Method for treating dacryocystitis (variants)

FIELD: medicine.

SUBSTANCE: by the first variant, one should widen lacrimal point, pass with the probe through inferior lacrimal canaliculus up to the rest into the bone followed by visualization of nasal cavity with endoscope, control for light guide's position should be performed due to diaphanoscopic X-raying via the bone. Burning through osseous tissue of lateral wall in nasal cavity should be fulfilled with laser radiation by developing anastomosis between lacrimal sac and nasal cavity till visualization of light guide in nasal tract. Moreover, lateral wall of nasal cavity should be burned through with a solid-state Nd YAG laser at wave length being 1.44 mcm, impulse energy of 300-440 mJ, impulse frequency 10-20 Hz, impulse duration of 50-150 mcsec. Time for osseous impact corresponds to 0.4-4 min. Intubation of developed anastomosis should be carried out through inferior lacrimal point by withdrawing into nasal cavity with drainage out of silicone as a hollow tube. By the second variant, one should perform visualization of nasal cavity with endoscope followed by burning through bony tissue of lateral wall in nasal cavity with laser radiation. Moreover, light guide's fiber should be applied out of nasal cavity. Burning through should be performed by contact being 3 mm to the front against concha nasalis media in projection of lacrimal fossa with a solid-state Nd YAG laser at wave length being 1.44 mcm at impulse energy of 300-350 mJ, impulse frequency of 10-12 Hz, impulse duration of 50-150 mcsec, time for impact is 0.4-4 min. Then comes passing acutely through inferior lacrimal canaliculus till probe's appearance in developed anastomosis. Then one should fulfill intubation of developed anastomosis through inferior lacrimal point at withdrawing into nasal cavity with drainage out of silicone as a hollow tube. The method enables to achieve permeability of tear-secretion tract at low traumatism and high efficiency in postoperative period at no relapses on closing the anastomosis developed between lacrimal sac and nasal cavity.

EFFECT: higher efficiency of therapy.

2 cl, 2 ex

 

The invention relates to medicine.

The relevance of the treatment given is stored in our time, since this pathology is 2-7,5% of all eyes diseases and is often a cause of long-term disability, and disability (Chirkunov B.F. “Diseases of the lacrimal organs”, Samara, 2001, s).

There is a method of treatment of dacryocystitis (classic external dacryocystorhinostomy), which promptly external access fistula is formed between the lacrimal SAC and the nasal cavity. An incision of skin and soft tissue length up to 3 cm, which start at 2-3 mm above the inner ligament of age and are down slightly around ninepenny edge. There are anorexicly. Soft tissue stupidly stratified to visualize the internal ligaments century. The periosteum is cut and tsaparevetsa outwards 0.5-1 cm the more medially internal ligament. Using the chisel and hammer formed bone window size of 1.5-2 1.2-1.5 cm within the holes longitudinally cut the inner wall of the lacrimal SAC and nasal mucosa. Pieces of the wall of the bag and the lining of the nose are sewn with catgut, forming the front and rear lips formed stoma. Skin and soft tissue sutured in layers (Chirkunov B.F. “Diseases of the lacrimal organs”, Samara, 2001, s.219-220).

Among the disadvantages of this method can be noted the ü high invasiveness, the greater duration of the operation, the presence of skin scar, frequent complications (including Bamyan formed stoma).

Also known is a method of treatment of dacryocystitis endonasal approach (internal dacryocystorhinostomy). In the nose, ahead of the middle shell, make the cutting and removal of the mucosa graft for the projection of the lacrimal fossa. Anteriorly from the resulting defect form a U-shaped flap of mucous membrane. A chisel or boron form the bone window. An incision of lacrimal SAC and remove its internal wall. The u-shape is placed back. The surgery is completed anterior tamponade nose (Chirkunov B.F. “Diseases of the lacrimal organs”, Samara, 2001, pp.272).

The application of this method may be limited by physiological or pathological narrow nasal passage, and the presence of pathology in the proximal lacrimal passages. It should also be noted that when endonasal approach the duration of operation may increase due to intraoperative bleeding and the number of relapses (Bamyan formed stoma) is large enough.

The closest analogue of the invention is a method of treatment of dacryocystitis with the use of laser radiation on the basis of the diode laser.

This method produces an extension of the lower lacrimal punctum. Then pass the t-probe lower the lacrimal canaliculus all the way into the bone. Under the extended lower the lacrimal canaliculus spend the fiber laser to lock into the bone and manual fix it. Visualize the nasal cavity by the endoscope with an optical tip 0 degrees. Burn laser radiation under endoscopic control bone of the lateral wall of the nasal cavity until the fiber laser in the nose. Formed dacryocystorhinostomy washed with 3%solution of collargol (Claflin P.P. “Transcanalicular laser endoscopic dacryocystorhinostomy”, abstract. Diss. Kida. the honey. of Sciences, Ufa, 2002, p.14). This method has several disadvantages. So, for the burning of bone tissue required a lot of power (15 W) or using less power (1-3 watts) increases the exposure time and increases the risk of heat damage to nearby structures (Claflin P.P. “Transcanalicular laser endoscopic dacryocystorhinostomy”, abstract. Diss. Kida. the honey. of Sciences, Ufa, 2002, p.12).

Also, the laser wavelengths does not provide adequate hemostatic effect. 4-6 days after surgery in 3.4% of cases, the patency of the stoma formed partial, and at 12 months in 10.1% of the cross partial and 4.8% of the cross is missing (Claflin P.P. “Transcanalicular laser endoscopic dacryocystorhinostomy is, abstract. Diss. Kida. the honey. of Sciences, Ufa, 2002, p.16-17).

The technical problem solved by the invention is the achievement of patency of lacrimal passages when dacryocystitis laser radiation in the absence of their Sardinia in the postoperative period.

To solve this problem developed two options for the treatment of dacryocystitis, providing the same technical result.

The technical result of both variants of the invention is the achievement of patency of lacrimal passages with low invasiveness and high efficiency in the postoperative period in the absence of relapses in sardenia fistula formed between the lacrimal SAC and the nasal cavity.

The technical result according to the first embodiment is achieved in that in the method of treatment of dacryocystitis, including the enlargement of the lacrimal point, the passage of the probe through the lower lacrimal canaliculus until it stops in the bone conduction through extended lower lacrimal canaliculus of the fiber laser to lock into the bone, the visualization of the nasal cavity by the endoscope, manual control of finding the light guide and the rest of the bone of the lateral wall of the nasal cavity laser radiation with the formation of a fistula between the lacrimal SAC and the nasal cavity to visualize the fiber in the forward course, the distinguishing feature is that the control noorden what I fiber produced by diaphanoscopy transmission through the bone. The lateral wall of the nasal cavity burn solid state Nd : YAG laser with a wavelength of 1.44 μm, pulse energy 300-440 MJ, a pulse frequency of 10-20 Hz, pulse duration of 50 to 150 μs. Time effects on bone is 0.4-4 minutes fistula Formed inkubiruut through the lower lacrimal point with the conclusion in the nasal cavity drainage of silicone in the form of a hollow tube.

The technical result according to the second variant is achieved in that in the method of treatment of dacryocystitis, including visualization of the nasal cavity by the endoscope and the rest of the bone of the lateral wall of the nasal cavity laser radiation, the distinguishing feature is that the announcement of fiber fiber is produced from the nasal cavity. The rest of the bone of the lateral wall of the nasal cavity provide contact 3 mm anterior to the middle turbinate in the projection of the lacrimal fossa solid-state Nd : YAG laser with a wavelength of 1.44 μm, pulse energy 300-350 MJ, a pulse frequency of 10-12 Hz, pulse duration of 50 to 150 μs. Time effects on bone of 0.4-1 min. and Then produce a passage acute through the lower lacrimal canaliculus until the probe is formed fistula. After that, perform intubation fistula formed through the lower lacrimal point with the conclusion in the nasal cavity drainage of silicone in the form of a hollow tube.

Each variant of the method allows to achieve patency of lacrimal passages through effective controlled burning bone tissue laser with the proposed characteristics. Unlike existing methods, this method allows to use as an approach through the lacrimal canaliculus, and through the nasal cavity with equal effectiveness in any clinical situation. Time is considerably reduced interference, which reduces the invasiveness of the intervention, and hence the possibility of postoperative complications. The painless way. The size of the fibers (0,45-0,6 mm) allows to deliver radiation through natural ways and work contact, which eliminates the possibility of heat damage to nearby structures. Also the proposed laser has a hemostatic effect due to the fact that this wavelength is located in the area of local absorption of laser radiation in oxyhemoglobin. No recurrence on sardenia anastomosis is achieved by intubation formed fistula drainage of silicone in the form of a hollow tube.

For the first variant of the invention the energy of the pulses ranges from 300 to 440 MJ, pulse frequency ranges from 10 to 20 Hz with a pulse duration of from 50 to 150 microseconds and time effects on bone of 0.4 to 4 minutes, because smaller features do not provide sufficient burn effect, which increases the exposure time to the bone, and there is a risk of heat damage to nearby structures due to heating of the fiber, and large to reduce traitement laser burning with pass-through damage to the structures of the nasal cavity.

For the second variant of the invention the energy of the pulses ranges from 300 to 350 MJ, pulse frequency ranges from 10 to 12 Hz with a pulse duration of from 50 to 150 microseconds and time effects on bone of 0.4-1 min, as smaller features do not provide sufficient burn effect, which increases the exposure time to the bone, and there is a risk of heat damage to nearby structures due to heating of the fiber, and large do not exclude end-to-end damage in the radiation pattern in the direction of the structures of the orbit and brain, which requires a more careful burning.

Proposed invention the characteristics of the radiation provide sufficient safe power (thermal damage is excluded in contact using a laser), but also hemostatic effect and the possibility of action in narrow and hard to reach areas by conducting radiation through the fiber optical fibers of small diameter.

Laser radiation of other wavelengths is not suitable for the treatment of dacryocystitis. Thus, carbon lasers with a wavelength of 10.6 microns have a very low coagulation effect and do not have fiber that does not allow you to work effectively in narrow cavities. Almost identical carbon lasers crystals activated with erbium wavelength of 2.9 μm. Organosilazane have low power. Lasers, copper vapor with a wavelength of 0.51-of 0.58 μm due to the high level of power density are dangerous to the eyes (the need for adequate protection reduces the possibility of visual control). Lasers on the grenade with neodymium with a wavelength of 1.06 µm with a large penetration depth in tissue (5-10 mm) dangerous in endoscopic surgery because of the possibility of thermal damage to the neurovascular bundles. Laser radiation on the media, activated holmium (wavelength of 2.05 μm) and erbium (1,54 µm), hemostatic effect approaches zero (Tigershark et al. “ENT treatment using laser scalpels”, Tver, 2001, p.6-8).

The method according to the first embodiment is as follows.

Produce expansion of the lower lacrimal punctum, then pass the probe through the lower lacrimal canaliculus all the way into the bone and injected into the lower lacrimal canaliculus, the fiber laser with a diameter of 0.45-0.6 mm all the way into the bone. Produce a visualization of the nasal cavity by the endoscope with an optical tip 0 ° C (if necessary, drill rinoskopicheskoy paintings - 30 degrees). Upon reaching diaphanoscopy transmission “pilot” laser through a bone in the nasal cavity perform manual fixation of optical fiber in the prescribed position. Then burn laser radiation under endoscopic control bone to VI is whlesale laser and smoke in the nose. The radiation parameters are: wavelength of 1.44 μm, pulse energy 300-440 MJ, pulse frequency of 10-20 Hz, pulse duration of 50 to 150 μs, the time effects on bone of 0.4-4 minutes Inkubiruut through the lower lacrimal point kazootoys way hollow silicone drain with a diameter of 0.5 mm orbit to the nasal cavity. No stitches are required. Instalacija in the conjunctival cavity R-RA levomycetin and in the nose of adrenaline. The duration of intervention 10-15 minutes

The method according to the second variant is as follows.

Is local anesthesia of the mucosa of the nasal cavity aerosol 10% R-RA lidocaine. Anteriorly to 3 mm from the middle turbinate on the projection of the lacrimal fossa burn laser hole to visualize soft tissues. The radiation parameters: wavelength of 1.44 μm, pulse energy 300-350 MJ, pulse frequency of 10-12 Hz, pulse duration of 50 to 150 μs, the time effects on bone of 0.4-1 min. Acute carried out by passing a probe through the lower lacrimal canaliculus until the tip in the nasal cavity. Inkubiruut through the lower lacrimal point kazootoys way hollow silicone drain with a diameter of 0.5 mm orbit to the nasal cavity. Instillation in the conjunctival cavity R-RA levomycetin and in the nose of adrenaline. The duration of intervention 15-20 minutes

Example 1: the Patient Was 45 years. Asked of IRTC “Microh rorge eye to them. Acad. Fyodorov complaining of constant tears from the left eye for 3 years. From the anamnesis it is known that for the last 2 years three times took place treatment in occasion of left-dacryocystitis. During examination: kazootoys the way to the left impassable, passable right. According to the radiological research lacrimal ducts on the left reveals a mechanical obstruction at the level of the lacrimal SAC.

Diagnosis: OS-Chronic recurrent dacryocystitis.

Obstruction of the lacrimal passages. OD: Well.

Given the history and survey data, the patient was recommended dacryocystorhinostomy (formation of a fistula between the lacrimal SAC and the nasal passage) in the first embodiment of the invention.

During the operation, after the expansion of the lower lacrimal punctum and the passage of the probe to the nasal cavity through the lower lacrimal canaliculus under manual (through the skin) and endoscopic (from the nasal cavity by visualizing the “pilot” Nd YAG laser) control was introduced fiber light guide with a diameter of 0.6 mm to the bone. Laser radiation under the control of the endoscope from the nasal cavity formed artificial fistula between the lacrimal SAC and the nasal cavity. The radiation parameters were: wavelength of 1.44 μm, pulse energy of 440 MJ, pulse frequency 12 Hz, pulse duration of 100 μs, glutelin is the terrain effects on bone 1.5 min. Formed in the tear path entered hollow silicone drainage. At discharge 6 days after surgery to outpatient treatment kazootoys the way to the left to cross. At the control examination after 1 month kazootoys the way to the left to cross. Drainage works, his position unchanged.

Example 2: Patient N. 34 years asked of IRTC “eye microsurgery” complaining tears from the left eye in the last 5 years. Every year marks the emergence of a mucous discharge from the left eye. Medical help is not sought, independently dripping chloramphenicol with a temporary effect. When examining kazootoys road passable right, left impassable. Also defined Bamyan lower lacrimal canaliculus in its horizontal part. According to x-ray contrast studies of the lower lacrimal canaliculus impassable, also is determined by the mechanical obstruction at the level of the lacrimal SAC. Diagnosis: OS-Chronic recurrent dacryocystitis. Stenosis of the lower lacrimal canaliculus. Mechanical obstruction kazootoys ways. OD-Healthy.

The patient is recommended dacryocystorhinostomy according to the second variant of the invention.

During the operation, after a local anesthetic spray lidocaine produced by the burning of the bone of the lateral wall of the nasal cavity is 3 mm anterior to the middle turbinate in the projection of the lacrimal fossa. The radiation parameters of the Nd YAG laser were: wavelength of 1.44 μm, pulse energy of 320 MJ, pulse frequency 10 Hz, pulse duration of 100 μs, the time effects on bone 50 C. Acute formed by passage through the lower lacrimal canaliculus to the imaging probe in the nose. Formed kazootoys way intubirovannam hollow silicone drainage. Instillation in the conjunctival cavity solution of chloramphenicol in the nose of epinephrine.

At discharge after 5 days kazootoys the way to the left to cross. When viewed through 1 month left full capacity. Drainage works, his position unchanged.

1. A method of treatment of dacryocystitis, including the extension of the lower lacrimal punctum, the passage of the probe through the lower lacrimal canaliculus all the way into the bone, the introduction of a lacrimal canaliculus of the fiber laser to lock into the bone, the visualization of the nasal cavity by the endoscope, the control of the location of the tip of the light guide and the rest of the bone of the lateral wall of the nasal cavity laser radiation with the formation of a fistula between the lacrimal SAC and the nasal cavity to visualize the tip in the forward move, characterized in that the control location of the tip of the fiber produced by diaphanoscopy transmission through the bone, the lateral wall of the nasal cavity burn solid state Nd : YAG laser with a wavelength of 144 μm, with pulse energies 300-440 MJ, a pulse frequency of 10-20 Hz, a pulse duration of between 50 and 150 μs, time effects on bone of 0.4-4 min, and formed fistula inkubiruut through the lower lacrimal point with the conclusion in the nasal cavity drainage of silicone in the form of a hollow tube.

2. A method of treatment of dacryocystitis, including visualization of the nasal cavity by the endoscope and the rest of the bone of the lateral wall of the nasal cavity laser radiation, characterized in that the summing up of fibers of the fiber produced from the nasal cavity, the rest of the bone of the lateral wall of the nasal cavity provide contact 3 mm anterior to the middle turbinate of the nasal cavity in the projection of the lacrimal fossa solid-state Nd : YAG laser with a wavelength of 1.44 μm, pulse energy 300-350 MJ, a pulse frequency of 10-12 Hz, a pulse duration of between 50 and 150 μs, time effects on bone of 0.4-1 min, then sharp produced by passage through the lower lacrimal the tubule until the probe is formed fistula and perform intubation fistula formed through the lower lacrimal point with the conclusion in the nasal cavity drainage of silicone in the form of a hollow tube.



 

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