Nasal injuries are one of the pressing problems in medicine due to their significant prevalence. Isolated fractures of the nasal bones account for 42.9–83.7% of injuries to the facial skeleton. In addition, a change in the shape of the nose can cause psychological discomfort for the patient and negatively affect his ability to work and social activity [1-3].
The need for surgical treatment of nasal bone fractures, its volume and anesthesia are determined by the specific clinical situation. The effectiveness of surgery on the external structures of the nose and nasal septum largely depends on the quality of anesthesia. When choosing an anesthetic method, the psycho-emotional status of the patient, the type of deformity and the expected volume and duration of the intervention are taken into account [4, 5]. The type of anesthesia is usually agreed upon with the patient, for which he gives informed consent [6].
The abundant blood supply to the nose during surgery creates a risk of bleeding. In this regard, the need to prevent blood aspiration and maintain airway patency is of particular relevance during such operations.
Currently, rhinosurgeons use various types of anesthesia when performing operations on victims with nasal trauma. In Russia today, according to various authors, about 80% of surgical interventions on the ENT organs are performed under local anesthesia [7]. This is due to reasons such as ease of implementation, saving time on preoperative preparation, greater safety, less bleeding of tissues of the surgical field, rapid postoperative adaptation, the possibility of constant contact with the patient during surgery, understanding by doctors and patients of the fact that general anesthesia is additional intervention and additional risk.
A number of authors note that with local anesthesia, disorders of brain activity, thromboembolic and bronchopulmonary complications are less likely to occur [8]. At the same time, the negative aspects of local anesthesia are emphasized: insufficient neurovegetative protection of the body, an increase in the concentration of stress hormones in the blood serum, psycho-emotional disorders [9].
Currently, with the introduction of improved anesthetic techniques into practice, an increase in the efficiency and safety of anesthesia, as well as an increase in the volume of surgical interventions performed, including septoplasty and endoscopic correction of intranasal structures, the number of operations for fractures of the nasal bones performed under intubation anesthesia is increasing [10]. When choosing pain relief, the individual characteristics of the patient, his psychological mood, and, in some cases, fear of surgery are also taken into account [11].
The purpose of the study is to conduct a comparative analysis of various methods of anesthesia during surgical interventions in patients with nasal bone fractures.
Patients and methods
The subjects of the study were 2676 patients (men - 1534, women - 1142) with fractures of the nasal bones aged from 15 to 78 years, who were treated in the otolaryngology department of the Karachay-Cherkess Republican Clinical Hospital for 15 years (2002-2016). During the acute period of injury, surgical interventions were provided to 1043 patients, 563 patients underwent reposition of the nasal bones, 473 underwent reposition and septoplasty. In the long-term period after the injury, surgical interventions were performed in 1634 patients. In 1182 cases septoplasty was performed, in 452 - rhinoseptoplasty.
The effectiveness of pain relief was assessed by comparing the patient's feeling of comfort during the operation. The level of cortisol in the blood of patients was monitored before the intervention, at the time of maximum surgical trauma and after surgery. The concentration of cortisol in the blood was determined using a radioimmunoassay using the Cortisol RIA kit (nmol/l). Blood sampling was carried out in the morning before the introduction of premedication, during surgery and 1 hour after surgery.
Statistical processing of the obtained data was carried out using the Statistika 6.0 program using the method of variation statistics with finding the arithmetic mean, standard deviation, and reliability indicator ( p
).
Differences were considered significant at p
<0.05.
Results and discussion
For 2002—2016 2682 operations of varying complexity were performed on the external nose and nasal septum (Table
1)
.
As can be seen from table. 1, on
Table 1. Distribution of the number of operations and types of anesthesia (2002—2016) For a long time, the department used mainly local anesthesia, which provides blockade of pain impulses and inhibition of autonomic reactions. The use of this type of anesthesia was limited not only to lubricating the nasal mucosa with a 2% dicaine solution and infiltration anesthesia of soft tissues at the fracture site, which leads to deformation of the intervention area, interferes with the accurate comparison of bone fragments, making it difficult for the surgeon to orientate. In addition, such anesthesia is ineffective due to insufficient pain relief. When performing an operation under local anesthesia, along with the above measures, we always additionally use carpule anesthesia with articaine-containing drugs. Other authors also point out the feasibility of this technique [12].
Articaine (ultracaine) has an analgesic effect 5-6 times greater than novocaine. To provide effective anesthesia, a significantly smaller dose of the drug is required, and pain relief occurs literally immediately after its administration. The high effectiveness of articaine is due to the diffusion of the anesthetic in bone and connective tissues, binding to nerve fiber proteins, as well as the presence of a vasoconstrictor (adrenaline) in the drug. Of great importance is the low toxicity of the drug, due to its entry into the blood in the form of a pharmacologically inactive metabolite.
The anesthetic is administered not only endonasally, but also from both lateral slopes of the nose towards the medial corner of the eye, as well as into the area of the nasal root. This makes it possible to achieve good pain relief, reliable hemostasis with a low allergenic potential of the drug. In fact, we use a combined method of pain relief - conduction anesthesia with a 4% solution of articaine with adrenaline and application anesthesia with a 2% solution of dicaine. The use of conduction anesthesia greatly simplifies the provision of care to injured patients. At the same time, as experience shows, good pain relief is achieved due to blocking of the nerves involved in the innervation of the external nose.
In case of more extensive injuries and the impossibility of using local anesthesia in full, we resort to intravenous anesthesia using short- and ultra-short-acting intravenous anesthetics (diprivan, thiopental), combining them with the administration of promedol, and sometimes with sedation with relanium or sibazon.
The choice of anesthesia technique depends both on the nature and extent of the upcoming operation, as well as on the age and condition of the patient. In particular, intravenous anesthesia is used for short-term interventions in adolescents, local anesthesia is more often used in adults in the acute period of a fracture of the nasal bones during reposition.
In recent years, thanks to the equipping of operating rooms with anesthesia equipment and the assignment of a qualified anesthesiologist to the ENT department, the number of patients operated on under intubation anesthesia has been increasing. Thus, over the previous 10 years, the number of operations performed in our clinic under general anesthesia has increased by more than 50%. The improvement of anesthesia techniques, which allows for good visualization of the surgical field and minimization of intraoperative bleeding, was of great importance. A significant role in the increase in the use of intubation anesthesia was played by the expansion of the scope of surgical intervention on nasal structures under endoscopic control.
The dynamics of cortisol levels in the blood of operated patients, depending on the type of anesthesia, are presented in Table. 2.
Table 2. Dynamics of cortisol levels in the blood of operated patients
As can be seen from table. 2, the level of cortisol in the blood of patients operated on under local anesthesia was higher than when using intubation anesthesia. The increase in cortisol levels was statistically significant at the height of the operation and immediately after its completion. Thus, increased levels of cortisol in the blood indicate a more stressful effect of surgery on the body when local anesthesia is used. In addition, after surgery under local anesthesia, cortisol levels remained quite high, while after surgery under general anesthesia it was lower than before.
Treatment of a humerus fracture.
The main threat of shoulder fractures is complications in the form of paresis or paralysis of the limb. Such situations most often develop when the radial nerve is damaged. Every fifth or sixth fracture is complicated by injury to the radial nerve.
Humeral fractures can be treated either surgically or conservatively. The choice of treatment method depends on the nature of the fracture, the degree of displacement of bone fragments and damage to soft tissues. Shoulder fractures occur in both young and old people. Most often they occur as a result of unsuccessful falls, road accidents, or illnesses. In older people, shoulder fractures often occur due to osteoporosis.
- Our specialists.
A fracture of the humerus is an emergency. Doctors of the Emergency Department will examine the injury, perform all necessary procedures to eliminate pain and perform diagnostic tests. The emergency department of Ilyinskaya Hospital operates around the clock. Treatment of shoulder fractures is carried out by experienced orthopedic traumatologists. The specialists of the Ilyinskaya Hospital successfully perform intramedullary and external osteosynthesis operations using a new generation of fixing plates, and are proficient in a full range of conservative techniques.
- Diagnostics.
To determine the complexity of the fracture and choose a treatment method, an examination by a traumatologist and radiography is sufficient. In some cases, a computed tomography scan is required. The Ilyinskaya Hospital is equipped with two modern multispiral computed tomographs, one of which is installed in the Emergency Department and operates around the clock. Experts in the Department of Radiation Diagnostics have the most current, constantly updated knowledge, work closely with clinicians and provide them with accurate interpretation of images.
- Conservative treatment.
Conservative treatment of humerus fractures shows good results - up to 90% of cases can be successfully treated conservatively. The condition for conservative treatment of a fracture is the permissible size of the displacement. Acceptable figures are as follows: angular displacements up to 20°, shortening up to 3 cm, rotation up to 15°. If these indicators are observed, you can obtain excellent functional results with conservative treatment. It should be understood that the pace of rehabilitation during surgical treatment is higher - the patient recovers faster. Therefore, if recovery time is important professionally (for athletes, stuntmen, dancers), then this is a strong argument in favor of choosing a surgical method.
- Surgery.
For surgical treatment, intramedullary (intraosseous) osteosynthesis is used (a method of treating fractures of long tubular bones, in which fixing material is introduced into the bone marrow cavity of both fragments), or extramedullary osteosynthesis with plates is used (bone fragments are fixed using plates of various thicknesses and shapes, connected to the bone at using screws and screws). The choice of method depends on many factors that are related to the nature of the injury, age, and field of activity of the patient. Absolute indications for surgery are a fracture of the shoulder as part of a polytrauma (with multiple fractures), open fractures of the humerus, fractures of both humeri, pathological fractures (with diseases of the humerus), in the case of false joints of the humerus. The metal structures that are installed during the operation are made of titanium alloy, they are extremely reliable and durable, they are not detected by metal detectors, and their presence is not a contraindication for MRI. The Ilyinskaya Hospital uses the most modern designs for osteosynthesis from European and American manufacturers. One year after the operation, the doctor and the patient make a joint decision on whether to remove the plate or not. The general practice is this: if the metal structure does not interfere or create any discomfort, including psycho-emotional, then it is not removed.
- Treatment of humerus fractures in elderly patients.
In the case of a shoulder fracture in elderly and senile patients, orthopedists and traumatologists at the Ilyinskaya Hospital, together with the patient and his relatives, discuss the optimal treatment path. In some cases, surgical treatment has direct indications. For example, with unstable fractures, when the external bandage does not sufficiently hold the fracture, there is a risk of developing nonunion and pseudarthrosis. Surgery is suggested in the presence of Parkinson's disease, since such patients have constant limb tremors. Surgery is also indicated for patients with severe obesity who find it difficult to wear an external bandage. Surgical treatment is indicated for elderly patients (80-90 years), even despite the presence of concomitant diseases. Such patients can no longer consciously wear a fixation bandage (it irritates and interferes with them, creates mental problems). Anesthesiologists at the Ilyinskaya Hospital will select the safest type of anesthesia, and in the postoperative period the patient will be provided with the best care and complete pain relief.
- Help for patients with pseudarthrosis.
In most cases, pseudarthrosis is the result of incorrectly performed surgical or conservative treatment. Our orthopedic traumatologists have extensive experience in providing care to patients with already formed pseudarthrosis. A false joint is a very complex and individual situation; its treatment is only surgical and, as a rule, requires autotransplantation - moving the patient’s healthy tissue from other organs to the fracture site (a fragment of the ilium is often used). This is high-level reconstructive surgery, which is meticulously mastered by specialists from the Ilyinsk Hospital.
- Pain management service.
The Ilyinskaya Hospital has implemented the concept of a “hospital without pain.” Our specialists have a full range of analgesics, including powerful opioid drugs. For the most persistent pain syndromes, therapeutic blockades, nerve stimulation with a high-frequency electric field, implantation of electrodes to stimulate the spinal cord and individual nerves are used, and special systems are used that inject morphine directly into the cerebrospinal fluid.
- Rehabilitation.
After surgical treatment of a fracture, rehabilitation and pain control are carried out. Even if the treatment technique was minimally invasive, this does not change the fact that the patient had severe soft tissue damage, to which was added trauma from the operation. For each patient, the rehabilitation specialists at the Ilyinskaya Hospital draw up an individual rehabilitation program that takes into account his capabilities and individual characteristics. Rehabilitation specialists at the Ilyinskaya Hospital, in collaboration with the operating surgeon and general practitioners, will make the recovery process as fast and efficient as possible.