Евaлуaцијa нa постоперaтивните резултaти кaј пaциенти со функционaлнa и естетскa септориноплaстикa
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Oперативната техника септоринопластика има за цел да го ремоделира и редизајнира носот, да ги отстрани екцесивните коскени или ʼрскавични структури, и/или со неа да се корегираат носните инсуфициенции, со цел носот да претставува хармонична единица во однос на останатите лицеви структури. Таа воедно претставува една од најфреквентните естетско - хируршки отоларинголошки процедури. Kартилагинозниот дел на назалниот септум претставува интегрален дел во регионот на истмусот и има значајна улога во струењето и турбуленцијата на воздухот. Поради оваа централна улога на носната преграда, многу е важна адекватноста на преземената оперативна техника како клуч за успешен третман, како во функционалната така и во естетската ринохирургија. Деформитетите на носната преграда можат да бидат локализирани во коскениот или ʼрскавичниот дел, но најчесто се комбинација од двете. ʼРскавичните девијации имаат најголем удел во нарушувањето на назалниот респираторен проток. Затоа e направена нивна адекватна класификација.
Во оваа опсежна студија главните цели беа:
- Риноманометраски, да се објективизира назалната воздушна резистенција (назална опструкција) при селекција на пациентите за септоринопластика.
- Да се изврши евалуација на фреквенцијата и интензитетот на назалните симптоми кај пациентите за септоринопластика пред и по интервенцијата.
- Да се класифицираат девијациите на носната преграда во однос на септалните структурно-анатомски промени врз база на КТ на нос и параназални синуси и интраоперативниот наод.
- Да се одреди адекватен психолошки модел на личност при селекција на пациентите за септоринопластика.
Поддржана од клинички важни информации, целта на оваа студија, беше да биде прифатена како протокол при селекција на пациентите за септоринопластика. Aвторот наведува дека оваа студија е проспективна нерандомизирана каде статистички беа анализирани вкупно 140 пациенти со девијација на носната преграда (deviatio septi nasi) одделно или во склоп со деформитети на носната пирамида: rhinokyphosis, rhinoscoliosis, rhinolordosis (седлест нос), „долг нос” (анг: functional tension nose).
Испитуваните пациенти беа ставени на оперативна листа за септоринопластика која беше доставена до Универзитетската клиника за уво, нос и грло – Клинички центар во Скопје, во периодот од септември 2008 г., до септември 2013 г. Риноманометриските испитувања беа изведувани на Институтот за Медицина на труд - Скопје, а психолошките тестирања беа извршени со помош на клинички психолог и психијатар на Клиниката за психијатрија.
Испитуваните групи беа поделени според следниве параметри:
- a) Според степенот на назална опструкција, пациентите беа поделени во 3 групи:
Група IA – испитаници кои имаа тежок степен на назална опструкција (тежок степен на назална резистенција).
Група IБ – испитаници кои имаа среден степен на назална опструкција (среден степен на назална резистенција).
Група II– испитаници кои имаа лесен степен на назална опструкција (лесен степен на назална резистенција), а кои беа опсервирани клинички една година, а потоа се донесе одлука за оперативна интервенција.
Кај сите пациенти-кандидати за септоринопластика, предоперативно беа следени назалните симптоми: назална опструкција, ринореа, назална болка, главоболка, хипосмија, ʼрчење, назален говор, епистакса и останато, и беа евидентирани на скалата на назални симптоми.
По извршената оперативна интервенција, испитаниците беа анкетирани колку се задоволни од извршената корекција, при што им беа понудени 5 скорови, односно модалитети: 1-многу задоволни, 2-задоволни, 3-неодредени, 4-незадоволни и 5- екстремно незадоволни.
б) Според видот на оперативната техника, при изведба на оперативната интервенција, пациентите
беа поделени во две групи:
- група I -1: каде се изведе само септопластика; тоа беа пациенти со Dg: Deviatio septi nasi.
- група I-2: каде се изведе септоринопластика: тоа беа пациенти кои освен девијација на носната преграда имаа и деформитет на носната пирамида од типот на: rhinokyphosis, rhinoscoliosis, rhinolordosis (седлест нос) „долг нос” (анг: functional tension nose).
Од двете групи, пациентите беа поделени во две подгрупи:
- подгрупа I2-а: во која се изведе лателарна и медијална остеотомија;
- подгрупа I2-б: во која не се изведе остеотомија.
в) Психолошка анализа се направи само на пациентите-кандидати за септоринопластика кои доброволно прифатија да го пополнат прашалникот за селекција на пациентите-кандидати за септоринопластика и нивните психолошки склоности. Врз база на повеќе светски стандардни тестови и прашалници кои би ги пополнил пациентот-кандидат за интервенција, се формира сличен прашалник, се разбира адаптиран за нашето поднебје во кој влегоа следните параметри:
- Селекција на пациентот за септоринопластика и неговите психолошки склоности (Психолошко тестирање-прашалник за self body image), Brief Symptom Inventory (BSI) тест, со кој беа анализирани добиените резултати добиени од прашањата поставувани на пациентите кандидати за септоринопластика. Преку Brief Symptom Inventory (BSI) тестот, кој претставува еден стандарден психолошки тест беа следени следните психолошки симптоми кај пациентот: соматизација, опсесивно-компулсивни реакции, интерперсонален сензибилитет, депресивност, анксиозност, фобична анксиозност, параноидни идеи, а беа евидентирани и пациентитие без симптоми.
Како методи на испитување беа користени: риноманометрија како метод за објективизирање на назалната воздушна резистенција, Компјутеризирана томографија –(КТМ) на носот и параназалните синуси. Испитуваните назални симптоми беа евидентирани и групирани во скалата на субјективни назални симптоми. Интраоперативно, структурните деформитети на носната преграда беа класифицирани во шест групи. Психолошките тестирања за селекција на пациентите за септоринопластика и неговите психолошки склоности беа извршени преку употреба на посебни прашалници. Беше утврден хируршкиот протокол, како и хируршки процедури и постапки при септоринопластика. При тоа, докторантот не се држеше до некоја ригидна насока при обавување на естетската и функционална ринохирургија. Која хируршка процедура требаше да биде преземена највеќе зависеше од патологијата на септумот. Наведени се и статистичките методи кои беа употребени при анализа на добиените резултати.
Врз база на резултатите, статистичката обработка, како и преку дискусијата, се воочија следниве заклучоци:
- Риноманометријата претставува метод за објективно мерење на степенот на назалната опструкција, клинички многу важен метод со кој може реално да се објективизира степенот на назална опструкција предоперативно. Во студијата, бенефитот од ринома-нометријата беше што се постигна важна клиничка цел: се направи дистинкција и се групираа пациентите на кои навистина им е потребна септоринопластика и пациентите кои требаа да бидат следени или третирани медикаментозно. Исто така, се докажа дека постои индикација за септопластика и кај оние пациенти кај кои постои лесен степен на назална резистенција (блага девијација на носната преграда) која и покрај тоа што е следена во период од една година, без лекови или со употреба на назални тописки стероиди, назалната резистенција била се уште присутна, па препораката за септопластика била неизбежна.
- Кај многу пациенти кои се јавуваат како за функционална, така и за естетско-функционална септоринопластика се поставува прашањето дали постои поврзаност помеѓу степенот на назалната опструкција и инциденцијата и јачината на појавата на назалните симптоми кои се јавуваат како резултат на девирана носна преграда. Разбирливо е очекувањето, дека најголем број од овие пациенти имаат асиметричен назален проток низ двете ноздри асоцирано со девијацијата на носната преграда и доколку девијацијата на носната преграда е потешка, а назалната резистенција е појака, назалните симптоми доминирале што доведувало до еднострана или двострана хипертрофија на носната школка. Чувството на отежнато дишење, пациентите-кандидати за септоринопластика го чувствуваа како доминантен симптом при назалната опструкција. Резултатите од истражувањето покажаа дека и предоперативно, како и на контролите по 3, 6 и 12 месеци најмал е бројот и процентот на испитаници кои назалната опструкција ја чувствуваа како слаба и која не им ги попречува секојдневните активности и спиењето. Укажувањето на главоболката како доминантен симптом кај пациентите со назална септална девијација и нејзината константност и во постоперативниот период укажа дека таа кај пациентите се појавува и од одредени субјективни причини кои се најчесто од психогена природа: анксиозност, немир, преголеми очекувања од интервенцијата. Ринореата беше драстично намалена, поради тоа што со корекцијата на носната преграда се ублажи едемот и хипертрофијата на назалната мукоза, особено промените во назалните конхи, што последователно доведе до намалување на екскудацијата на назалниот секрет. Појавата на епистакса беше повеќе детектирана кај назални септални девијации во предните и предно-задните партии, но без сигнификантност. Тоа доведе до мислење дека и други причинители, функционални, инфламаторни, субјективни и останати можат да доведат до појава на овие симптоми. Резултатите сигнификантно ја прикажуваа корелацијата помеѓу анатомските (објективни) и психолошките (субјективни) причини кои ја одредуваа фреквенцијата и тежината на присутноста на назалните симптоми.
- Беа разгледани поделбите на назалната септална девијација според Младина, како и поделбата врз основа на короналните пресеци на назалниот септум добиени со направени коронални и аксијални пресеци на носната преграда добиени со Компјутеризирана томографија. Исто така, се направи компарација во однос на корелација на носната девијација и консеквентните промени во средната носна школка, споредувајќи ги испитувањата што ги направиле Бауман (Baumann) и соработниците во студијата за класификација на назална септална девијација. Системската поделба на девијацијациите на носната преграда направени во оваа студија има доста предности во однос на претходно наведените поделби, бидејќи поранешните, најчесто ги опфаќаа поделбите во пределот на картилагинозниот септум, воедно не земајќи ја во обѕир улогата на поставеноста на носната преграда во однос на надворешната конфигурација на носот. Оваа класификација се цели да ги опфати сите патолошки алтерации на носната преграда и да ги документира, со цел да се имплементира адекватна оперативна техника. Оваа класификација се стреми и кон тоа, систематската обука на младите ринохирурзи во обавувањето на септопластиката да биде олеснета, како и да тежнее таа да биде интересна и прифатлива за работа.
- Во поглавјето за Хируршкиот протокол при изведба на септоринопластика се одредија и утврдија хируршките процедури и постапки при изведба на оперативната интервенција септоринопластика. Преку одредени оперативни техники беше прикажан еден современ пристап при обавување на оперативната техника септопластика. Крајната цел на оперативната процедура беше да се посочи дека не само медиопонирање на носната преграда, туку и просторот помеѓу септумот и носните школки е неопходно важен за правилна назална респирација. Мотото и бенефитот на адекватно изведената интервенција во септалната хирургија и хирургијата на носните конхи е: „Не септумот, не носните конхи, туку просторот помеѓу нив е вистинскиот погодок”.
- Преку тестирањето на психолошкиот профил на личноста обидот беше, пациентот да препознае и да донесе зрела одлука за евентуална промена која би настанала, која не само телесно, туку и духовно би му го променила животот. Тоа би било од голема корист и за хирургот во донесување на правилна одлука околу оперативниот тек на интервенцијата, како и исклучително во постоперативниот тек при разграничување на објективните очекувања на хирургот од реализираната хируршка процедура и очекувањата на пациентот.
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