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Вестник хирургии Казахстана №4, 2014
Opportunities of trigeminy-sympathetic blockade under the planned bilateral tonsillectomy
Shakhmetova K.S.
National Scientific Center of Surgery named after A.N.Syzganov, Almaty, Kazakhstan
Аннотация. Статья посвящена изучению преимуществ разработанной методики плановой тонзиллэктомии под проводниковой центральной анестезией по С.Н.Вайсблату.
Ключевые слова: хронический тонзиллит, тонзиллэктомия, проводниковая анестезия
Actuality
Chronic tonsillitis is one of the most common human diseases. Special socio-economic importance of this disease is that mostly children and young people of working age suffer from chronic tonsillitis and its complications and the ineffectiveness of conservative methods of treatment or decompensation of the process requires surgical intervention - routine tonsillectomy.
Fighting with pain - one of the most pressing medical problems, especially in surgical practice. The solution to this problem is forcing us to seek new ways of painless surgery with simultaneous provision of long-term analgesia in the postoperative period, prevention of tonzillogenic bleeding and requires the development of effective, simple and affordable method for the general medical practice of anesthesia for routine tonsillectomy. In our opinion, the use of conductive anesthesia of II and III branches of the trigeminal nerve in the oval and round holes with tonsillectomy is an alternative in the choice of adequate pain relief and duration of the surgery.
The urgency of the problem also lies in the fact that bleeding associated with the operation of tonsillectomy become more frequent, as it is conducted intimely and is not appointed in the period of development of somatic metatonzillar diseases, which, in turn, significantly affect on the state of the blood coagulation system and other metabolic processes.
Deeper analgesic effect of conductive anesthesia of II and III branches of the trigeminal nerve in the oval and round holes, also called central anesthesia, is well known. The mechanism of draining of blood is that the branches of the trigeminal nerve contain sympathetic nerve branches extending from the external and internal carotid arteries, which are vasoconstrictors of afferent vessels. These afferent vessels vascularize areas corresponding to zones of innervation of the trigeminal nerve's branches and called trigeminy-sympathetic blockade (2, 4).
Materials and methods
We used subzygomaticus central anesthesia for the maxillar and mandibular nerve in the round and oval holes by Vaisblat S.N. The technique of conductive anesthesia for the routine tonsillectomy is that during sedation it is used only analginum and diphenhydramine. Atropine to reduce salivation is excluded.
Anesthesia is performed in the operating room, according to all the rules of asepsis and antisepsis, there is a 5-7 minute
Figure 1 - Place puncture needle under the zygomatic arch, between the condylar and coronoid process of the mandible
break between the right and left side anesthesia, lubrication of the throat with toxic solution of Dicain is not conducted. Then tonsillectomy is performed by the conventional method without additional infiltration anesthesia.
The degree of analgesic effect was assessed according tenzometric device called tonzilometr, which is used in surgical and neurological practice (2). The degree of bleeding was assessed gravimetrically by measuring blood loss by Wangtnsteen in modification of Nicolas, blood circulation in the operated area was recorded by rheographic study.
The advantage of a developed technique is more profound and long-lasting pain relief with fewer injections and anesthetic, analgesia of a greater operative field, which remains unchanged, reduced bleeding and salivation, pharyngeal reflex is removed, which greatly facilitates the technique of surgery.
The acceleration of the healing of tonsillar niches due to the smaller postoperative wound edema is determined in the postoperative period, where anesthetic still affects on the nervous tissue that retains in its normal state, there is no trophic disorders. Conductive anesthesia is also therapeutic measure and a useful therapeutic effect of anesthetic injections even after a single application is proved (1, 2).
Table 1 - Number of patients by somatic metatonzillar diseases
Decompensation I group, n -67 II group, n -31
abs. % abs. %
Rheumatism, autoimmune form 14 20,9 8 25,8
Glomerulonephritis, autoimmune form 13 19,4 6 19,4
Toxic myocarditis 12 17,9 5 16,1
Toxic pyelonephritis 8 11,9 3 9,7
Toxic arthritis 10 14,9 6 19,4
Paratonsillitis 5 7,5 2 6,4
Recurrent sore throat 5 7,5 1 3,2
All 67 100 % 31 100 %
For the prevention of syncope occurring in patients with non-steady mentality, it is necessary to hold the needle
Журнал Национального научного центра хирургии им. А.Н. Сызганова
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puncture at the height of a deep breath, there is a 5-7 minute break between the right and left side anesthesia that allows the doctor to not only divert the attention of the patient, but also prevents the occurrence of brain hypoxia and vegetative-vascular changes in the form of redness or blanching of the skin, sweating, increased heart rate and respiration (1, 2).
Reo- graphic research has explained the mechanism of anemization and absence of bleeding during operation of tonsillitis-ectomya under the conductor anesthesia.
There are surveyed in total 98 patients, suffering by a chronic tonsillitis of de-compensated form. The 67 patients from them - are the 1 group (researched); they were operated on tonsillitis-ectomya under conductor- blockade of I and II branches of trigeminal nerve in the field of oval and round apertures, and to II group of patients (control group) the operation of tonsillitis-ectomya was carried out under the standard infiltration anesthesia.
Table 2 - Number of patients by gender
Sex I group, n -67 II group, n -31
abs. % abs. %
Men 32 47,8 14 45,2
Women 35 52,2 17 54,8
All 67 100 % 31 100 %
Table 3 - Number of patients by age
Age I group, n -67 II group, n -31
abs. % abs. %
13 - 16 12 -15 11 16,4 4 12,9
17 - 21 16 - 20 20 29,9 11 35,5
22 - 35 30 44,8 12 38,7
36 - 60 6 8,9 4 12,9
All 67 100 % 31 100 %
During research we was reveal an expressed anesthetizing, sedative and stabilizing hemo-dynamics action of conduct blockade to hemo-dynamics, and also there are provided an optimum conditions for tonsillitis-ectomya performance due to salivation decrease, reduction of bleeding and removal of pharyngeal reflex.
Conclusions
The developed method of conductive anesthesia for routine tonsillectomy is easy to perform in the presence of certain skills, and can be incorporated into routine clinical practice ENT offices.
Long analgesic effect promotes more smooth current of the postoperative period without analgesic using and long starvation, stimulates healing tonsil niches and leads to reduction of patient's residence time in a hospital: for the
I group (basic) - 2,84 ± 0,06 in-bed-days, for the II group (control) 4,84 ± 0,32 in-bed-day, p<0,001.
A degree of analgesic effect of anesthesia on «Tonsilmeter's» parameters has revealed an authentic difference between conduct and infiltration anesthesia's in 30, 60, 90, 120 and 180 minutes of the postoperative period (p <0,001).
Duration of anesthesia at planning tonsillectomya has made in I group approximately 145,52 ±3,02 minutes, and in
II group 26,09± 1,69 minutes (p <0,001).
Conduct blockade results in abatement of a blood-loss because of conduct bleeding in comparison with infiltration local anesthesia. As to the I group it has made 35,51±3,44 ml, and in II group of patients - 125,16±10,14 ml (p <0,001).
References
1. Vaysblat SN. Local anesthesia during operations on the face, jaw and teeth.- Kiev.- Gov.med.publ. USSR.- 1962.469 p.
2. Tulebayev RK, Taukeleva SA, Shakhmetova KS. The device for the objective assessment of the level of pain in tonsillectomy - «Tonsillometr» .- provisional patent for the invention of Kazakhstan № 17035.-Astana. 2006.
3. Krylov, NV, Iskrenko IA. Cranial nerves. Publisher of the Russian Peoples' Friendship University, Moscow, 2002.
4. Fedyaev IM. Conductive anesthesia and prolonged conductive blockade in maxillofacial surgery. Kuibyshev, 1987.
Summary. This article is devoted to the study of worked-out method advantage of planned tonsillectomy under conduction central anesthesia by Vaisblat S.N.
Keywords: ^ronic tonsillitis, tonsillectomy, conductive anesthesia
