injected, the lumen of the larynx was up to 8.0 mm wide in the posterior commissure.

The anterior 1/3 of the vocal folds converge when phonation is attempted. From the 10th day, breathing and voice exercises were prescribed under the control of a phonopedist. At discharge, the patient was restored sonorous speech, recommendations were given to continue classes with a phonopedist.

When examining the function of external respiration 2 weeks after the operation, the following indicators were obtained: VC - 91.7% of the proper values; FVC - 99.1%; FEV1 - 95%; the ratio of FEV1 to VC - 103.6%; POS exhalation - 66.6; MOS 50 - 51.1%, MOS 75 - 37.1%. According to spirometry, it was found that the patency of the respiratory function of the larynx was restored.

Upon re-examination in the late postoperative period (6 months), the glottis lumen was 9.0 mm. Breathing through the natural airways is free.

The protective function of the larynx is not broken.

The study of the function of external respiration in the late postoperative period (half a year later) also showed a positive trend, which indicates the absence of a recurrence of the disease and the restoration of the respiratory function of the larynx.

Currently, 7 patients have been operated on.

All patients showed restoration of respiratory function with the preservation of a satisfactory voice. None of the patients had a recurrence of stenosis and a violation of the protective function of the larynx. The length of stay in the hospital was 10-14 days from the date of admission.

In the early postoperative period, the glottis lumen was 8.0 mm and remained in the late postoperative period (after 6-10 months).

The proposed method has the following advantages:

- is the least traumatic, since only endoscopic access is used, which is the most optimal for operations in the laryngeal cavity;

- is the most gentle due to the operation of the diode laser in specially developed modes by the contact method in a high-power pulsed mode and under inert gas conditions, which contributes to minimal thermal damage to tissues without the formation of necrosis and carbonization of the wound surface;

- work with a surgical laser takes place without bleeding on a “dry” surgical field, which reduces the operation time by 2-3 times and reduces surgical trauma;

- does not require the use of monocoagulation, since the laser has high coagulation properties, which does not lead to additional thermal damage;

- no additional operations - endolaryngeal intervention with external access;

- does not require stenting and tracheostomy due to minor reactive phenomena of the mucosa in the postoperative period;

- the volume of tissues resected during the operation is optimal for the formation of the lumen of the larynx, sufficient to restore the respiratory function and maintain the protective function of the larynx;

- closure of the surgical wound with a comparison of the edges of the mucous membrane provides rapid healing by primary intention, which allows you to start early medical and phonopedic rehabilitation;

- the voice function is satisfactorily preserved after surgical treatment, which, in combination with further phonopedic therapy, creates the prerequisites for successful voice rehabilitation (to obtain an even more sonorous voice).

Claims (1)

A method of surgical treatment of stenosis of the vocal larynx, including endolaryngeal performance of submucosal chordaritenoidtomy using a laser, in the process, a resection of the posterior third of the thyroid muscle, arytenoid cartilage, namely the vocal process, anterior 2/3 of its body, apex, muscular process, is performed, characterized in that that a laser fiber with a diameter of 400 microns is used in an inert gas atmosphere in a pulsed mode: a wavelength of 445 nm, a laser radiation power of 7.0 W with a pulse duration of 15 ms and a pause between pulses of 120 ms, while in the contact mode, an incision is made in the mucous membrane of the vocal folds along its upper surface from the border between the anterior and middle third of the vocal fold, continuing along the vestibular fold, resect the posterior portion of the vestibular fold, then dissect the mucous membrane of the vocal fold under the vestibular fold, the upper and medial surfaces of the mucous membrane from separated from the thyroid arytenoid muscle, the flap is folded medially, submucosal chordaritenoidtomy is performed, then interrupted sutures are placed endolaryngeally on the separated flap and on the wound endolaryngeally alternately from the anterior angle of the wound, at the end of the operation, hemostasis is controlled and the consistency of the sutures is performed.

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