Евaлуaцијa нa постоперaтивните резултaти кaј пaциенти со функционaлнa и естетскa септориноплaстикa

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Gabriela Kopacheva Barsova

Апстракт

Oперативната техника ÑепториноплаÑтика има за цел да го ремоделира и редизајнира ноÑот, да ги отÑтрани екцеÑивните коÑкени или ʼрÑкавични Ñтруктури, и/или Ñо неа да Ñе корегираат ноÑните инÑуфициенции, Ñо цел ноÑот да претÑтавува хармонична единица во Ð¾Ð´Ð½Ð¾Ñ Ð½Ð° оÑтанатите лицеви Ñтруктури. Таа воедно претÑтавува една од најфреквентните еÑтетÑко - хируршки отоларинголошки процедури. Kартилагинозниот дел на назалниот Ñептум претÑтавува интегрален дел во регионот на иÑтмуÑот и има значајна улога во Ñтруењето и турбуленцијата на воздухот. Поради оваа централна улога на ноÑната преграда, многу е важна адекватноÑта на преземената оперативна техника како клуч за уÑпешен третман, како во функционалната така и во еÑтетÑката ринохирургија. Деформитетите на ноÑната преграда можат да бидат локализирани во коÑкениот или ʼрÑкавичниот дел, но најчеÑто Ñе комбинација од двете. ʼРÑкавичните девијации имаат најголем удел во нарушувањето на назалниот реÑпираторен проток. Затоа e направена нивна адекватна клаÑификација.

Во оваа опÑежна Ñтудија главните цели беа:

1. РиноманометраÑки, да Ñе објективизира назалната воздушна резиÑтенција (назална опÑтрукција) при Ñелекција на пациентите за ÑепториноплаÑтика.

2. Да Ñе изврши евалуација на фреквенцијата и интензитетот на назалните Ñимптоми кај пациентите за ÑепториноплаÑтика пред и по интервенцијата.

3. Да Ñе клаÑифицираат девијациите на ноÑната преграда во Ð¾Ð´Ð½Ð¾Ñ Ð½Ð° Ñепталните Ñтруктурно-анатомÑки промени врз база на КТ на Ð½Ð¾Ñ Ð¸ параназални ÑинуÑи и интраоперативниот наод.

4. Да Ñе одреди адекватен пÑихолошки модел на личноÑÑ‚ при Ñелекција на пациентите за ÑепториноплаÑтика.

Поддржана од клинички важни информации, целта на оваа Ñтудија, беше да биде прифатена како протокол при Ñелекција на пациентите за ÑепториноплаÑтика. Aвторот наведува дека оваа Ñтудија е проÑпективна нерандомизирана каде ÑтатиÑтички беа анализирани вкупно 140 пациенти Ñо девијација на ноÑната преграда (deviatio septi nasi) одделно или во Ñклоп Ñо деформитети на ноÑната пирамида: rhinokyphosis, rhinoscoliosis, rhinolordosis (ÑедлеÑÑ‚ ноÑ), "žÐ´Ð¾Ð»Ð³ ноÑ" (анг: functional tension nose). ИÑпитуваните пациенти беа Ñтавени на оперативна лиÑта за ÑепториноплаÑтика која беше доÑтавена до УниверзитетÑката клиника за уво, Ð½Ð¾Ñ Ð¸ грло – Клинички центар во Скопје, во периодот од Ñептември 2008 г., до Ñептември 2013 г. РиноманометриÑките иÑпитувања беа изведувани на ИнÑтитутот за Медицина на труд - Скопје, а пÑихолошките теÑтирања беа извршени Ñо помош на клинички пÑихолог и пÑихијатар на Клиниката за пÑихијатрија.

ИÑпитуваните групи беа поделени Ñпоред Ñледниве параметри:

a) Според Ñтепенот на назална опÑтрукција, пациентите беа поделени во 3 групи:

Група IA – иÑпитаници кои имаа тежок Ñтепен на назална опÑтрукција (тежок Ñтепен на назална резиÑтенција).

Група IБ – иÑпитаници кои имаа Ñреден Ñтепен на назална опÑтрукција (Ñреден Ñтепен на назална резиÑтенција).

Група II– иÑпитаници кои имаа леÑен Ñтепен на назална опÑтрукција (леÑен Ñтепен на назална резиÑтенција), а кои беа опÑервирани клинички една година, а потоа Ñе донеÑе одлука за оперативна интервенција.

Кај Ñите пациенти-кандидати за ÑепториноплаÑтика, предоперативно беа Ñледени назалните Ñимптоми: назална опÑтрукција, ринореа, назална болка, главоболка, хипоÑмија, ʼрчење, назален говор, епиÑтакÑа и оÑтанато, и беа евидентирани на Ñкалата на назални Ñимптоми.

По извршената оперативна интервенција, иÑпитаниците беа анкетирани колку Ñе задоволни од извршената корекција, при што им беа понудени 5 Ñкорови, одноÑно модалитети: 1-многу задоволни, 2-задоволни, 3-неодредени, 4-незадоволни и 5- екÑтремно незадоволни.

б) Според видот на оперативната техника, при изведба на оперативната интервенција, пациентите беа поделени во две групи:

 - група I -1: каде Ñе изведе Ñамо ÑептоплаÑтика; тоа беа пациенти Ñо Dg: Deviatio septi nasi.

- група I-2: каде Ñе изведе ÑепториноплаÑтика: тоа беа пациенти кои оÑвен девијација на ноÑната преграда имаа и деформитет на ноÑната пирамида од типот на: rhinokyphosis, rhinoscoliosis, rhinolordosis (ÑедлеÑÑ‚ ноÑ) "žÐ´Ð¾Ð»Ð³ ноÑ" (анг: functional tension nose).

Од двете групи, пациентите беа поделени во две подгрупи:

- подгрупа I2-а: во која Ñе изведе лателарна и медијална оÑтеотомија;

- подгрупа I2-б: во која не Ñе изведе оÑтеотомија.

в) ПÑихолошка анализа Ñе направи Ñамо на пациентите-кандидати за ÑепториноплаÑтика кои доброволно прифатија да го пополнат прашалникот за Ñелекција на пациентите-кандидати за ÑепториноплаÑтика и нивните пÑихолошки ÑклоноÑти. Врз база на повеќе ÑветÑки Ñтандардни теÑтови и прашалници кои би ги пополнил пациентот-кандидат за интервенција, Ñе формира Ñличен прашалник, Ñе разбира адаптиран за нашето поднебје во кој влегоа Ñледните параметри:

- Селекција на пациентот за ÑепториноплаÑтика и неговите пÑихолошки ÑклоноÑти (ПÑихолошко теÑтирање-прашалник за self body image), Brief Symptom Inventory (BSI) теÑÑ‚, Ñо кој беа анализирани добиените резултати добиени од прашањата поÑтавувани на пациентите кандидати за ÑепториноплаÑтика. Преку Brief Symptom Inventory (BSI) теÑтот, кој претÑтавува еден Ñтандарден пÑихолошки теÑÑ‚ беа Ñледени Ñледните пÑихолошки Ñимптоми кај пациентот: Ñоматизација, опÑеÑивно-компулÑивни реакции, интерперÑонален Ñензибилитет, депреÑивноÑÑ‚, анкÑиозноÑÑ‚, фобична анкÑиозноÑÑ‚, параноидни идеи, а беа евидентирани и пациентитие без Ñимптоми.

Како методи на иÑпитување беа кориÑтени: риноманометрија како метод за објективизирање на назалната воздушна резиÑтенција, Компјутеризирана томографија –(КТМ) на ноÑот и параназалните ÑинуÑи. ИÑпитуваните назални Ñимптоми беа евидентирани и групирани во Ñкалата на Ñубјективни назални Ñимптоми. Интраоперативно, Ñтруктурните деформитети на ноÑната преграда беа клаÑифицирани во шеÑÑ‚ групи. ПÑихолошките теÑтирања за Ñелекција на пациентите за ÑепториноплаÑтика и неговите пÑихолошки ÑклоноÑти беа извршени преку употреба на поÑебни прашалници. Беше утврден хируршкиот протокол, како и хируршки процедури и поÑтапки при ÑепториноплаÑтика. При тоа, докторантот не Ñе држеше до некоја ригидна наÑока при обавување на еÑтетÑката и функционална ринохирургија. Која хируршка процедура требаше да биде преземена највеќе завиÑеше од патологијата на Ñептумот. Ðаведени Ñе и ÑтатиÑтичките методи кои беа употребени при анализа на добиените резултати.

Врз база на резултатите, ÑтатиÑтичката обработка, како и преку диÑкуÑијата, Ñе воочија Ñледниве заклучоци:

1. Риноманометријата претÑтавува метод за објективно мерење на Ñтепенот на назалната опÑтрукција, клинички многу важен метод Ñо кој може реално да Ñе објективизира Ñтепенот на назална опÑтрукција предоперативно. Во Ñтудијата, бенефитот од ринома-нометријата беше што Ñе поÑтигна важна клиничка цел: Ñе направи диÑтинкција и Ñе групираа пациентите на кои навиÑтина им е потребна ÑепториноплаÑтика и пациентите кои требаа да бидат Ñледени или третирани медикаментозно. ИÑто така, Ñе докажа дека поÑтои индикација за ÑептоплаÑтика и кај оние пациенти кај кои поÑтои леÑен Ñтепен на назална резиÑтенција (блага девијација на ноÑната преграда) која и покрај тоа што е Ñледена во период од една година, без лекови или Ñо употреба на назални топиÑки Ñтероиди, назалната резиÑтенција била Ñе уште приÑутна, па препораката за ÑептоплаÑтика била неизбежна.

2. Кај многу пациенти кои Ñе јавуваат како за функционална, така и за еÑтетÑко-функционална ÑепториноплаÑтика Ñе поÑтавува прашањето дали поÑтои поврзаноÑÑ‚ помеѓу Ñтепенот на назалната опÑтрукција и инциденцијата и јачината на појавата на назалните Ñимптоми кои Ñе јавуваат како резултат на девирана ноÑна преграда. Разбирливо е очекувањето, дека најголем број од овие пациенти имаат аÑиметричен назален проток низ двете ноздри аÑоцирано Ñо девијацијата на ноÑната преграда и доколку девијацијата на ноÑната преграда е потешка, а назалната резиÑтенција е појака, назалните Ñимптоми доминирале што доведувало до едноÑтрана или двоÑтрана хипертрофија на ноÑната школка. ЧувÑтвото на отежнато дишење, пациентите-кандидати за ÑепториноплаÑтика го чувÑтвуваа како доминантен Ñимптом при назалната опÑтрукција. Резултатите од иÑтражувањето покажаа дека и предоперативно, како и на контролите по 3, 6 и 12 меÑеци најмал е бројот и процентот на иÑпитаници кои назалната опÑтрукција ја чувÑтвуваа како Ñлаба и која не им ги попречува Ñекојдневните активноÑти и Ñпиењето. Укажувањето на главоболката како доминантен Ñимптом кај пациентите Ñо назална Ñептална девијација и нејзината конÑтантноÑÑ‚ и во поÑтоперативниот период укажа дека таа кај пациентите Ñе појавува и од одредени Ñубјективни причини кои Ñе најчеÑто од пÑихогена природа: анкÑиозноÑÑ‚, немир, преголеми очекувања од интервенцијата. Ринореата беше драÑтично намалена, поради тоа што Ñо корекцијата на ноÑната преграда Ñе ублажи едемот и хипертрофијата на назалната мукоза, оÑобено промените во назалните конхи, што поÑледователно доведе до намалување на екÑкудацијата на назалниот Ñекрет. Појавата на епиÑтакÑа беше повеќе детектирана кај назални Ñептални девијации во предните и предно-задните партии, но без ÑигнификантноÑÑ‚. Тоа доведе до миÑлење дека и други причинители, функционални, инфламаторни, Ñубјективни и оÑтанати можат да доведат до појава на овие Ñимптоми. Резултатите Ñигнификантно ја прикажуваа корелацијата помеѓу анатомÑките (објективни) и пÑихолошките (Ñубјективни) причини кои ја одредуваа фреквенцијата и тежината на приÑутноÑта на назалните Ñимптоми.

3. Беа разгледани поделбите на назалната Ñептална девијација Ñпоред Младина, како и поделбата врз оÑнова на короналните преÑеци на назалниот Ñептум добиени Ñо направени коронални и акÑијални преÑеци на ноÑната преграда добиени Ñо Компјутеризирана томографија. ИÑто така, Ñе направи компарација во Ð¾Ð´Ð½Ð¾Ñ Ð½Ð° корелација на ноÑната девијација и конÑеквентните промени во Ñредната ноÑна школка, Ñпоредувајќи ги иÑпитувањата што ги направиле Бауман (Baumann) и Ñоработниците во Ñтудијата за клаÑификација на назална Ñептална девијација. СиÑтемÑката поделба на девијацијациите на ноÑната преграда направени во оваа Ñтудија има доÑта предноÑти во Ð¾Ð´Ð½Ð¾Ñ Ð½Ð° претходно наведените поделби, бидејќи поранешните, најчеÑто ги опфаќаа поделбите во пределот на картилагинозниот Ñептум, воедно не земајќи ја во обѕир улогата на поÑтавеноÑта на ноÑната преграда во Ð¾Ð´Ð½Ð¾Ñ Ð½Ð° надворешната конфигурација на ноÑот. Оваа клаÑификација Ñе цели да ги опфати Ñите патолошки алтерации на ноÑната преграда и да ги документира, Ñо цел да Ñе имплементира адекватна оперативна техника. Оваа клаÑификација Ñе Ñтреми и кон тоа, ÑиÑтематÑката обука на младите ринохирурзи во обавувањето на ÑептоплаÑтиката да биде олеÑнета, како и да тежнее таа да биде интереÑна и прифатлива за работа.

4. Во поглавјето за Хируршкиот протокол при изведба на ÑепториноплаÑтика Ñе одредија и утврдија хируршките процедури и поÑтапки при изведба на оперативната интервенција ÑепториноплаÑтика. Преку одредени оперативни техники беше прикажан еден Ñовремен приÑтап при обавување на оперативната техника ÑептоплаÑтика. Крајната цел на оперативната процедура беше да Ñе поÑочи дека не Ñамо медиопонирање на ноÑната преграда, туку и проÑторот помеѓу Ñептумот и ноÑните школки е неопходно важен за правилна назална реÑпирација. Мотото и бенефитот на адекватно изведената интервенција во Ñепталната хирургија и хирургијата на ноÑните конхи е: "žÐе Ñептумот, не ноÑните конхи, туку проÑторот помеѓу нив е виÑтинÑкиот погодок".

5. Преку теÑтирањето на пÑихолошкиот профил на личноÑта обидот беше, пациентот да препознае и да донеÑе зрела одлука за евентуална промена која би наÑтанала, која не Ñамо телеÑно, туку и духовно би му го променила животот. Тоа би било од голема кориÑÑ‚ и за хирургот во донеÑување на правилна одлука околу оперативниот тек на интервенцијата, како и иÑклучително во поÑтоперативниот тек при разграничување на објективните очекувања на хирургот од реализираната хируршка процедура и очекувањата на пациентот.

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Како да се цитира
Kopacheva Barsova, G. (2014). Евaлуaцијa нa постоперaтивните резултaти кaј пaциенти со функционaлнa и естетскa септориноплaстикa. Македонско медицинско електронско списание, 2015, 1–164. https://doi.org/10.3889/mmej.2015.50001
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