RU2309700C1 - Method for treating benign laryngeal neoplasms - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: for removing neoplasms being above 2 mm one should apply the radiation of YAG-Ho laser. Beforehand one should create the area of tension of underlying mucosa due to pulling back the neoplasm with the help of a clamp. Then a light guide's edge should be introduced into submucosal layer for the depth of about 1-5 mm under the neoplasm's bottom to replace it along the bottom, 5-7 impulses of laser radiation should be supplied so that the wound from every further impulse should conjugate with that of the previous impulse. Neoplasms of below 2 mm should be affected by contact with CTR laser with 1-8 impulses. Coagulation of neoplasms' bottoms and their residues should be fulfilled with defocused beam of CTR laser which should be installed above the neoplasm's surface at the distance of 1-2 mm. The innovation enables to decrease traumatism of operation due to applying differentiated laser impact upon different neoplasms.

EFFECT: higher efficiency of therapy.

2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used for surgical treatment of benign neoplasms of the larynx using lasers

A known method of treating benign neoplasms of the larynx "Art. Konopleva O.I. “Endolaryngeal contact laser surgery of laryngeal neoplasms”, journal “News of Otorhinolaryngology and Logopathology”, 2000, No. 3 p.150-162). In this method, under anesthesia, with direct microlaryngoscopy, endolaryngeal removal of neoplasms is performed.

The disadvantage of this method is its low efficiency, due to the fact that after the operation a relapse is possible. Repeated removal of the neoplasm leads to scarring of the larynx, trachea, and a violation of their functions. The effect on neoplasms and their remnants in the thickness of the vocal cords is accompanied by significant bleeding.

A known method of treating benign neoplasms of the larynx, including laser irradiation with a light guide on the affected areas (V. Zenger et al. “Endolaryngeal microsurgery and holmium laser in children with respiratory popillomatosis.” Methodical recommendations, M., 1999, p. 13).

The disadvantage of this method is its limited capabilities, due to the lack of differentiated effects on neoplasms of various shapes and sizes. So, for example, when exposed to laser radiation with a wavelength of 2.09 μm on neoplasms with a diameter of less than 2 mm, a deep wound channel is obtained, which increases the invasiveness of the operation. In addition, coagulation of the remnants of neoplasms is also preferable to carry out by laser exposure of shallow penetration, which will avoid significant burn tissue reactions.

In accordance with this, a task was set to increase the effectiveness of treatment and reduce its morbidity through the use of differentiated laser exposure to various neoplasms.

To solve this problem, in a method for treating benign neoplasms of the larynx, including laser exposure of the affected areas, it was proposed to use radiation from a YAG-holmium laser to remove neoplasms larger than 2 mm, while first creating a tension zone of the underlying mucous membrane by pulling the neoplasm by clamping, then the fiber end inject into the submucosal layer to a depth of 1-5 mm under the base of the neoplasm, move the end along the base and send 5-7 laser pulses and radiation in such a way that the wound from each subsequent pulse matches the wound from the previous pulse, contact the KTP laser with 1-8 pulses for neoplasms less than 2 mm, and coagulate the neoplasm bases and their residues with a defocused KTP laser beam, which must be installed above the neoplasm surface at a distance of 1-2 mm.

The method is as follows.

Neoplasms larger than 2 mm are removed using a YAG-holmium laser. Previously, to create a zone of tension of the underlying mucous membrane, the neoplasm is delayed by micro-clamping. Then, with a little effort, touch the working end of the fiber to the mucous membrane and send a series of YAG pulses of holmium laser radiation with a wavelength of 2.09 μm, in a pulse-periodic mode, pulse duration 200-500 μs, with an energy of 0.1-2.5 J , a pulse frequency of 10-15 Hz, and then the end of the fiber is introduced into the submucosal layer to a depth of 3-5 mm. Without removing the fibers from the tissues, they send a series of 5-7 pulses of YAG-holmium laser radiation with a wavelength of 2.09 μm, a pulse energy of 0.1-2.5 J, a pulse frequency of 10-15 Hz, a pulse duration of 200-500 μs, at the same time, the working end of the fiber is slowly moved inside the soft tissues along the base of the neoplasm so that the wound from each subsequent impulse mates with the wound from the previous impulse, trying to prevent the fiber end from going outside, i.e. into the lumen of the larynx. In this case, a cut line is formed. If the tissue being cut is in a state of tension, then the edges of the incision diverge and a typical cut wound forms, therefore, the neoplasm is tensioned by clamping. If there is no tissue tension, then the cut from the laser beam is difficult to differentiate, since the edges of the wound fall off.

Removal of small neoplasms up to 2 mm (for example, nodules of singers) is performed by contacting them with a KTP laser (Nd: YAG Neodymium laser with frequency doubling on a KTP crystal: potassium-titanium phosphate) with a wavelength of 0.53 μm, in pulsed mode , with an energy of 1-3 J, a pulse frequency of 2 Hz, after which the remains of the “legs, stump” of neoplasms are coagulated by a defocused beam of a KTP laser with a wavelength of 0.53 μm, in a pulsed mode, with an energy of 1-3 J, a pulse frequency of 2 Hz, while the working end of the fiber of the KTP laser ra considered over the surface at a distance of 1-2 mm.

The operation is carried out under the control of direct microlaryngoscopy (the progress of the operation is monitored under a microscope with a focal length of 350-400 mm or using a Karl Storz No. 11001 UD fibrolaringoscope, working length is 34 mm, while the fiber optic cable of the STN-10 device is passed through the instrument channel of the fiberscope - inner diameter 2.3 mm) with FHFIVL (transcatheter high-frequency artificial ventilation of the lungs), the working end of the fiber of the STN-10 apparatus (diameter 400-600 microns), passed through a hollow metal tread, under the control of vision, is brought to the mucosa the membrane at the base of the neoplasm of the larynx.

As for laser surgery of specific nosological forms of laryngeal tumors, then, taking into account the above methods of operation, they can be distributed as follows. Coagulation or evaporation of tissues is carried out in cases of detection of pachydermia, leukoplakia and Reineck's disease, although in the latter case, an instrumental laser operation is performed with mechanical diepithelization of the altered mucosa followed by coagulation of the underlying tissues. Tumor is cut off more often with exophytic growth or on the leg. Such neoplasms include single papillomas, polyps, angiomas and angiofibromas, granulomas, chondroma. However, operations in these cases end with coagulation of the site of attachment of the leg.

Most operations are performed by tissue dissection with creeping tumors or located on a wide base. This method is used for papillomatosis, fibromas, cysts, chondroma, adenoma. During the operation, it is necessary to pay attention to the interaction of the anesthesiologist and the surgeon operating with the help of a YAG-holmium laser and a CTE laser in the airway lumen. To prevent local outbreaks of the narcotic mixture at the command of the surgeon, ventilation of the lungs is stopped (for 10-20 s). This technique is a feature of laser operations.

Specific examples.

Example 1. Patient B., born in 1965, medical record No. 19059, was admitted to the ENT department of MONICA with a diagnosis of “Singing nodules of the vocal folds”. From the anamnesis it is known that voice changes appeared 4 years ago, was treated with conservative methods with a temporary effect.

Upon receipt, the general condition is satisfactory. There is severe hoarseness.

The patient underwent direct microlaryngoscopy with FVCHIVL. On examination, paired nodules are visualized symmetrically located on the edges of the vocal folds at the border of the anterior and middle thirds, on the right - about 2 mm in size, on the left - about 5 mm in diameter.

During the operation, the nodule was removed from the vocal fold on the left using the combined method of using two surgical lasers: alternately for the destruction of biological tissues (cutting) using a focused beam of a YAG-holmium laser with a wavelength of 2.09 μm, in a pulse-periodic mode, pulse duration 300 μs, energy 2.0 J, pulse frequency 12 Hz, for coagulation by exposing the biotissue surface to a defocused laser beam of a KTP laser with a wavelength of 0.53 μm, in a pulsed mode, energy 1 J, frequency and pulses of 2 Hz. The nodule was removed from the vocal fold on the right by contacting it with a KTP laser with a wavelength of 0.53 μm, in a pulsed mode, with an energy of 2 J, a pulse frequency of 2 Hz, after which a coagulating effect was applied to the residues with a defocused KTP laser beam at a distance of 1 mm with a wavelength of 0.53 microns, in a pulsed mode, an energy of 2 J, a pulse frequency of 2 Hz. Postoperative course without complications, anti-inflammatory, hyposensitizing therapy was carried out. Histological response: fragments of fibrous polyps of the vocal folds.

During the follow-up examination, 8 months after the operation, fibrolaryngoscopy was performed, there were no neoplasms in the larynx, and breathing was free. The voice is clear.

Example 2. Patient P., born in 1985, medical record No. 21390, was admitted to the ENT department of MONICA with a diagnosis of laryngeal papillomatosis, relapse. Laryngeal stenosis, grade I ”It is known from the anamnesis that hoarseness was observed by parents from the age of 1 year of birth, hoarseness gradually progressed, the last month before admission the patient began to notice difficulty breathing, especially during physical exertion. A history of repeated surgery for laryngeal papillomatosis.

Upon receipt, a moderate condition. Breathing is noisy, difficulty increases with physical exertion. Laryngeal stenosis of the first degree, severe hoarseness.

The patient produced a minimum list of examinations for surgery according to emergency indications. Direct microlaryngoscopy with FVCHIVL was performed. On examination, the growth of papillomas in the area of the commissure and the anterior third of both vocal folds. Separate papillomas of different sizes from 2 to 6 mm in diameter, in the region of the lingual surface of the periglottis on the arytenoid cartilage. Glottis narrowed by 1/2. In the operation, the removal of papillomas from the larynx more than 2 mm was performed using the combined method of using two surgical lasers: alternately for the destruction of biological tissues (perforation and cutting) using a YAG-holmium laser with a wavelength of 2.09 μm, in a pulse-periodic mode, pulse duration 400 μs, energy 1.5 J, pulse frequency 15 Hz, for coagulation by exposing the biotissue surface to a defocused laser beam of a KTP laser with a wavelength of 0.53 μm, in pulsed mode, energy 3 J, pulse frequency 2 Hz. Papillomas were removed from the larynx less than 2 mm by contacting them with a KTP laser with a wavelength of 0.53 μm, in a pulsed mode, with an energy of 1 J, and a pulse frequency of 2 Hz, after which a coagulating effect was made on the papilloma residues by a defocused KTP laser beam with a length waves of 0.53 microns, in pulsed mode, with an energy of 1 J, pulse frequency of 2 Hz. Postoperative course without complications, anti-inflammatory, hyposensitizing therapy was carried out.

When discharged on the seventh day after surgery, the condition is satisfactory. Breathing through the natural paths is free, the voice is clear. During the follow-up examination, 14 months after the last operation, fibrolaryngoscopy was performed, no papillomas were found in the larynx, and breathing was free. The voice is clear.

Using this method will provide effective treatment of the larynx, reduce its morbidity through the use of differentiated laser exposure to various neoplasms.

Claims (1)

A method of treating benign neoplasms of the larynx, including laser exposure of the affected areas, characterized in that radiation from a YAG-holmium laser is used to remove neoplasms greater than 2 mm, and a tension zone of the underlying mucous membrane is preliminarily created by delaying the neoplasm by clamping, then the end of the fiber is introduced into submucosal layer to a depth of 1-5 mm under the base of the neoplasm, move the end along the base and send 5-7 pulses of laser radiation in this way m, so that the wound from each subsequent impulse mates with the wound from the previous impulse, tumors less than 2 mm are contacted by a KTP laser with 1-8 pulses, and coagulation of the base of the neoplasm and their residues is carried out by a defocused KTP laser beam, which is placed over the neoplasm surface at a distance of 1 -2 mm.