ПРОБЛЕМНЫЕ СТАТЬИ ИОБЗОРЫ
УДК: 616.22-009.11:007.211 -089.844
НОВЫЕ МЕТОДЫ ЛАРИНГОПЛАСТИКИ У БОЛЬНЫХ С
ХРОНИЧЕСКИМ ПАРАЛИТИЧЕСКИМ СТЕНОЗОМ ГОРТАНИ
У.Н. Вохидов, О.Н. Шерназаров, Д.М. Султонов
Ташкентский государственный стоматологический институт
ABSTRACT
The aim of the study was to evaluate the effectiveness
of various types of surgical treatment of patients with
bilateral paralytic stenosis of the larynx. The study
involved 22 patients aged 2 to 60 years, suffering from
paralytic stenosis of the larynx, who was treated in the
period from 2015 to 2020. The results of treatment with
the use of laser resection of the vocal fold, Closing the
surgical wound with matching the edges of the mucous
membrane and suturing provides fast healing by primary
intention, which allows you to start early therapeutic
and phonopedic rehabilitation. All this allows us to
recommend laser submucosal chordaritenoidotomy for
use in clinical practice.
Key words:
paralytic stenosis of the larynx, laser
laryngoplasty, chordaritenoidotomy; vocal folds, surgical
intervention.
РЕЗЮМЕ
Целью исследования явилось оценка эффективно
сти различных видов хирургического лечения боль
ных с двусторонними паралитическими стенозами
гортани. В исследовании приняли участие 22 па
циентов в возрасте от 20 до 60 лет, страдающий
паралитическим стенозом гортани, находившийся
на лечении в период с 2015 по 2020 год. Результаты
лечения с применением лазерную резекцию голосовой
складки. Закрытие операционной раны с сопостав
лением краев слизистой оболочки и наложением
швов обеспечивает быстрое заживление первичным
натяжением, что позволяет начать раннюю лечеб-
но-фонопедическую реабилитацию. Все это позво
ляет рекомендовать лазерную подслизистую хор-
даритеноидотомию к использованию в клинической
практике.
Ключевые слова:
паралитический стеноз
гортани, лазерная ларингопластика, хордаритенои-
дотомия, голосовые складки, хирургическое вмеша
тельство.
ХУЛОСА
Тадқиқотнинг мақсади хиқилдоқнинг икки томон-
лама паралитик торайиши бўлган беморларни турли
хил жарроҳлик даволаш самарадорлигини баҳолаш-
дан иборат эди. Тадқиқотга 2015 йилдан 2020 йилгача
бўлган даврда 20 ёшдан 60 ёшгача бўлган хиқилдоқ
паралитик торайиши билан оғриган 22 нафар бемор
жалб қилинган. Овоз бойлами лазерли резекцияси
натижалари шуни кўрсатдики, юқоридаги жарроҳлик
аралашув усулларидан сўнг бирламчи жароҳатнинг
қисқа вақт ичида тикланиши эрга даволаш- фонопе-
дик реабилитацияга имкон беради. Буларнинг бар-
часи лазерли шиллиқ ости хордаретиноидотомияни
амалиёт кенг қўллашга йўл очиб беради.
Калит сўзлар:
уиқилдоқнинг паралитик торайи
ши, лазерли ларингопластика, хордаритеноидото-
мия, овоз бурмалари, жарроулик аралашуви.
A method of surgical treatment of chronic paralyt
ic stenosis of the larynx - laser endoscopic submucosal
chordaritenoidotomy, based on the studies, has shown
its clinical effectiveness. Antibacterial inhalation therapy
occupies an important place in the complex of medical
rehabilitation of patients, it is an effective method of pre
venting complications, a method of local anti-inflamma
tory treatment, which promotes rapid rehabilitation in the
postoperative period.
Chronic stenosis of the larynx (CSL) is a group of dis
eases that differ in etiological factor, the main symptom
of which is persistent narrowing of the larynx lumen, dis
rupting the flow of air into the respiratory tract, leading
to the development of obstructive respiratory failure, as
well as pronounced impairment of the voice Sanction. The
course of CSL is characterized by a slowly progressive
development. Decompensation of stenosis is a life-threat
ening condition for the patient that in some cases requires
immediate surgical intervention. The presence of a tra
cheostomy leads to social maladjustment and persistent
disability in a significant number of patients of working
age [1,5, 6,9, 10, 13].
One of the types of stenosis is paralytic stenosis of the
larynx (PSL), in which the narrowing of the larynx lu
men is associated with a disorder of motor function in the
form of a decrease in the strength / amplitude of volun
tary movements (paresis) or their complete absence (pa
ralysis) due to a violation of the innervation of the corre
sponding muscles of the larynx. Neurogenic disorders of
the motor function of the larynx account for up to 30% of
all diseases of the vocal apparatus. Up to 90% of patients
with this pathology are persons of working age, of which
86% are women [11].
Paresis and paralysis of the muscles of the larynx are
subdivided into central (cortical, cortico-bulbar, bulbar),
developing with encephalitis, encephalopathy of various
origins, congenital cerebral palsy, diffuse atherosclerosis
of the cerebral vessels, circulatory disorders in the arter
ies of the anterior and lower upper, middle, lower lateral
branches), neoplasms of the cerebellum. Peripheral steno
sis occurs at various levels of the laryngeal nerve lesion.
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ПРОБЛЕМНЫЕ СТАТЬИ ИОБЗОРЫ
In case of damage above the origin of the superior laryn
geal nerve from the trunk of the vagus nerve, both laryn
geal nerves are affected, and in case of damage below the
origin, only one lower laryngeal nerve is affected.
The main causes of bilateral laryngeal nerve damage
are:
• surgical interventions on the organs of the neck and
mediastinum - 82,8%, including primary and revision
interventions on the thyroid gland - 75,8%;
• neoplasms, diseases of the central and peripheral nerv
ous system, toxic lesions, injuries - 17,8% [11].
The problem of surgical treatment of chronic para
lytic stenosis of the larynx remains relevant to this day,
which is associated with the lack of a unified approach to
treatment tactics, the variety of proposed surgical inter
ventions, high technological complexity of their imple
mentation, a long period of rehabilitation and not always
satisfactory results [3,6, 7].
Tasks of surgical treatment for chronic paralytic steno
sis of the larynx at the present stage:
• formation of a lumen of the larynx, sufficient to restore
respiratory function and improve the quality of life;
• preservation of the protective (dividing) function of
the larynx;
• the most sparing surgical access, operative reception,
economical volume of resection, minimum time of
surgical intervention;
•
minimum indications for preventive tracheostomy,
prolonged intubation and laryngeal stenting;
• rejection of extra-laryngeal surgical access as more
traumatic;
• quick rehabilitation (in the presence of a stoma - de
cannulation) of the patient;
• the possibility of an early start of therapeutic and pho-
nopedic rehabilitation [3,16].
The combination of transoral endoscopic access to the
structures of the larynx as the most gentle with the mi
crolaryngoscopy technique according to O. Kleinsasser
(1968) is a universal technology that most closely match
es the tasks of modem laryngoplasty and is widely used
by laryngologists all over the world [12, 13].
Today, many laser systems are used in medicine with
various media fillers, wavelengths and physical effects:
CO2 (10 600 rnn.), Ho: YAG (2 100 nm.), Nd: YAG (1
064 nm.), KTP (532 nm.), Diodes (600-1000 run.), Dye
(608-1 300 nm.), Alexandrite (710-820 nm.), Ruby (694
nm.), Kr + (568 run.), Ar + (514 run.), Excimer (170-532
run.), Er: YAG (2940 run.). The use of a surgical laser for
endoscopic interventions has opened up new possibilities
in endolaryngeal microsurgery, which has become mini
mally invasive and has significantly expanded its indica
tions for use [2, 4, 6, 8].
In traditional direct reference microlaryngoscopy ac
cording to O. Kleinsasser (1968), the delivery of laser
energy to the operating field is carried out in two modes:
• distant (non-contact) - using mirror optical systems
(Ruby, Nd: YAG, CO2);
contact - using flexible light guides (Diodes, KTP, Nd:
YAG). Each of these methods has its own advantages
and disadvantages.
CO2 - the laser works in a non-contact mode, is well
absorbed by water and causes instant tissue evaporation,
while thermal damage to surrounding healthy tissues is
minimal and spreads to a depth of 500-100 microns out
side the ablation crater. CO2 laser is a convenient tool for
deep resections of the larynx structures, provides good he
mostasis of small capillary vessels, but is insufficient for
bleeding from large vessels. In addition, given the com
plex anatomy of the larynx cavity, working in a non-con-
tact mode creates certain difficulties when performing
operations in hard-to-reach areas. With direct laryngos
copy, CO2 laser radiation is supplied from the source at a
considerable distance - up to 400 mm. At the same time,
radiation can be repeatedly reflected from the walls of the
laryngoscope, instruments, and the surgical field, which
requires the use of serious measures for the safety of the
patient, medical workers, and the development of special
instruments with an anti-reflective coating [12, 13].
The 960-980nm diode laser also absorbs well in
water, providing minimal damaging effect and good
regeneration. Radiation is transmitted from the source
to the working tool through flexible quartz fiber with
minimal loss. The active chromophores for the diode
laser are hemoglobin and oxyhemoglobin. The opera
tion of a diode laser is possible both in a distant mode
and when the quartz tip is in contact with tissues. In
the non-contact mode of exposure, the laser energy is
accumulated in the capillaries and blood cells, pro
viding coagulation of blood vessels. When tissue is
dissected, hemostasis occurs instantly, surgical inter
vention takes place with a "dry’’ operating field. The
operation of the tip of the diode laser in the dissection
mode makes it easy to carry out bloodless separation
of the mucous membrane of the larynx, connective,
cicatricial, cartilaginous tissues, performing the func
tions of a scalpel, coagulator and raspator simultane
ously [2, 6, 7, 8].
Objective:
To evaluate the effectiveness of laser en
doscopic laryngoplasty in patients with chronic bilateral
paralytic laryngeal stenosis.
Patients and methods:
We observed 22 patients with
chronic bilateral paralytic stenosis of the larynx. The age
of patients ranged from 22 to 66 years, of which 16 were
female, 6 were male. In 11 admitted patients, the cause of
bilateral vocal cord paralysis was surgery on the thyroid
gland; there was no history of surgery on the larynx. A
combined (cicatricial-paralytic) form of stenosis was di
agnosed in 11 patients: in 3 patients in history, in addition
to surgical interventions on the thyroid gland, repeated
interventions were performed on the larynx. In 7 patients,
paralysis of the laryngeal muscles and cicatricial process
were of traumatic etiology. At admission, 8 patients were
chronic cannulated carriers. The duration of wearing a
tracheostomy ranged from 6 months, up to 4 years.
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MEDICINE AND INNOVATIONS |
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ПРОБЛЕМНЫЕ СТАТЬИ ИОБЗОРЫ
Evaluation of the effectiveness of the treatment was
carried out on the basis of the data of general clinical,
standard otorhinolaryngological examination, video en
dostroboscopy, fibrolaryngoscopy, spirometry [11, 14].
According to the data of endoscopic research methods,
the vocal folds of the patients were in the paramedian po
sition before the surgical treatment. In 7 of them, cicatri
cial changes were revealed in the area of the interscapular
part of the larynx, in 4 patients, scars and granulations
were noted in the sublining space, above and around the
tracheostomy tube.
Based on the data of the examination of patients, when
planning the surgical intervention, we adhered to the fol
lowing indications for endoscopic laryngoplasty:
• the patient has no positive dynamics and the effective
ness of conservative treatment for 6-12 months, from
the onset of the disease;
• with a stenosis area less than 50 mm2;
• deviation from the norm in the gas composition and
acid-base state of the blood;
• the presence of inspiratory dyspnea and stridor at rest;
• lack of exercise tolerance;
• high threat of decompensation of stenosis and asphyx
ia in case of potential upper respiratory tract infection
(URTI) [3, 14].
In the surgical treatment of patients with chronic par
alytic stenosis of the larynx, we used the method of laser
endoscopic submucosal chordaritenoidotomy. A diode la
ser with a wavelength of 980 nm was used in the contact
mode. The radiation was delivered using a quartz optical
fiber with a diameter of 600 pm. We used a pulsed mode
with a pulse duration of 30 ms, a pulse repetition rate of
12,5 Hz, a pulse energy of 0.75 J and an average radiation
power of 9.4
W. This mode of action provides effective ablation of
tissues without thermal damage to deep- lying tissues,
without necrosis and wound carbonization. [3,4,7, 8].
Operation technique. Suigery is performed under gen
eral anesthesia. Tracheal intubation is performed tran-
sorally or through a tracheostomy. With mechanical ven
tilation, it is possible to use both the traditional ventilation
mode and high-frequency jet ventilation of the lungs
through a microcatheter.
In conditions of direct supporting microlaryngoscopy,
using a surgical diode laser, the mucous membrane of
the vocal fold is incised along its upper surface from the
middle of the vocal fold through the vocal process to the
apex of the arytenoid cartilage. Then the vocal process
of the arytenoid cartilage is submucosally secreted and
freed from the muscle fibers. The posterior third of the
vocal fold muscle fibers are isolated and resected using
laser vaporization. Then the fibers of the arytenoid muscle
are separated from the muscular process of the arytenoid
cartilage. During the operation, using a surgical diode
laser, the arytenoid cartilage is resected in the following
volume: the vocal process, most of its div, the apex and
part of the muscular process. Catgut (chrome-plated cat
gut 4-0, 5-0) interrupted sutures are applied to the wound
of the mucous membrane. First, a suture is applied to the
front comer of the wound. In this case, the needle is in
jected into the area of the upper edge of the wound. Then
the lower edge of the wound is captured together in the
vocal cord and the upper edge of the elastic cone. The
suture of the mucous membrane is tightened and tied in
such a way as to achieve contact of the edges of the mu
cous membrane incision and the expansion of the larynx
lumen. When suturing a wound, 3 to 5 sutures are applied
from the front to the back comer of the wound.
In 7 patients, we performed laser vaporization of scars
in the laryngeal cavity and granulations in the sublining
space and trachea.
During the first days after the operation, the patients
were under observation in the intensive care unit, then
transferred to the clinic.
Medical treatment. Suigical trauma inevitably causes
reactive inflammation from all the anatomical structures
of the larynx. In fact, in the postoperative period there is
acute laryngitis caused not by an infectious agent, but by
a physical (heat energy) and mechanical factor (surgery).
Under the conditions of an operating injury, the systems
of local immunological protection of the respiratory ep
ithelium are significantly affected, the risk of infection
with pathogenic flora, colonization of opportunistic mi
croorganisms and the development of formidable puru
lent complications increases. Prevention of these condi
tions is the most important component of drug treatment
in the postoperative period.
Antibiotic prophylaxis (intravenous administration of
ceftriaxone or amoxicillin / clavulanate) is carried out 1
hour before the start of the operation and during the first
days after it. Along with symptomatic treatment (pain
relievers, agents for the prevention and control of bleed
ing), parenteral administration of glucocorticosteroid
hormones (prednisolone, dexamethasone), which have
anti-inflammatory and desensitizing effects, is indicated.
Doses of glucocorticosteroids (GCS) are calculated indi
vidually per course. Compulsory in the treatment of GCS
is the appointment of proton pump inhibitors (omepra
zole) to prevent complications from the gastrointestinal
tract [3].(Figure 1).
Research results.
Already on the second day after the
operation, all patients noted an improvement in breathing.
During fibrolaryngoscopy and video endostroboscopy,
the following dynamics of the laryngoscopic picture was
observed: during the first 48 hours after the operation,
there was edema of the mucous membrane in the area
of the surgical intervention. On the 3rd-7th day after the
operation, the edema of the laryngeal mucosa decreased
significantly (Fig. 1), on the 10th-14th day, reactive
inflammation in the larynx was minimal (Fig. 1). Can
nulation carriers: 6 patients were decannulated in the
early postoperative period. A silicone T-shaped stent
according to Montgomery was installed in 2 patients
59
ПРОБЛЕМНЫЕ СТАТЬИ ИОБЗОРЫ
Fig.1. Videoendostroboscopy after endoscopic laser submucosal chordarinetoidotomy
after laser vaporization of coarse scars of the larynx
cavity for a period of 3-6 months.
We studied the function of external respiration be
fore the operation, 14 days after the operation and in
the long-term postoperative period. The dynamics of
the main spirographic indicators was assessed in per
cent. Analyzing the data before and after surgery, we
can conclude that there is a statistically significant im
provement in the patency of the upper airways.
All patients in the early postoperative period under
went phonopedic exercises in a gentle mode: the for
mation of the lower diaphragmatic type of breathing,
activation of articulatory motor skills. From the 10-
12th day after the operation, the goal of phonopedic
training was to get a sonorous voice. In all patients,
after a course of phonopedic exercises in the early
postoperative period, an improvement in voice func
tion was noted.
In the long-term postoperative period (after 4-6
months), we examined 9 patients. With video en
dostroboscopy: the glottis is triangular; during phona
tion, the anterior 2/3 of the vocal fold on the side of
the operation performed touch the contralateral side,
which provides a sonorous voice (Fig. 1).
All patients subjectively noted a significant im
provement in breathing. In spirographic exami
nation, an increase in peak expiratory volumetric
velocity and an increase in lung volume were re
corded.
In the late postoperative period, 7 patients underwent
a course of phonopedic rehabilitation, which made it
possible to significantly improve the vocal function: to
increase the sonority and volume of the voice.
Thus, transoral endoscopic access, microlaryngos
copy according to O. Kleinsasser and the use of modem
laser surgical systems are today the optimal technology
in reconstructive surgery of the larynx. Based on the
studies carried out, it can be concluded that the pro
posed method of surgical treatment of chronic paralyt
ic stenosis of the larynx is sufficiently effective. Laser
submucosal chordaritenoidotomy is a gentle method of
surgical treatment due to the fact that the volume of the
resected tissues is optimal for the formation of a lumen
of the larynx sufficient for breathing and preservation
of the voice and protective function of the larynx. Also,
the proposed modes of laser surgical exposure have
high coagulation properties, which ensures the absence
of intraoperative bleeding, minimal surgical trauma.
Closing the operating wound with matching the edges
of the mucous membrane and suturing ensures rapid
healing by primary intention, which allows early ther
apeutic and phonopedic rehabilitation to begin. All this
allows us to recommend laser submucosal chordarite
noidotomy for use in clinical practice.
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УДК: 616.716.8+617.52]-002:615.826.65
KINESIO TASMALASH VA UNING YUZ-JAG’ SOXASI YALLIG’LANISH
KASALLIKLARIDA QO’LLANILISH IMKONIYATLARI
Juraev B.N.
1
, Xalmatova M.A.
1
, Ksembaev S.S.
2
1
Tashkent davlat stomatologiya instituti, yuz-jag jarroxligi kafedrasi.
2
Rossiya Sog'liqni saqlash vazirligining "Oozon davlat tibbiyot imiversiteti"FSBEI, Qozon, Rossiya
ХУЛОСА
Yuz-jag' jarrohligi va jarrohlik stomatologiyaning
dolzarb muammolaridan biri - yuz-jag' soxasi o'tkir
odontogen yiringli yallig'lanish kasalliklarida xirurgik
muolajadan
so'ng
kinesio
tasmalari
yordamida
reabilitatsiya qilish samaradorligini oshirish bo'yicha
adabiyotlar sharxi.
Maqsad
-
yuz-jag
’
sohasi
kasalliklarida
kinesio
tasmalariga
bag
’ishlangan
nashrlarning
materiallarini о ’rganish.
Metodika.Mikrosirkulyatsiyaninormallashtirishda,
shish paydo bo 'lishini kamaytirishda va og 'riqning
og'irligida
amalga
oshiriladigan
sanogenetik
jarayonlar uchun qulay sharoitlar yaratilishiga olib
keladigan, teriga dasturlar shaklida qo 'llaniladigan
kinesiologik tasmaning ta sir qilish mexanizmlari
batafsil
tavsiflangan.
Sportchilarda
mushak-
skelet tizimining shikastlanishlarini oldini olish va
davolashda
kinesio
teyplash
usulidan
foydalanish
yuzasidan nashrlar sonining ко 'payishi qayd etilgan.
Bundan tashqari, hozirgi vaqtda kinesio tasmalari
klinik tibbiyotda, masalan, nevrologiya va ortopediya
amaliyotida ham qo ’llanilmoqda. Zamonaviy ilmiy
izlanishlargako
'ra,
surunkalibelog
'rigsubakromial
impijment sindromi bilan og 'rigan bemorlarda kinesio
lentalarini qo 'Hash og 'riq sindromining og 'irligini
sezilarli darajada kamaytirishi mumkin.
Natijalar.
Kinesio lenta usuli sport va klinik
tibbiyotda Juda keng qo llanilishiga qaramay, mavjud
adabiyotlarda uni yuz-jag Jarrohligida, xususan soxasi
о tkir odontogen yiringli yallig lanish kasalliklari
uchun foydalanishga bag 'ishlangan oz sonli ishlar
mavjud. Yuz- jag' soxasi о tkir odontogen yiringli
yallig 'lanish kasalliklari operativ muolajaidan so 'ng
kinesio
tasma
usulidan
foydalanish
yallig’lanish
shishishi
darajasini
va
og
'riq
sindromining
intensivligini sezilarli darajada kamaytirishga imkon
berdi.
Xulosa.
Chop etilgan adabiyotlarni ко 'rib chiqish
natijalari shuni ко 'rsatadiki, kinesio tasmasi - bu
yuz-jag ’ soxasining о tkir odontogen yallig 'lanish
kasalliklarini
operativ
davolashidan
so
'ng
reabilitatsiya
qilishning
istiqbolli,
sodda,
shikast
yetkazmaydigan usuli hisoblanib, и nojo 'ya ta 'sir
va asoratlarni yuzaga keltirmaydi va bemorlarning
hayot sifatini sezilarli darajada yaxshilaydi. Taqdim
etilgan
ilmiy
nashrlarning
materiallarini
tahlil
qilish natijasi, hozirgi vaqtda yuqorida keltirilgan
ta’sir mexanizmlariga hamda og’riq va shishishni
kamaytirish imkoniyatiga qaramay yuz-jag 'soxasining
о tkir odontogen yallig 'lanish kasalliklarida kinesio
tasmalarini qo 'Hash bo 'yicha tadqiqotlar yetarli
emasligini ко 'rsatib berdi.
Kalit so’zlar:
Yuz-jag’ soxasi o’tkir odontogen
yallig 'lanish kasalliklari, yuz-yuz sohasi, og 'riq
sindromi, operatsiyadan keyingi shish, reabilitatsiya,
kinesio tasmalari
РЕЗЮМЕ
Предмет.
Представлен
обзор
литературы,
посвященный актуальной проблеме челюстно-ли
цевой хирургии и хирургической стоматологии
— повышению эффективности реабилитации па
циентов с переломами нижней челюсти с исполь
зованием кинезиотейпирования.
Цель —
изучить материалы публикаций, по
священных
кинезиотейпированию
при
воспали
тельных заболевании челюстно-лицевой области.
Методология. Подробно описаны механизмы дей
ствия
кинезиологического
тейпа,
наложенного
в виде аппликаций на кожу, которые приводят к
созданию благоприятных условий для саногенети-
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