RU2627351C1 - Method for external nasal valve reconstruction in case of its dysfunction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: underwing incision is made. Lateral lower leg of the lateral cartilage is allocated. A pocket of soft tissue is formed to the pyriform hole bone edges; retreating 6 mm from the nose dome, excised in the lateral direction and the lateral lower leg of the lateral own cartilage is removed. An autologous transplant from the nose septum cartilage is laid medially - on the remaining lateral portion of the lower lateral cartilage. The transplant lateral edge is placed in the soft tissues pocket on the bone edge of the pyriform hole. The transplant is fixed by suturing the wing of the nose through by one or two sutures.

EFFECT: effective recovery of nasal breathing at the level of the external nasal valve due to increased stiffness and the external nasal valve width.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used to restore nasal breathing at the level of the external nasal valve with vertically oriented lateral legs of the lower lateral cartilage.

There are many ways to restore nasal breathing: "A method of restoring nasal breathing" - RU 2012106537; "A method of reconstructing the cartilaginous skeleton of the wing of the nose with functional insufficiency of the internal nasal valve" - RU 2276586; "A way to eliminate stenosis of the nasal cavity" - RU 2317031; “A method of narrowing the nasal septum of the nose and expanding the nasal wings and nasal valve using the device” - EP 2720654; “Method of implantation for abduction of the wing of the nose, wings of the nose” - EP 1857078; "The method of" nose tension "and surgical correction of the nose tip for the treatment of obstructive sleep apnea, snoring and airway obstruction" - EP 2700385; "A method of treating a nasal valve" - US 2013178937; "A method of creating negative pressure with nasal obstruction using a check valve" - CN 202355483; "A method for optimizing the external nasal valve using an implant device" - US 645480; "Method of device for nasal dilatation" - WO 200805836; "A method of creating and using a disposable device to provide a greater lumen of the nostrils" - FR 2965474; “A method of reconstructing the cartilaginous skeleton of the wing of the nose in case of functional insufficiency of the external nasal valve” - RU 2004113573. However, below we give only a few of them - those that we consider closest to our invention.

There is a method of reconstructing the cartilaginous skeleton of the wing of the nose with functional insufficiency of the internal nasal valve, RU 2276586. The method consists in conducting inter-cartilage and trans-septal incisions in the nose in the projection of the connection of the upper lateral and large wing cartilage with continuation to the nasal septum. Peel the nasal mucosa upward from the incision beyond the deformed section of the upper lateral and septal cartilage, followed by the installation of a replacement material. In this case, the replacement material is made in the form of a superelastic porous plate of titanium nickelide with a thickness of 0.15-0.20 mm, a width of 3-4 mm in the form of a spacer with a bend at an angle of 17-20 °, which is installed between the outer edge of the nasal septum and the inner part superior lateral cartilage. The method allows to prevent the recurrence of functional insufficiency of the internal nasal valve.

The disadvantages of the analogue are: this method is suitable only for functional insufficiency of the internal nasal valve, the use of a plate of titanium nickelide makes it impossible for the person to conduct certain diagnostic and treatment methods in the future, increase the time of surgical intervention, and laser action on the body when the scar is excised in anticipation of the nose, forming its atresia, employment of more equipment, extension in time of the treatment process.

A known method of reconstructing the cartilaginous skeleton of the wing of the nose with functional insufficiency of the external nasal valve, RU 2004113573. The method consists in exfoliating a skin-fat flap with exposure of the cartilaginous part of the tip of the nose, the outer surface of the lateral leg of the large wing cartilage and additional cartilage, lower outer edge pear-shaped holes on the affected side, replace the cartilaginous flaw of the wing of the nose and fixate the replacement material to the altered cartilaginous part of the wing of the nose, then suturing the wound. The replacement material is presented in the form of a porous plate of titanium nickelide with a thickness of 0.15-0.20 mm, a width of 3-4 mm, repeating the outer contour of the cartilaginous skeleton of the nose wing, which is installed with support on the edge of the pear-shaped opening in the projection of the distal edge of the additional wing cartilage and between the middle legs of large winged cartilage, previously divided.

The disadvantages of the analogue are: the analogue is suitable only for functional insufficiency of the internal nasal valve, the use of a titanium nickelide plate makes it impossible for the person to continue to perform certain diagnostic and treatment methods, increase the time of surgical intervention; employment of more equipment, extension in time of the treatment process.

The closest to our proposed method of restoring nasal breathing at the level of the external nasal valve with vertically oriented lateral legs of the lower lateral cartilage is the previously developed method (prototype) "Evaluation of a new reconstruction method when the nasal valve is omitted (collapse) and the free edge of the nose wing" (Evaluation of a new procedure for nasal alar rim and valve collapse: Nasal alar rim reconstruction / Robert J. Troell, Nelson B. Powell, Robert W. Riley and Kasey K. Li // Otolaryngology. - Head and Neck Surgery. - 2000. - Vol 122. - P. 204-211). We take this method as a prototype.

According to the prototype, a reconstruction method is proposed for the omission (collapse) of the nasal valve and the free edge of the nose wing. The authors propose an operative technique for correcting the prolapse of the nasal valve by placing the cartilage rack along with respect to the free edge of the wing of the nose. A cartilaginous nose wing positioned along the lower edge of the wing provides sufficient support for the wing edge and valve area. As a rule, a homologous irradiated costal cartilage is implanted on the inner side of the wing edge from the pear-shaped aperture, not reaching a few millimeters to the tip of the nose. This design provides sufficient structural support for the nasal margin and valve area. Each procedure was performed on a patient under general anesthesia, intravenous sedation and / or local anesthesia. Patients requiring other additional surgical interventions in the upper respiratory tract were given general anesthesia. The operation begins with the introduction of local anesthesia. Initially, 0.5% lidocaine with 1: 200000 adrenaline is injected into the tip of the nose and wing. Next, a 4 mm vertical skin incision on the threshold of the nose at the junction of the nostril and nasal lobule, which is 2/3 of the free edge of the wing of the nose to the pear-shaped aperture. The skin under the lower lateral cartilage is dissected with scissors from the pear-shaped aperture, not reaching a few millimeters to the tip of the nose. During transplantation, autologous cartilage of the auricle, or nasal septum, or irradiated allogeneic cartilage is used. The graft is adjusted to the appropriate valve size and is taken with care so that the perichondrium on one side of the cartilage is intact, to improve survival and reduce absorption. The cartilage implant (2.5-3 cm in length and 3-4 mm in width and height) is cut out from a special irradiated cartilage and its ends are cut off. The incision is made in the area of the valve adjacent to the place of retreat. Subcutaneous pockets of the wings of the nose are created between the vestibule and the lower lateral cartilage, where the cartilage graft is inserted. Transplants are between the vestibule of the nose and the lower lateral cartilage. After installing the implant correctly, the elasticity, wing symmetry and aesthetics are properly evaluated. The incision is sutured with simple single sutures (chrome 5.0). The outer bandage does not overlap. The postoperative outcome should provide structural support while maintaining aesthetics.

The disadvantages of the prototype aimed at reconstruction during the omission (collapse) of the nasal valve and the free edge of the wing of the nose are:

1) peculiarities of implant placement - do not remove the patient’s own cartilage, but simply place the graft along the lower edge of the wing, which does not provide a reliable increase in the lumen width of the external nasal valve zone and reliable fixation of the graft, as well as the “rigidity” of the nasal valve on inspiration;

2) if an allogeneic cartilage is used as an implant — an expensive graft that needs to be purchased in advance — a homologous irradiated costal cartilage (rather than an autologous graft taken in advance from the cartilage of the person being operated on), which may be rejected,

3) if auto-cartilage from the area of the auricle boat is used as an implant, which is a relatively thick cartilaginous plate, therefore there is a technical difficulty / impossibility of uniformly reducing its thickness with a scalpel. In addition, a limited amount of auto-cartilage from the area of the auricle boat in the event that the first transplant sample was excised more than necessary, and there is a need for re-collection of cartilage. Another significant disadvantage of this method, we consider the complexity of the above-mentioned performance of this intervention, as well as the cosmetic and aesthetic defect of the auricle.

4) There is no fixation by flashing the wing of the nose through at least one or two sutures, due to which the implant can move, and therefore the functionality, symmetry of the wings and aesthetics will be impaired.

Those. The method proposed in the prototype is not 100% effective, technically simple, reliable, structured, as well as cosmetically and aesthetically appropriate procedure.

The disadvantages of the previous methods, including those claimed by the prototype, together with their main architecture, led to the emergence and development of an effective, technically simple, reliable, structured, as well as cosmetically and aesthetically appropriate procedure for reconstructing nasal breathing at the level of the external nasal valve, compared with other available alternative reconstruction techniques.

The objective of the claimed invention is to remedy these disadvantages of the prototype and reconstruction of the external nasal valve, i.e. in creating a simple, reliable way to improve nasal breathing at the level of the external nasal valve, while maintaining the cosmetic function of the external nose.

The technical result of the proposed method consists in the effective restoration of nasal breathing at the level of the external nasal valve, with vertically oriented lateral legs of the lower lateral cartilage due to an increase in the lumen width (diameter) of the zone of the external nasal valve and the stiffness of the valve itself with a technically simple surgical procedure (cosmetically and appropriate procedure ), aimed at the reconstruction of the external nasal valve with its dysfunction, providing reliable fixation of trans lanthanum.

To eliminate the disadvantages of the previously proposed prototype, we offer a method of reconstruction of nasal breathing developed by us at the level of the external nasal valve with vertically oriented lateral legs of the lower lateral cartilage.

The way to restore nasal breathing at the level of the external nasal valve, with vertically oriented lateral legs of the lower lateral cartilage by increasing the stiffness and width of the valve during surgical intervention, consists in making an axillary incision, the lateral leg stupidly stands out and a pocket is formed in soft tissues to the bone edge of the pear-shaped opening, retreating from the 6 mm dome of the nose, is dissected in the lateral direction and the lateral pedicle of the lower lateral sac is removed natural cartilage. The substitute material (autologous cartilage graft) in the form of a strip of quadrangular cartilage (5 mm wide, 20 mm long, 1-1.5 mm thick), taken in advance from the cartilage of the nasal septum of the person being operated on, is laid medially through the underwing incision - on the remaining lateral part of the lower lateral cartilage, laterally - the edge of the graft is placed in a pocket of soft tissues on the bone edge of the pear-shaped opening; the graft is fixed by flashing the wing of the nose through one or two sutures.

Common features of the prototype and the claimed invention are: the same purpose - reconstruction; type of incision - underwing; the point of application of the method is the level of restoration of nasal breathing, the external nasal valve; implant material - cartilage - strips of a quadrangular shape; features of implant placement - place a cartilage graft in soft tissue; the place of implantation is the wing of the nose; formation of access in the form of a subcutaneous canal pocket; the place of introduction of the graft into the canal pocket, consisting of soft tissues; both methods are reliable practice of restoring nasal breathing at the level of the external nasal valve, with vertically oriented lateral legs of the lower lateral cartilage and provide sufficient support for the valve area, as well as its elasticity, symmetry of the wings and aesthetics.

Distinctive features of the claimed invention from the prototype are:

1) features of implant placement - not all lateral cartilage is removed, but only the vertically oriented lateral leg of the lower lateral cartilage is removed; removal of a vertically oriented lateral leg extends the area of the external nasal valve, subsequent installation with reliable fixation to the surrounding tissues in its place of a fragment of the patient’s own cartilage, which ensures “rigidity” of the nasal valve on inspiration;

2) autologous cartilage is used as an implant - a free transplant taken in advance from the cartilage of the person being operated on, which will not lead to rejection;

3) there is no need to use auto-cartilage from the area of the boat of the auricle as an implant, which prevents a cosmetic defect of the auricle;

4) the presence of fixation by flashing the wing of the nose through one or two sutures to fix the implant so that it could not move, and therefore the functionality and symmetry of the wings would not be broken.

Thus, our proposed method is 100% effective, technically simple, reliable, structured, as well as cosmetically and aesthetically appropriate procedure.

A cartilage graft mounted in the wing of the nose, placed along the lower edge of the wing, provides sufficient support for the edge of the wing and the valve area. This procedure has proven itself as an effective technique, available as well as other alternative reconstruction techniques. Patients' nasal breathing improved at the level of the external nasal valve with vertically oriented lateral legs of the lower lateral cartilage according to the sensor-analogue scale. Indicators of anterior active rhinomanometry increased.

Clinical experience has shown that it is most effective to use a cartilaginous autologous graft as a replacement material in the form of a strip of quadrangular cartilage (5 mm wide, 20 mm long, 1-1.5 mm thick), taken in advance from the cartilage of the nasal septum of the person being operated on, placed medially - on the remaining lateral portion of the upper lateral cartilage, laterally - the edge of the graft is placed in a pocket of soft tissues on the bone edge of the pear-shaped opening; the graft is fixed by flashing the wing of the nose through one or two sutures.

The method of reconstruction of the external nasal valve during its dysfunction is illustrated by drawings, where:

in FIG. 1 shows the allocation of the lateral pedicle of the superior lateral cartilage throughout, oblique-frontal projection;

in FIG. 2 shows the allocation of the lateral pedicle of the superior lateral cartilage throughout, axial lower projection;

in FIG. 3 shows the removal of a vertically oriented leg of the lower lateral cartilage, oblique-frontal projection;

in FIG. 4 shows the removal of a vertically oriented leg of the lower lateral cartilage, axial lower projection;

in FIG. 5 shows the placement and fixation of the graft in place of the removed vertically oriented lateral portion of the lower lateral cartilage, oblique-frontal projection;

in FIG. 6 shows the placement and fixation of the graft in place of the removed vertically oriented lateral portion of the lower lateral cartilage, axial lower projection.

Numbers 1-6 indicate *:

1 - lateral leg of the lower lateral cartilage;

2 - vertically oriented lateral leg lower lateral cartilage;

3 - the dome of the nose;

4 - cartilaginous autologous transplant;

5 - the remaining part of the lateral portion of the lower lateral cartilage;

6 - the bone edge of the pear-shaped opening.

* - soft tissue is not shown in figures 1-6, since only the bone-cartilaginous model is depicted.

The proposed method is as follows.

1. An underwing incision is made, parallel to the edge of the nostril (soft tissues are not shown in Fig. 1, since only the bone-cartilaginous model is shown), 3 mm indent.

2. The lateral leg of the lower lateral cartilage 1 is stupidly distinguished, together with the vertically oriented lateral leg of the lower lateral cartilage 2 along its entire length (Figs. 1, 2).

3. Through this access, a pocket is formed in the soft tissues to the bone edge of the pear-shaped opening.

4. Retreating from the dome 3 of the nose 6 mm, is dissected in the lateral direction and the vertically oriented lateral leg of the lower lateral cartilage 2 is removed (Fig. 3, 4).

5. Cartilaginous autologous graft 4 in the form of a strip of quadrangular cartilage from the nasal septum (5 mm wide, 20 mm long, 1-1.5 mm thick), taken in advance from the cartilage of the nasal septum of the person being operated on, is placed through an underwing incision (in Fig. 5 soft tissue is not shown, since only the bone-cartilage model is shown) medially to the remaining lateral part of the lower lateral cartilage.

6. The medial edge of the graft is sutured to the remaining part of the lateral portion of the lower lateral cartilage 5.

7. The lateral edge of the graft is placed in a pocket 6 of soft tissues on the bone edge of the pear-shaped opening (Fig. 4).

8. The graft is fixed by flashing the wing of the nose through one or two sutures.

Example 1

Patient K., 36 years old, with obstruction of the nasal valve, as the leading cause of obstruction, was offered surgical intervention in the form of surgical reconstruction.

The patient was examined using anterior rhinoscopy, endoscopic examination with a 0-degree endoscope and sent for surgical treatment.

The preoperative assessment included an analysis of the medical history, including a subjective feeling of congestion and impaired nasal patency, fiber optic nasopharyngoscopy, anterior active rhinomanometry, and computed tomography of the paranasal sinuses.

The physical examination included an assessment of the appearance of the nose, the Cottle technique, manual dilatation of the edge of the wing and the valve area with the raising of the wing of the nose from the inside with a cotton swab, anterior rhinoscopy without anemia and anemization of 0.05% oxymetazoline. Fiber optic nasopharyngoscopy was performed after topical application of 0.5% lidocaine and 0.5% oxymetazoline.

The course of surgery. An underwing incision is made. The lateral pedicle of the lower lateral cartilage is stupidly secreted throughout. Through this access, a pocket is formed in the soft tissues to the bone edge of the pear-shaped opening. Departing from the canopy of the nose 0.6 cm is excised in the lateral direction and the vertically oriented lateral leg of the lower lateral cartilage is removed. A cartilaginous autologous graft in the form of a strip of quadrangular cartilage (5 mm wide, 20 mm long, 1-1.5 mm thick), taken in advance from the cartilage of the nasal septum of the person being operated on, is laid medially through the underwing incision medially onto the remaining lateral portion of the upper lateral cartilage. The lateral edge of the graft is placed in a pocket of soft tissue on the bone edge of the pear-shaped opening. The graft is fixed by flashing the wing of the nose through the skin with one or two sutures.

After surgery, the patient's nasal breathing improved at the level of the external nasal valve with vertically oriented lateral legs of the lower lateral cartilage according to the sensor-analogue scale. Indicators of anterior active rhinomanometry increased. A reliable increase in the lumen width of the zone of the external nasal valve, reliable fixation of the graft, and “rigidity” of the nasal valve during inspiration, which is a reliable practice of restoring nasal breathing at the level of the external nasal valve, with vertically oriented lateral legs of the lower lateral cartilage, are provided. A cartilage graft mounted in the wing of the nose, placed along the lower edge of the wing, provides sufficient support for the edge of the wing and the area of the external nasal valve.

The results of surgical intervention were evaluated 6 months after surgery as excellent.

Example 2

Patient M., 44 years old, with obstruction of the nasal external nasal valve. Surgical intervention in the form of surgical reconstruction was proposed.

The patient was examined using anterior rhinoscopy, endoscopic examination with a 0-degree endoscope and sent for surgical treatment. The preoperative assessment included an analysis of the medical history, including a subjective feeling of congestion and impaired nasal patency, fiber optic nasopharyngoscopy, anterior active rhinomanometry, and computed tomography of the paranasal sinuses.

The physical examination included an assessment of the appearance of the nose, the Cottle technique, manual dilatation of the edge of the wing and the valve area with the raising of the wing of the nose from the inside with a cotton swab, anterior rhinoscopy without anemia and anemization of 0.05% oxymetazoline. Fiber optic nasopharyngoscopy was performed after topical application of 0.5% lidocaine and 0.5% oxymetazoline.

Conducted surgery. After it, the nasal breathing of patients at the level of the external nasal valve improved with vertically oriented lateral legs of the lower lateral cartilage according to the sensor-analogue scale. Indicators of anterior active rhinomanometry increased. A reliable increase in the lumen width of the zone of the external nasal valve, reliable fixation of the graft, and “rigidity” of the nasal valve on inspiration are provided, which is a reliable practice for restoring nasal breathing at the level of the external nasal valve, with vertically oriented lateral legs of the lower lateral cartilage. A cartilage graft mounted in the wing of the nose, placed along the lower edge of the wing, provides sufficient support for the edge of the wing and the valve area. The results of surgical intervention were evaluated 6 months after surgery as a significant improvement.

Example 3

Patient A., 59 years old, with obstruction of the nasal valve, as the leading cause of obstruction, was offered surgical intervention in the form of surgical reconstruction.

The patient was examined using anterior rhinoscopy, endoscopic examination with a 0-degree endoscope and sent for surgical treatment. The preoperative assessment included an analysis of the medical history, including a subjective feeling of congestion and impaired nasal patency, fiber optic nasopharyngoscopy, anterior active rhinomanometry, and computed tomography of the paranasal sinuses.

The physical examination included an assessment of the appearance of the nose, the Cottle technique, manual dilatation of the edge of the wing and the valve area with the raising of the wing of the nose from the inside with a cotton swab, anterior rhinoscopy without anemia and anemization of 0.05% oxymetazoline. Fiber optic nasopharyngoscopy was performed after topical application of 0.5% lidocaine and 0.5% oxymetazoline.

Conducted surgery. After it, the patient’s nasal breathing improved at the level of the external nasal valve with vertically oriented lateral legs of the lower lateral cartilage according to the sensor-analogue scale, the anterior active rhinomanometry increased slightly. Provided an increase in the width of the lumen of the zone of the external nasal valve, reliable fixation of the graft, "rigidity" of the nasal valve on inspiration. A cartilage graft mounted in the wing of the nose, placed along the lower edge of the wing, provides sufficient support for the edge of the wing and the valve area. The results of surgical intervention were evaluated 6 months after surgery as a moderate improvement.

Information sources

1. Evaluation of a new procedure for nasal alar rim and valve collapse: Nasal alar rim reconstruction / Robert J. Troell, Nelson B. Powell, Robert W. Riley and Kasey K. Li // Otolaryngology. - Head and Neck Surgery. - 2000. - Vol. 122. - P. 204-211 (prototype).

2. Source: http://kursak.net/klinicheskaya-anatomiya-nosa-i-okolonosovyx-pazux/ MTkursak.net.

3. Patent CN 202355483 U, 2012.

4. Patent EP 1857078 (A2), 2006.

5. Patent EP 2700385, 2014.

6. Patent EP 2720654 (A2), 2014.

7. Patent FR 2965474 A1, 2012.

8. Patent RU 2004113573 A, 2004.

9. Patent RU 2012106537 A, 2012.

10. Patent RU 2276586 C2, 2006.

11. Patent RU 2317031 C1, 2006.

12. Patent US 2013178937 A1, 2013.

13. Patent US 6454803 B1, 2002.

14. Patent WO2008058367 A1, 2008.

Claims (1)

A method of reconstructing the external nasal valve with its dysfunction, including carrying out an axillary incision parallel to the edge of the nostril at a distance of 3 mm, with the release of the lateral leg of the lower lateral cartilage along its entire length and the formation of a pocket in soft tissues to the bone edge of the pear-shaped opening, with the installation of a graft, characterized in that is removed at a distance of 6 mm from the dome of the nose, the vertically oriented lateral leg of the patient’s lower lateral own cartilage, and cut in advance from the cartilage of the nasal septum of the operated autologous graft in the form of a strip of cartilage 5 mm wide, 20 mm long, 1-1.5 mm thick, which is placed medially on the remaining lateral part of the lower lateral cartilage, while the edge of the graft is laterally placed in a soft pocket tissues on the bone edge of the pear-shaped opening, and the graft itself is fixed by flashing the wing of the nose through the skin with one or two sutures.

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