RU2808033C1 - Method for eliminating restriction of mouth opening in cancer patients after combined treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: namely maxillofacial surgery, dentistry, reconstructive, plastic surgery and oncology. At the first stage, contrast-enhanced MRI and CT images taken before surgery to remove a tumor of the maxillofacial area are analyzed. The volume and configuration of the removed area and the size of the resulting defect are determined. At the second stage, a contrast-enhanced CT scan of the upper limb is performed to determine the diameter of the main great vessels of the arm and detect the anatomical features of the vessels. Then, MSCT of the maxillofacial area with contrast is performed to determine the vascular flow of the external carotid artery and suitable vessels for future microsurgical anastomosis are selected. At the third stage, surgical intervention is performed, during which all scar tissue formed in the oral cavity after combination therapy is removed. The radial flap is formed in such a way that its size and configuration corresponds to the size and configuration of the removed area, determined at the first stage according to preoperative CT images. A vascular pedicle is formed. After this, the formed flap is placed in the area of the formed defect, covering its entire surface. A tunnel is formed in the soft tissues from the origin of the vascular pedicle to the point of contact of the flap vessels with the donor vessels of the external carotid artery, into which the vessels of the vascular pedicle of the flap are then placed. The indicated vessels are sutured end-to-end. After this, the graft is fixed. Wounds on the neck and forearm are closed in layers with interrupted sutures. 7-10 days after the operation, the patient begins mechanotherapy, which lasts at least 10 weeks.

EFFECT: eliminating restrictions on mouth opening, restoring chewing function and improving the results of mechanotherapy and physiotherapy.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to maxillofacial surgery, dentistry, reconstructive and plastic surgery, oncology, and can be used to eliminate restrictions in mouth opening in cancer patients who have undergone combined treatment.

Limitation of mouth opening (trismus) affects 38-45% of all patients with head and neck cancer who received combined or only radiation therapy. Trismus significantly reduces the quality of life of patients. It not only significantly complicates the acts of chewing and swallowing, but also leads to a reduced level of oral hygiene. In addition, if there is restriction in mouth opening, dental procedures may be difficult because it will be difficult for the doctor to access the teeth for treatment. There are still no unified and standardized approaches to eliminating restrictions in mouth opening. Moreover, each component of trismus treatment (mechanotherapy, physiotherapy, injections) is also not standardized. In addition, the main line of therapy for post-radiation trismus (mechanotherapy) is ineffective for severe degrees of restriction of mouth opening (less than 1.5 cm).

Excision of fibrotic tissue inevitably leads to recurrence of trismus. However, “radical” excision of scars “within healthy tissue” with immediate closure of the defect with a soft tissue flap will prevent future tissue retraction and recurrence of trismus.

The most common method for correcting limited mouth opening is mechanical therapy. Of all the known methods of mechanotherapy, the devices are “TheraBite” and “Engstro’m jaw device”. These devices have successfully completed numerous clinical trials and have proven effective in reducing pain, improving jaw mobility and improving the quality of life of patients with TMJ disorders. They are also easy to use and non-invasive. Their effectiveness has also been proven in correcting limited mouth opening in patients with head and neck cancer. [Pauli N, Fagerberg-Mohlin B, Andrell R, Finizia C. Exercise intervention for the treatment of trismus in head and neck cancer. Acta Oncol. 2014 Apr;53(4):502-9. doi: 10.3109/0284186X.2013.837583. Epub 2013 Oct 31. PMID: 24175896.]. Having developed various training programs (from 3 to 7 approaches), doctors or the patient himself carry out mechanotherapy for an average of 10 to 12 weeks.

Disadvantages of this method: the process of mechanotherapy can be painful for patients, which can lead to decreased compliance with treatment; The effectiveness of mechanotherapy in the treatment of limited mouth opening can vary greatly among patients: some may not experience significant improvement; There is a risk of injury during mechanical therapy (eg TMJ), especially if the attending physician does not have experience working with the devices or the therapy is carried out by the patient himself.

There is a known method of eliminating opening restrictions using cost-effective devices. The method is carried out by making rubber devices that mechanically, with the help of a gradual increase in load, lead to an increase in mouth opening. One such homemade device is a device developed by Singh K et al. in the form of a corkscrew with threads made of acrylic polymer [Singh K, Rashmikant US, Alvi HA, Singh RK. Management of trismus following radiation therapy by cost-effective approach. BMJ Case Rep.2012 Oct 19;2012:bcr2012007326. doi: 10.1136/bcr-2012-007326. PMID: 23087289; PMCID: PMC4543707.]. Using a conical structure and a spiral thread, the device is “screwed” into the oral cavity. In the clinical case of Singh K et al., after 2 weeks, the patient’s opening from 0.5 cm reached 1.5 cm.

Disadvantages of this method: strong physical impact on the dentition, which can ultimately lead to traumatic dislocation and loss of teeth, lack of positive dynamics 4-6 weeks after mechanotherapy. Training and results with such devices are highly dependent on the motivation and interest of patients to engage in their treatment.

There is a known method of eliminating the restriction of mouth opening using surgical methods. Bhrany AD et al suggest delayed removal of the coronoid processes in patients with head and neck cancer. [Bhrany AD, Izzard M, Wood AJ, Futran ND. Coronoidectomy for the treatment of trismus in head and neck cancer patients. Laryngoscope. 2007 Nov; 117(11):1952-6. doi: 10.1097/MLG.0b013e31812eee13. PMID: 17767087.]

Disadvantages of this method: observing patients 1-2 years after coronoidectomy, the authors report a decrease in mouth opening by 5-6 mm. Also, if there are scar deformities in the oral cavity, the effect of coronoidectomy will be minimal.

The closest analogue of the claimed invention is a method of surgical treatment of limited mouth opening, which consists in myotomy of the masticatory muscles, in particular the temporal muscle. Myotomy is considered one of the most accessible methods of eliminating trismus, but there have been studies examining the effectiveness of myotomy as a single therapy rather than in combination with other techniques (eg, coronoidectomy). [Satheeshkumar PS, Mohan MP, Jacob J. Restricted mouth opening and trismus in oral oncology. Oral Surg Oral Med Oral Pathol Oral Radiol. (2014) 117:709–15. doi: 10.1016/j.oooo.2014.02.031]

The disadvantage of this method is that, according to the general opinion of head and neck surgeons, myotomy alone is not enough to correct limited mouth opening. The reason is that the main etiological factor in limiting mouth opening in the patients we are considering is the presence of fibrous tissue.

The problem solved with the help of the claimed invention is the development of a method for eliminating restrictions in mouth opening in cancer patients after combined treatment, which allows eliminating restrictions in mouth opening, restoring chewing function and improving the results of mechanotherapy and physiotherapy.

To solve this problem, we propose a method for eliminating restrictions in mouth opening in cancer patients after combined treatment, which consists in the fact that at the first stage, an analysis of contrast-enhanced MRI and CT images of patients with formed scars after removal of a tumor, limiting mouth opening, taken before surgery is performed. to remove a neoplasm of the maxillofacial area and determine the volume and configuration of the removed area and, accordingly, the size of the resulting defect; at the second stage, a contrast-enhanced CT scan of the upper limb is performed to determine the diameter of the main great vessels of the arm and detect the anatomical features of the vessels, after which the patient undergoes MSCT maxillofacial area with contrast to determine the vascular flow of the external carotid artery and select suitable vessels for future microsurgical anastomosis,

at the third stage, a surgical intervention is performed, during which all scar tissue formed in the oral cavity after combination therapy is removed, a radiation flap is formed in such a way that its size and configuration corresponds to the size and configuration of the removed area, determined at the first stage according to preoperative CT images , and also form a vascular pedicle, after which the formed flap is placed in the area of the formed defect, covering its entire surface, a tunnel is formed in the soft tissues from the origin of the vascular pedicle to the point of contact of the flap vessels with the donor vessels of the external carotid artery basin, into which the vessels are then placed vascular pedicle of the flap, the indicated vessels are sutured end-to-end, after which the graft is fixed, the wounds on the neck and forearm are closed in layers with interrupted sutures, 7-10 days after the operation the patient begins mechanotherapy, the duration of which is at least 10 weeks.

The method is carried out as follows

At the first stage, patients with formed scars after removal of a tumor that limit mouth opening are subjected to a preoperative examination, including an analysis of contrast-enhanced MRI and CT images taken before surgery to remove a tumor of the maxillofacial area and determine the volume and configuration of the removed area and , respectively, the size of the resulting defect.

At the second stage, a contrast-enhanced CT scan of the upper limb is performed to determine the diameter of the main great vessels of the arm and detect the anatomical features of the vessels. Using duplex scanning of the vessels of the upper limb, the presence of organic pathologies of the vessels of the forearm is determined. To clinically assess the patency of the arteries and collateral blood supply to the hand, the Allen test is performed.

After this, the patient undergoes MSCT of the maxillofacial area with contrast to determine the vascular flow of the external carotid artery and select suitable vessels for future microsurgical anastomosis.

At the third stage, surgical intervention is performed, during which all scar tissue formed in the oral cavity after combination therapy is removed.

The radial flap is formed in such a way that its size and configuration corresponds to the size and configuration of the removed area, determined at the first stage according to preoperative CT images, and a vascular pedicle is also formed. After this, the formed flap is placed in the area of the formed defect, covering its entire surface. A tunnel is formed in the soft tissues from the origin of the vascular pedicle to the point of contact of the flap vessels with the donor vessels of the external carotid artery, into which the vessels of the vascular pedicle of the flap are then placed. The indicated vessels are sutured end-to-end with Prolene 10/0 threads, after which the graft is fixed with Vicryl 4/0 threads.

When fixing the graft, attention must be paid to preventing physical impact of the teeth on the flap. A way to prevent the occurrence of such situations can be a pre-made mouth guard that eliminates “chewing” of the flap. After the stage of suturing the vessels and fixing the graft, the wounds on the neck and forearm are closed in layers with interrupted sutures using Prolene 4.0, Vicryl 4.0 threads. Rubber graduates are installed on the neck.

7-10 days after surgery, the patient begins/resumes mechanotherapy, which should last at least 10 weeks. It should be noted that with surgical correction of limited mouth opening, all other methods of elimination are not canceled, but, on the contrary, are used in full.

The technical result of the invention is the elimination of restrictions on mouth opening, facilitating subsequent mechanotherapy.

The technical result is achieved by complete surgical elimination of cicatricial deformation of the oral mucosa, which is the immediate cause of the restriction in mouth opening. Closing the defect with a free revascularized radial flap prevents the recurrence of scar deformities.

Along with surgical correction of limited mouth opening, all other methods of elimination are not canceled, but, on the contrary, are used in full. Thus, mechanotherapy not only allows you to record the result of mouth opening, which is already achieved intraoperatively, but also allows you to improve this indicator, also preventing the appearance of new fibrous “strands” and the occurrence of muscle spasm. Moreover, after the operation according to the claimed method, mechanotherapy and physiotherapy are significantly easier for cancer patients who have undergone combination therapy, and chewing function is effectively restored.

Brief description of explanatory materials

Fig. 1. - After combined treatment, the patient experiences cicatricial deformation with the formation of fibrous “strands” in the retromolar area

Fig. 2. - Excision of scar tissue is performed

Fig. 3. - Free revascularized radiation was collected

flap

Fig. 4. - Modeling and fixation of the radial flap in the area of the retromolar defect.

Clinical example.

Patient D, 22 years old. 02/01/2023 was admitted to the Department of Maxillofacial Surgery of the National Medical Research Center of the Federal Medical and Biological Agency of Russia with early detected mucoepidermoid cancer of the hard palate, Low-grade (2 points on the AFIP scale), 1CD-0. On October 26, 2015, surgical treatment involving resection of the upper jaw was performed. A fragment of the upper jaw was removed, including the alveolar process, a fragment of the hard palate with adjacent soft tissues. An urgent histological examination of the tumor edges was performed and positive resection margins were obtained along the medial and superior edges. Excision of areas of soft and bone tissue of these areas was performed, fragments of the nasal septum, nasal mucosa and left maxillary sinus were removed.

On November 5, 2015, tumor growth was noted at the resection margins, and the operation was regarded as R1. On November 10, 2015, an interdisciplinary consultation was held and adjuvant radiation therapy at a radical dose was recommended. From November 30, 2015 to January 15, 2016, radiation therapy was performed: ROD 2.0 Gy SOD 66.0 Gy. On October 3, 2016, reconstruction of the upper jaw and hard palate was performed with a bone graft from the right iliac crest. From 2017 to 2018, multiple surgical operations were performed to eliminate scar deformities of the buccal mucosa and close the defect of the hard palate. A through defect of the hard palate and trismus of II-III degree remain.

The patient was referred with complaints of limited mouth opening (less than 1.5 cm), difficulty chewing food, pain when opening her mouth, and food getting into the nasal cavity (Fig. 1).

In the preoperative period, along with basic tests and instrumental methods for examining patients with pathologies of the maxillofacial area, contrast-enhanced MRI and CT images taken before surgery to remove a tumor of the maxillofacial area were analyzed to determine the volume and configuration of the removed area and, accordingly, the size formed defect, which required to be closed with a radial fasciocutaneous flap. Then, the donor area of the forearm was prepared for collection and transplantation of the radial flap: contrast-enhanced computed tomography (CT) was performed to determine the diameter of the main great vessels of the arm and detect the anatomical features of the vessels. Using duplex scanning of the vessels of the upper limb, the presence of organic pathologies of the vessels of the forearm was determined. To clinically assess the patency of the arteries and collateral blood supply to the hand, the Allen test was performed. The patient also underwent MSCT of the maxillofacial area with contrast to determine the vascular flow of the external carotid artery and select suitable vessels for future microsurgical anastomosis.

Description of the operation:

Position the patient on her back with her right arm extended to the side. After treating the surgical field three times with Chlorhexidine solution, scar tissue was excised in the retromolar area on the left (Fig. 2). Under water cooling conditions, the bone edges of the iliac autograft were smoothed with a ball bur. Blunt and sharp dissection provided access to the residual edge of the left coronoid process of the mandible. Under water cooling conditions, the bony edges of the coronoid process were smoothed with a ball bur. The patient underwent mobilization of the edges of the mucous membrane of the oroantral anastomosis. The edges are sutured with interrupted Vicryl 4.0 sutures. Teeth No. 3.5, 3.6, 3.7 removed

An incision was made in the skin and subcutaneous fat along the cervical fold in the submandibular region on the left. Blunt and sharp dissection identified the external carotid artery, internal and external jugular veins, facial artery and vein on the left.

Using pre-made markings and in accordance with previously determined dimensions, a free radial fasciocutaneous forearm flap measuring 3x14 cm was harvested (Fig. 3). The radial artery and concomitant veins were isolated all the way to the cubital fossa, the vessels were clipped and transected.

Using a dermatome, free skin was collected from the anterolateral surface of the thigh on the left, measuring 3x14 cm and 1 mm thick, and an aseptic bandage was applied to the site of skin sampling. The skin flap is perforated, placed in the donor area on the forearm and fixed with Prolene 5.0 thread. The wounds in the donor area were sutured with Vicryl 3.0, Vicryl 4.0 and Prolene 5.0 threads. Active drainage installed. Pilots, aseptic dressing.

Using optical magnification and microsurgical instruments, donor and recipient vessels are prepared for anastomosis. Arterial anastomoses were performed between the left facial artery and the radial artery, as well as between the facial vein and the radial vein, end-to-end, Prolene 10-0. The branches in the area of the radial artery and veins that make up the vascular pedicle were ligated. Starting blood flow: the artery is pulsating, the veins are filled. Adequate blood supply to the flap was noted.

The wound in the submandibular region on the left was sutured with Vicryl 3.0, Vicryl 4.0, Vicryl 5.0 thread. Rubber drainage left in place. Aseptic dressing. The skin area of the flap is modeled and sutured to the defect in the retromolar region and the hard palate with Vicryl 4.0 thread (Fig. 4). The wounds are washed with antiseptic solutions. Hemostasis during the operation.

In the postoperative period, already from the first days, the patient’s mouth opening reached 2.8-3.0 cm. On the 7th day after the operation, the patient began to undergo mechanotherapy according to the program we developed using a dental mouth expander. Mechanotherapy was carried out for 10 weeks. The patient performed static, dynamic and static-dynamic exercises 6 times a day for 20 minutes. The patient also underwent a course of physiotherapy (ultrasound therapy and magnetic therapy). On the 15th day, a process of mucus formation on the surface of the radial flap is observed in the oral cavity. After 3 weeks, the patient is discharged from the hospital in satisfactory condition.

6 weeks after surgery, mouth opening reaches 3.2-3.5 cm.

The claimed method was used to treat 6 cancer patients with limitations in mouth opening after combination therapy. As a result of treatment and follow-up, they noted that there was no restriction in mouth opening, chewing function improved, and the effectiveness of subsequent mechanotherapy and physiotherapy increased.

Claims (3)

A method for eliminating restriction of mouth opening in cancer patients after combined treatment, which consists in the fact that at the first stage, an analysis of contrast-enhanced MRI and CT images of patients with formed scars after removal of a tumor, limiting mouth opening, taken before surgery to remove a maxillofacial tumor is carried out area and determine the volume and configuration of the remote area and, accordingly, the size of the resulting defect, at the second stage, a contrast-enhanced CT scan of the upper limb is performed to determine the diameter of the main great vessels of the arm and detect the anatomical features of the vessels, after which the patient undergoes an MSCT of the maxillofacial area with contrast to determine the vascular flow of the external carotid artery basin and select suitable vessels for future microsurgical anastomosis , at the third stage, a surgical intervention is performed, during which all scar tissue formed in the oral cavity after combination therapy is removed, a radiation flap is formed in such a way that its size and configuration corresponds to the size and configuration of the removed area, determined at the first stage according to preoperative CT images , and also form a vascular pedicle, after which the formed flap is placed in the area of the formed defect, covering its entire surface, a tunnel is formed in the soft tissues from the origin of the vascular pedicle to the point of contact of the flap vessels with the donor vessels of the external carotid artery basin, into which the vessels are then placed vascular pedicle of the flap, the indicated vessels are sutured end-to-end, after which the graft is fixed, the wounds on the neck and forearm are closed in layers with interrupted sutures, 7-10 days after the operation the patient begins mechanotherapy, the duration of which is at least 10 weeks.