Method for treating benign neoplasms of larynx using photoangiolytic laser

Abstract

FIELD: otorhinolaryngology.SUBSTANCE: flexible catheter for epidural anesthesia is inserted into the working channel of the rhinolaryngofiberscope. Through the catheter, the assistant introduces an anesthetic solution for sequential anesthesia of the nasopharynx, oropharynx and laryngopharynx. Next, the endoscope is inserted into the supraglottic region of the larynx and the supraglottic and vocal regions are anesthetized with a 2% lidocaine solution. A flexible endoscope is passed closer to the vocal part of the larynx and, using a flexible catheter for epidural anesthesia, the vocal folds are touched. Once anesthesia is achieved, the flexible epidural anesthesia catheter is removed from the working channel of the flexible endoscope. Next, after inserting a 445 nm laser fiber through the working channel of the endoscope, the neoplasm in the vocal part of the larynx – a cyst, polyp, or papilloma – is visualized. After this, the end of the laser fiber is brought to the neoplasm at a distance of about 1–3 mm to the vocal fold. Next, in a remote mode, a step-by-step coagulation of the neoplasm is carried out over the entire surface until it turns white. In this case, for edematous neoplasms – polyps, only distant coagulation is performed over the entire area of the neoplasm. In case of neoplasms with the presence of contents – cysts, distant coagulation is performed followed by contact action with pulses at 4 W 10–30 ms – 200 ms pause on the surface of the neoplasm to obtain the liquid contents and its evacuation. In the case of papillomas, after distant coagulation – whitening of the neoplasm, the laser fiber is inserted into the thickness of the neoplasm interstitially, with pulses at 4 W 10–30 ms – 200 ms pause, the neoplasm is separated from the epithelial layer of the vocal fold, after which the bed of the neoplasm is treated with pulses in a distant mode.EFFECT: method allows for improved functional results, reduced trauma to the vocal fold, minimizing scarring, and rapid restoration of voice quality.7 cl, 6 dwg, 1 ex

Description

[0001] The invention relates to medicine, namely to otolaryngology.

[0002] Laryngeal neoplasms are a significant component of upper respiratory tract pathologies. According to P. H. Holinger (1951), benign laryngeal diseases include all neoplasms that occupy space within the larynx and have no potential for malignancy.

[0003] Therapy for any neoplasms of the larynx, as a rule, is comprehensive and includes conservative treatment methods, phonopedics and physiotherapy.

[0004] Surgical intervention is indicated when conservative treatment is ineffective. Various techniques are used to remove benign tumors, ranging from microsurgical instruments to high-tech methods, including cryosurgery, cold plasma and argon plasma coagulation, as well as electrosurgical and laser technologies.

[0005] The primary approach to surgical treatment is direct microlaryngoscopy under endotracheal anesthesia. However, in cases where general anesthesia is contraindicated due to severe comorbidities, local anesthesia may be an alternative, including the use of a fiber laser, which primarily has phonoangiolytic properties.

[0006] The most well-known representative of the photoangiolytic laser group is the "blue" laser with a wavelength of 450 nm (±5 nm). It is characterized not only by a pronounced hemostatic effect but also by the ability to vaporize tissue without creating an extensive zone of thermal damage to adjacent tissue. Due to these properties, it is widely used to achieve various biological effects, such as coagulation and tissue ablation.

[0007] The invention relates to a method for surgical treatment of benign neoplasms of the larynx using a laser with a wavelength of 445 nm.

[0008] A known method for treating tumor-like formations of the larynx using a semiconductor laser with a wavelength of 445 nm, including performing preventive coagulation of the vessels of the vocal fold, making an incision in the mucous membrane of the vocal fold using a laser in pulsed mode at a power of 6.0-8.0 W for 10-20 ms with a pause between pulses of 100-130 ms (see patent RU No. 2772098, IPC A61B 17 / 24, A61B 18 / 20).

[0009] When implementing the known method under conditions of endotracheal anesthesia with direct microlaryngoscopy, preventive coagulation of the vocal fold vessels is performed, then the tumor-like formation is captured with microinstruments and an incision is made in the mucous membrane of the vocal fold in the projection of the formation, followed by plastic surgery of the defect of the adjacent mucosa using a 445 nm laser in a pulsed mode: with a wavelength of 445 nm and a radiation power of 6.0-8.0 W, for 10-20 ms with a pause between pulses of 100-130 ms.

[0010] The disadvantages of this method are:

[0011] - performing surgery under endotracheal anesthesia using direct support microlaryngoscopy provides good visualization and direct access to the surgical field, but is not possible in patients with serious comorbid pathology and contraindications to anesthesia;

[0012] - To operate with the specified laser parameters in an inert gas atmosphere, a specialized Flow Control helium system is required. The lack of such a system, as well as specialized instruments for delivering helium to the surgical site under local anesthesia, makes it impossible to perform the surgical procedure with the specified parameters.

[0013] The closest in technical essence to the claimed solution, accordingly, adopted as a prototype, is a method for treating vocal fold leukoplakia, including inserting a flexible fibronasopharyngoscope through the nasal cavity into the laryngopharynx after anesthesia, introducing a laser with a wavelength of 445 nm through the working channel of the fibronasopharyngoscope, contact or contactless coagulation with a laser with a wavelength of 445 nm of a neoplasm of the vocal fold in pulsed mode (see Hamdan AL, Ghanem A, Abou Raji Feghali P. et al. “Office-Based Blue Laser Therapy for Vocal Fold Leukoplakia: A Preliminary Report of 12 Cases”, OTO Open, 2023, Vol. 7, No. 2, 59).

[0014] A well-known method involves administering local anesthesia: sponges with 1% lidocaine and 1:100,000 adrenaline are inserted into the nasal cavity, a 2% xylocaine (lidocaine) spray is used in the oropharynx, and 4% lidocaine is injected into the larynx after passing a flexible nasopharyngoscope (Pentax Medical FNL-15RP3) through the nasal cavity through the working channel of the endoscope during patient phonation. After administering anesthesia, a 445 nm laser fiber (TrueBlue; ARC Laser Company) is inserted through the working channel of the endoscope and brought to the site of the tumor. The work is performed using the following parameters in contact and pre-contact modes: power of 10 W, pulse duration of 30 ms, and interpulse interval duration of 300 ms.

[0015] The disadvantages of the known method are:

[0016] - the nasopharyngoscope used (Pentax Medical FNL-15RP3) has a diameter of 4.9 mm, which may cause discomfort when inserted in patients with a narrow nose, and may also increase the activity of the gag reflex, which in turn may require an increase in the volume of anesthetic to anesthetize the area of ​​​​the nose, nasopharynx, and oropharynx;

[0017] - administration of anesthetic directly through the working channel of the endoscope, which leads to uneven distribution of the anesthetic in the laryngopharynx (difficulty dosing the volume of anesthetic), as well as contamination of the internal channel of the nasopharyngoscope;

[0018] - recommended parameters for use: power 10 W, pulse duration 30 ms, pause 300 ms lead to a pronounced coagulation and ablation effect on the affected tissue when working in contact and pre-contact modes (1-3 mm), which is suitable for the treatment of precancerous diseases of the larynx (leukoplakia, leukokeratosis), the purpose of which is to perform the most ablastic approach, however, these parameters are highly traumatic due to extensive thermal damage for the treatment of benign neoplasms of the larynx, the intervention in which consists of minimal trauma to the epithelial layer in order to exclude scarring of the fold and improve the quality of the voice (phonosurgical approach).

[0019] The technical problem in the area under consideration is the severe trauma to the fold due to extensive thermal damage during the treatment of benign tumors using a 445 nm laser under local anesthesia, as well as the presence of discomfort during surgery in patients with a narrow nose, technical difficulties in administering anesthesia, and the severity of the gag reflex, which can lead to an increase in the volume of anesthetic for anesthesia of the nose, nasopharynx, and oropharynx.

[0020] The technical result consists in improving the functional result, due to the characteristics of the laser effect, reducing trauma to the vocal fold in order to minimize its scarring and quickly restore voice quality (phonosurgical approach).

[0021] An additional technical result is the elimination of discomfort during surgery in patients with a narrow nose, improving the quality of anesthesia, reducing the severity of the gag reflex without increasing the volume of anesthetic for anesthesia of the nose, nasopharynx, and oropharynx.

[0022] The technical result is achieved in that in the proposed method for treating benign neoplasms of the larynx using a photoangiolytic laser, including surgical intervention under local application anesthesia, positioning the patient on an operating chair or table in a sitting position with support at the level of the back and head, using a 2% lidocaine solution with drops of adrenaline on a cotton swab for anesthesia of the nasal cavity, using a 2% lidocaine solution for anesthesia of the oropharynx, introducing a lidocaine solution through the working channel of a flexible endoscope for anesthesia of the laryngopharynx, larynx against the background of phonation of the patient, subsequent introduction of a 445 nm laser fiber through the working channel of the endoscope with coagulation of the laryngeal neoplasm, according to the invention, a rhinolaryngofibroscope is used as an endoscope, with a flexible catheter for epidural anesthesia previously installed in the working channel,through which the assistant introduces an anesthetic solution for sequential anesthesia of the nasopharynx, oropharynx and laryngopharynx, followed by insertion of a flexible endoscope into the supraglottic region of the larynx and anesthesia of the supraglottic and glottic regions with a 2% lidocaine solution.

[0023] The flexible endoscope is advanced closer to the vocal part of the larynx and, using a flexible catheter for epidural anesthesia, the vocal folds are touched. After achieving anesthesia, the flexible catheter for epidural anesthesia is removed from the working channel of the flexible endoscope.

[0024] Then, after inserting a 445 nm laser fiber through the working channel, a neoplasm in the vocal section of the larynx is visualized - a cyst, polyp, papilloma, after which the end of the laser fiber is brought to the neoplasm at a distance of about 1-3 mm to the vocal fold.

[0025] Then, in a remote mode, a step-by-step coagulation of the neoplasm is carried out over the entire surface until it turns white.

[0026] In this case, for edematous neoplasms - polyps, only distant coagulation is performed over the entire area of ​​the neoplasm; for neoplasms with contents - cysts, distant coagulation is performed followed by contact action with pulses at 4 W 10-30 ms 200 ms pause on the surface of the neoplasm to obtain the liquid contents and evacuate them.

[0027] For papillomas, after distant coagulation - whitening of the neoplasm, the laser fiber is inserted into the thickness of the neoplasm interstitially, with pulses at 4 W 10-30 ms 200 ms pause, the neoplasm is separated from the epithelial layer of the vocal fold, after which the bed of the neoplasm is treated with pulses in a distant mode.

[0028] Also:

[0029] The rhinolaryngofiberscope has a diameter of 4.0 mm, a length of 300 mm, with a working channel of 2.0 mm;

[0030] A flexible epidural anesthesia catheter is used to deliver anesthetic - a polyamide or polyurethane catheter, diameter ≤1 mm;

[0031] staged coagulation of the neoplasm is performed remotely;

[0032] The detachment of the neoplasm is performed with pulses in the interstitial mode, if its complete removal is necessary;

[0033] The bed of the neoplasm after its removal is treated with impulses in a remote mode;

[0034] If the patient experiences a pain or cough reflex, add anesthesia with a total volume of 2% Lidocaine solution used: minimum 2 ml, maximum 4 ml.

[0035] An experimental study has determined the optimal parameters for laser exposure with a wavelength of 445 nm, which are used to coagulate a laryngeal neoplasm, followed by a step-by-step ablation of the neoplasm without the occurrence of a wide zone of thermal damage, which minimizes scarring of the vocal fold and reduces the severity of the inflammatory reaction in the area of ​​exposure, which leads to rapid rehabilitation of the patient's voice function.

[0036] Experiments have established the effective characteristics of laser treatment: 10-30 ms pulse duration, 200 ms pause at 4 W. This laser treatment is characterized by the most gentle action, meaning coagulation and ablation of the tumor within the superficial layer of the lamina propria without damaging functionally significant areas of the larynx, with the goal of maximally preserving the normal anatomy of the vocal fold.

[0037] The essence of the proposed method is explained by the following figures, where:

[0038] - Fig. 1 shows the passage of a fiberolaryngoscope through the nasopharynx, oropharynx to the laryngopharynx with the removal of a flexible catheter for epidural anesthesia for the purpose of anesthesia;

[0039] - Fig. 2 shows the passage of a fiberoptic laryngoscope through the nasopharynx, oropharynx to the laryngopharynx with the removal of a laser with a wavelength of 445 nm;

[0040] - Fig. 3 shows distant coagulation of a laryngeal neoplasm using a laser with a wavelength of 445 nm;

[0041] - Fig. 4 shows interstitial coagulation of a laryngeal neoplasm using a laser with a wavelength of 445 nm;

[0042] - Fig. 5 shows the detachment of a laryngeal neoplasm using a laser with a wavelength of 445 nm from the epithelial layer of the vocal fold;

[0043] - Fig. 6 shows distant treatment of the tumor bed with a laser with a wavelength of 445 nm.

[0044] The following positions are used in the figures: 1 - flexible endoscope (videonasopharyngolaryngoscope); 2 - flexible catheter for epidural anesthesia; 3 - vocal part of the larynx; 4 - laser with a wavelength of 445 nm; 5 - laryngeal neoplasm; 6 - bed of the laryngeal neoplasm.

[0045] The method is carried out as follows.

[0046] The surgery is performed under local anesthesia, the patient is positioned on the operating chair or table in a sitting position with support at the level of the back and head.

[0047] To anesthetize the nasal cavity, use a 2% lidocaine solution with 0.1% adrenaline drops on a cotton swab inserted into one half of the nose; to anesthetize the oropharynx, use a 10% lidocaine spray.

[0048] Next, a flexible endoscope 1 (videonasopharyngolaryngoscope, diameter 4.0 mm, length 300 mm) with a working channel (diameter 2.0 mm) with a flexible catheter 2 for epidural anesthesia previously installed in the working channel (polyamide or polyurethane catheter, diameter ≤1 mm), not protruding beyond the end of the endoscope, is inserted into the anesthetized half of the nose.

[0049] After inserting the flexible endoscope 1 into the nasopharynx, the flexible catheter 2 for epidural anesthesia is advanced along the working channel until it is visualized in the lumen of the nasopharynx (5-7 mm), after which the assistant, using an insulin syringe, delivers a 2% lidocaine solution dropwise through the flexible catheter 2 for epidural anesthesia, with its outflow into the area of ​​the nasopharynx, oropharynx and laryngopharynx.

[0050] Next, the flexible endoscope 1 is passed through the nasopharynx into the supraglottic part of the larynx until the epiglottis is visualized, after which the assistant administers a 2% lidocaine solution dropwise to anesthetize this area.

[0051] Next, the flexible endoscope 1 is passed along the epiglottis to visualize the vestibular and vocal folds, after which the assistant administers a 2% lidocaine solution intravenously. To better distribute the anesthetic in the supra- and glottal regions of the larynx, the patient is asked to pronounce the letter "i" and then cough.

[0052] To assess the quality of anesthesia, the flexible endoscope 1 is advanced closer to the vocal folds 3 of the larynx and the vocal folds are touched using a flexible epidural anesthesia catheter 2 inserted through the working channel. If the patient exhibits a pain or cough reflex, anesthesia is administered. The total volume of 2% lidocaine solution used is a minimum of 2 ml and a maximum of 4 ml.

[0053] After achieving anesthesia, flexible epidural anesthesia catheter 2 is removed from the working channel of flexible endoscope 1. Laser fiber 4 with a wavelength of 445 nm is then inserted through the working channel. The fiber tip has been pre-treated (the braid has been removed, and the fiber tip has been trimmed using a special ruler to form a rounded marker). Laser 4 with a wavelength of 445 nm is inserted through the working channel of flexible endoscope 1 along its entire length and extended beyond its edge by 5-7 mm.

[0054] A neoplasm (cyst, polyp, or papilloma) is visualized in the vocal tract of the larynx. The tip of the laser fiber is then advanced to a distance of approximately 2-3 mm from the vocal fold. Next, staged coagulation of the entire laryngeal neoplasm is performed remotely until it turns white.

[0055] Coagulation of the neoplasm of the 5th larynx is performed during the patient’s inhalation in a state of maximum separation of the vocal folds.

[0056] In case of edematous neoplasms (polyps), only distant coagulation is performed over the entire area of ​​the neoplasm 5 of the larynx, followed by its reduction in size during the postoperative period.

[0057] For neoplasms of the 5th larynx with the presence of contents (cyst), distant coagulation is performed followed by contact action of impulses on the surface of the neoplasm of the 5th larynx to obtain liquid contents and their evacuation.

[0058] In case of papillomas, after distant coagulation (whitening of the neoplasm), the laser fiber is inserted into the thickness of the neoplasm of the 5th larynx (interstitially), and by means of pulses at the same power, the neoplasm of the 5th larynx is detached from the epithelial layer of the vocal fold, after which the bed of the 6th neoplasm is treated with pulses in a distant mode.

[0059] After completing the treatment of the bed 6 of the neoplasm, the laser fiber 4 with a wavelength of 445 nm is removed back into the working channel, after which the flexible endoscope 1 is removed through the nasal cavity, this completes the surgical treatment.

[0060] The method is explained by the following example.

[0061] Patient S., 64 years old, consulted the Federal State Budgetary Institution "St. Petersburg Research Institute of Ear, Throat, Nose and Speech" of the Ministry of Health of the Russian Federation with complaints of persistent dysphonia and vocal fatigue during vocal exertion. These complaints have been bothering the patient for the past year with a gradual increase in symptoms. His professional activity is not associated with speaking. Concomitant pathology: ischemic heart disease: ASA, coronary angiography with stenting of the right ventricular mass in 2013. CHF with preserved EF stage 1, 1 f. class, hypertension stage 3, hypertension stage 1, cardiovascular disease type 4. Type 2 diabetes. ICD. Chronic pyelonephritis, remission. GERD, not exacerbated. Chronic prostatitis, not exacerbated.

[0062] Preoperative video endostroboscopy of the larynx revealed a free laryngeal entrance, pink laryngeal mucosa, and unchanged epiglottis, arytenoid-supraglottic folds, and arytenoid cartilage areas. The mucosa above the esophageal entrance is slightly edematous and moderately hyperemic. No pathological contents were found. The arytenoid cartilages were symmetrically located. The vestibular folds were unchanged. Fold mobility was fully preserved. The vocal folds were grayish, the left one was smooth, and the right one had a rounded grayish-whitish formation with transparent contents (cyst) approximately 4 mm in diameter along the medial edge in the middle 1 / 3. They did not close completely during phonation, and oscillations were regular. The glottis was wide during breathing. The visible subglottic region was normal.

[0063] The established main clinical diagnosis: Cyst-like neoplasm of the right vocal fold.

[0064] Considering the patient's age and the presence of comorbid pathology, a decision was made to remove the laryngeal neoplasm using a 445 nm laser under local anesthesia.

[0065] The surgery was performed under local anesthesia with the patient seated on the operating table. A 2% lidocaine solution with 0.1% adrenaline drops on a cotton pad was used to anesthetize the nasal cavity, and a 10% lidocaine spray was used to anesthetize the oropharynx.

[0066] A flexible endoscope (videonasopharyngolaryngoscope, 4.0 mm diameter, 300 mm length) with a working channel (2.0 mm diameter) was inserted into the anesthetized half of the nose. A flexible epidural anesthesia catheter (polyamide catheter, 1 mm diameter) was previously inserted into the working channel. An assistant gradually injected 2 ml of 2% lidocaine solution through the flexible epidural anesthesia catheter to anesthetize the nasopharynx, oropharynx, laryngopharynx, and all parts of the larynx. When the 2% lidocaine solution entered the vocal tract of the larynx, the patient vocalized the letter "i" to distribute the anesthetic widely.

[0067] After anesthesia, the flexible epidural anesthesia catheter was removed from the flexible endoscope, followed by insertion of a 445 nm laser fiber through the entire length of the working channel, extending approximately 5 mm beyond the edge.

[0068] After visualizing a cyst-like tumor in the middle third of the right vocal fold, the fiber tip was advanced to the tumor. The tumor was coagulated remotely until it turned white. The thinned surface of the tumor was then treated with contact pulses, obtaining a small volume of fluid. After evacuation of the contents, the tumor bed was treated with remote pulses, forming a thin coagulum on the surface.

[0069] After completing the treatment of the tumor bed, the laser fiber was removed into the working channel, the flexible endoscope was removed through the nasal cavity, and the surgical intervention was completed.

[0070] The patient was transferred to the surgical department 10 minutes after the manipulation.

[0071] Minor reactive phenomena of the laryngeal mucosa were noted on the 1-2nd day after surgery, subsequently the phenomena of postoperative inflammation quickly regressed.

[0072] Video fiberoptic laryngoscopy on the first postoperative day revealed a clear laryngeal entry, pink, moist laryngeal mucosa. The epiglottis, arytenoid-supraglottic folds, and arytenoid cartilage areas are unchanged. The interarytenoid space is slightly edematous. The left vocal fold is gray, with no signs of reactive phenomena; the right vocal fold is slightly hyperemic along the median edge with a thin coagulum in the affected area. Phonation produces uneven vibrations, and the vocal folds are fully mobile. The airway is wide. The subglottic region is free.

[0073] During the patient's two-day hospital stay, decongestant, inhalation, and antireflux therapy were prescribed. Upon discharge, a restricted voice regimen was recommended for 7 days, along with inhalations of anti-inflammatory and decongestant medications.

Claims

1. A method for treating benign neoplasms of the larynx using a photoangiolytic laser, including surgical intervention under local application anesthesia, positioning the patient on an operating chair or table in a sitting position with support at the level of the back and head, using a 2% lidocaine solution with drops of adrenaline on a cotton swab for anesthesia of the nasal cavity, using a 2% lidocaine solution for anesthesia of the oropharynx, introducing a lidocaine solution through the working channel of a flexible endoscope for anesthesia of the laryngopharynx, larynx against the background of phonation of the patient, subsequent introduction of a 445 nm laser fiber through the working channel of the endoscope with coagulation of the laryngeal neoplasm, characterized in that a rhinolaryngofibroscope is used as an endoscope, with a flexible catheter for epidural anesthesia previously installed in the working channel, through which an assistant introduces an anesthetic solution for sequential anesthesia of the zones of the nasopharynx, oropharynx and laryngopharynx,with subsequent insertion of a flexible endoscope into the supraglottic part of the larynx and anesthesia of the supraglottic and vocal areas with a 2% lidocaine solution, the flexible endoscope is advanced closer to the vocal part of the larynx and the vocal folds are touched using a flexible catheter for epidural anesthesia, after achieving anesthesia, the flexible catheter for epidural anesthesia is removed from the working channel of the flexible endoscope, then after inserting a 445 nm laser fiber through the working channel, the neoplasm in the vocal part of the larynx - a cyst, polyp, papilloma - is visualized, after which the end of the laser fiber is brought to the neoplasm at a distance of about 1-3 mm to the vocal fold, then in a remote mode, step-by-step coagulation of the neoplasm is performed over the entire surface until it turns white, while in edematous neoplasms - polyps, only distant coagulation is performed over the entire area of ​​​​the neoplasm,In case of neoplasms with the presence of contents - cysts, distant coagulation is performed followed by contact action with pulses at 4 W 10-30 ms 200 ms pause on the surface of the neoplasm to obtain the liquid contents and evacuate it; in case of papillomas, after distant coagulation - whitening of the neoplasm, the laser fiber is inserted into the thickness of the neoplasm interstitially, with pulses at 4 W 10-30 ms 200 ms pause, the neoplasm is separated from the epithelial layer of the vocal fold, after which the bed of the neoplasm is treated with pulses in a distant mode.

2. The method according to claim 1, characterized in that the rhinolaryngofiberscope has a diameter of 4.0 mm, a length of 300 mm, with a working channel of 2.0 mm.

3. The method according to paragraph 1, characterized in that a flexible catheter for epidural anesthesia is used to deliver the anesthetic - a polyamide or polyurethane catheter, diameter ≤1 mm.

4. The method according to paragraph 1, characterized in that staged coagulation of the neoplasm is performed remotely.

5. The method according to paragraph 1, characterized in that the detachment of the neoplasm is carried out by pulses in the interstitial mode when its complete removal is necessary.

6. The method according to paragraph 1, characterized in that the bed of the neoplasm after its removal is treated with impulses in a remote mode.

7. The method according to paragraph 1, characterized in that in the presence of a pain or cough reflex on the part of the patient, anesthesia is added with a total volume of 2% Lidocaine solution used: minimum 2 ml, maximum 4 ml.

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