Methods of local anesthesia in postoperative anesthesia of oncosurgical operations on the nasopharynx in children

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Introduction

     It should be noted that such a pathology as cancer of the oropharynx and nasopharynx (RN) in children is rare. Among the total number of malignant tumors of the head and neck, which is 12%, ROP accounts for only 1-3%. Undifferentiated cancer comes to the fore, which occupies 97% of malignant epithelial neoplasms of the nasopharynx and develops mainly in children of 15 years of age, more often in boys. At the same time, in 40% of cases, tumors are located in the nasal cavity and paranasal sinuses, in 25% of cases they are localized in the nasopharynx, in 20% - in the oropharynx, in 15% - in the middle ear. This pathology is found everywhere, however, the highest prevalence is observed in residents of Southeast Asia and accounts for about 10-20% of all malignant tumors in children. Often, manifestations of nasopharyngeal cancer are hidden under the mask of acute respiratory viral infections, rhinopharyngitis, and adenoid vegetations. Very often, the first clinical signs in children are enlarged lymph nodes in the neck. About 90% of undifferentiated cancers are prone to metastasis, and regional cervical lymph nodes are involved in 70–75% during the first months of the disease [1, 2].

     There are a lot of alternative methods of anesthetic management in modern functional endoscopic oncosurgery of the nasopharynx and oncosurgery of the nasopharynx. Nevertheless, despite a number of side effects caused by narcotic drugs, as before, the key role is given to combined anesthesia with the use of narcotic analgesics [3, 4]. However, postoperative pain relief in this case requires additional pain relief for the patient. Discomfort from a nasal swab, combined with postoperative nausea and vomiting, which are a side effect of the use of narcotic drugs, seriously exhausts the patient in the immediate postoperative period.

     Nowadays, there is a certain modification in terms of managing patients in the perioperative period, characterized by improved methods of anesthesia, which can reduce the stress response of the body to surgical trauma, using minimally invasive surgical interventions. The main goal of modern medicine is the technology of multimodal Fast Tgask Surgery (surgery of the "fast path"), which implies the acceleration of various stages of the treatment process - the selection of anesthesia methods, minimally invasive methods of surgical treatment, high-quality pain relief in the early postoperative period, and active postoperative recovery [5, 6].

      Moreover, oncosurgery of the nasopharynx is no exception. The union of combined anesthesia with endoscopic oncosurgery of the nasopharynx, recognized as a low-traumatic intervention, improves the quality of the operation, ensuring the effectiveness and safety of the surgical intervention. Taking into account the recommendation of E. Kesimci et al. [7] on the use of bilateral blockade of the pterygopalatine ganglion, in order to optimize the anesthetic management in the endoscopic method in pediatric oncosurgery of the nasopharynx, we offer a method of combined anesthesia using pterygopalatine blockade by palatal access on both sides (or palatal), and after the completion of the surgical intervention to minimize discomfort and reduce the pain factor when using the nasal tampon Merocel Chemox to perform infraorbital or infiltration anesthesia of the nose from three points according to Weisblat [8], which allows you to create a guaranteed postoperative analgesia, while creating comfortable conditions for the surgeon, for example, minimizing bleeding, and this in turn implies reducing the intensity of postoperative pain. There is information about the presence of significant correlations between the bleeding of the surgical field and the intensity of postoperative pain syndrome [9, 10]

          Considering that the sensitive innervation of the nasal cavity comes from the first and second branches of the trigeminal nerve (n. ophthalmicus et n. maxillaris) [11], postoperative pain associated with the use of the Merocel Chemox nasal tampon is the result of a reflexogenic reaction [12]. The use of regional anesthesia in endoscopic oncosurgery of the nasopharynx in children makes it possible to completely block the innervation of the lateral (outer) wall of the nasal cavity, the lower and middle turbinates, the floor of the nasal cavity and its septum, as well as the maxillary and sphenoid sinuses, the ethmoid labyrinth, preventing the development of reflex trigeminocardial reactions, to achieve stability of the hemodynamic picture, to minimize bleeding in the operated area.

     In addition, used as a local anesthetic - a solution of ropivacaine - an amide group drug with moderate toxicity and long-term action, allows you to achieve not only intraoperative pain relief, but also provide sufficient analgesia in the postoperative period, on average up to 6 hours.

According to the works of Coronado G.C. et al., it is known that the volume of the pterygopalatine fossa is 1.2 ml [13].

     In her dissertation Korobova L.S. draws attention to the fact that the volume of local anesthetic solution of ropivacaine during regional anesthesia on the face in pediatric practice is calculated by the formula: V (ml) = Age / 10 for injection into the cavity and V (ml) = Age / 5 for injection subcutaneously with blockade peripheral branches of the facial nerve [14]. For children under 12 years old, a 0.5% solution is used, for older patients - 0.75%, while the total dose of ropivacaine does not exceed the maximum allowable dose for regional blockades.

The goal is to optimize the methods of postoperative analgesia in oncosurgery of the nasopharynx in children.

Material and methods

     The study was carried out in the immediate postoperative period (16 hours) in the department of anesthesiology, resuscitation and intensive care of the Research Institute of Do and G them. N.N. Blokhin in 10 patients with an average age of 14 years with ENT oncosurgical pathology. The physical status of the children corresponded to the I-II class according to the ASA classification. According to the proposed method, the patients were divided into two equal groups of 5 people: the 1st group (study group) included children who, for the purpose of postoperative analgesia, underwent conduction anesthesia of the nose from three points according to Weisblat at the end of the surgical intervention; Group 2 (comparison group) is represented by children who used infraorbital anesthesia after surgery.

   Non-invasive monitoring of systolic blood pressure (BPsyst.), diastolic blood pressure (BPdiast.), heart rate (HR) was carried out. Data were recorded every hour. Oxygen status was monitored by pulse oximetry (SpO2).

     All patients underwent combined anesthesia, where pterygopalatine anesthesia with palatal access was used as a regional component, in particular, palatal anesthesia, characterized by the absence of penetration into the pterygopalatine canal, performed with the patient lying on the roller. Having found the boundary between the hard and soft palate (Fig. 1), on the hard palate closer to the gingival margin, the retraction was determined, where, respectively, on each side with respect to the axis of symmetry of the face, an insulin syringe was injected with a 29G needle (0.33x13 mm) at an angle of 45⁰, with a preliminary aspiration test, a local anesthetic was administered. A solution of ropivacaine 0.75% (naropin) was used as a local anesthetic.

Fig.1 Guidelines for wing anesthesia

     In order to prolong anesthesia in the 1st group (study group), at the end of the surgical intervention, conduction anesthesia of the nose was performed from three points according to Weisblat. After surgery, prior to tracheal extubation, to minimize discomfort and reduce pain, using a compressed microporous oxycellulose sponge nasal swab (Merocel Hemox), a three-point Weissblat nasal infiltration anesthesia with ropivacaine solution was performed, calculated as: V (ml) = age in years /5, distributed into three points: one injection point is located on the bridge of the nose (Fig. 2a), from where the needle advances on both sides of the nose obliquely from top to bottom - from the inside to the outside (in the medial-distal direction); two other points are located on both sides of the nose at the level of its lower border, from where the needle is first advanced in the direction from the bottom up, releasing local anesthetic in portions, and then, without removing the needle from the tissues, it is directed from outside to inside parallel to the border of the nose (Fig. 2b).

Fig.2a Infiltration anesthesia of the nose from three points according to Weissblatt (bridge of the nose)

Fig.2b Infiltration anesthesia of the nose from three points according to Weisblatt (left point)

     In order to prolong anesthesia in the 2nd group (comparison group), at the end of the operation, infraorbital anesthesia was used by oral access, when the patient was injected with a 23G needle (0.6x30mm) of a 2-gram syringe in the area of ​​the transitional mucosal fold between the central and lateral incisors, advancing needle back, up and out. Stabilization of the position of the needle in the infraorbital foramen allows, after an aspiration test, to inject a local anesthetic with simultaneous massage in the area of ​​the projection of the infraorbital foramen on the face in order to sufficiently distribute the local anesthetic (Fig. 3).

Fig.3 Infraorbital anesthesia

     The intensity and severity of pain after surgery was assessed according to the visual analog scale of pain (VAS, Visual Analog scale - VAS), which is a horizontal line 10 cm (100 mm) long, the ends of which are proportional to the extreme degrees of pain intensity - "no pain" and " the worst pain imaginable." Estimated range from 0 to 100 (0-10). After waking up every hour, the patient marked the point of his pain by pointing a point on this ruler.

 

Results and its discussion

      In patients of the 1st group in the postoperative period, the hemodynamic picture had a stably smooth course, saturation indicators did not change (Fig. 4).

Fig.4 Dynamics of indicators of ADsist., ADdiast., heart rate, SpO2 in the 1st group

 

     Within 15 hours, patients of the 1st group had no complaints and assessed their pain at 0 points according to VAS. Only after 16 hours of follow-up after surgery, the children characterized their pain as mild and more related to discomfort from using a nasal tampon made of a compressed microporous sponge with hydroxycellulose (Merocel Hemox), but in this case anesthesia was not required.

     In patients of the 2nd group in the postoperative period after 10 hours of observation, there was an increase in blood pressure. and BPdiast, as well as an increase in heart rate, saturation indicators were stable (Fig. 5).

 

Fig.5 Dynamics of indicators of ADsist., ADdiast., heart rate, SpO2 in the 2nd grou

 

     Within 10 hours, patients of the 2nd group assessed their pain according to a VAS score of 0-1, however, at 12 hours of observation, the data changed, which is also confirmed by the hemodynamic picture. Children characterized their pain as moderate - 4 points. In this case, intravenous administration of a solution of paracetamol at the rate of 15 mg/kg was sufficient according to the patients' assessment of their pain status according to the VAS.

 

Conclusions

     It is advisable to use the studied options for postoperative analgesia in patients after endoscopic surgical intervention in oncosurgery of the nasopharynx in children, as effective and safe, allowing to refuse the use of opioid analgesics. Considering that the sensitive innervation of the nasal cavity comes from the first and second branches of the trigeminal nerve, the applied methods of regional anesthesia level the risk of reflex trigeminocardial reactions. The use of a regional blockade of the nose from three points according to Weisblat is indicated when using the Merocel Hemox nasal tampon in the postoperative period because it allows you to fully help patients to level the inconvenience caused by the nasal tampon (pain, foreign body sensation) and refuse additional anesthesia. At the same time, the use of infraorbital anesthesia as a component of postoperative pain relief is essentially a worthy method with no less prolonged analgesic effect. At the same time, it also allows you to abandon narcotic analgesics, limiting yourself to an antipyretic analgesic (paracetamol solution).

     And as a result, the issue of effective postoperative pain relief and a comfortable state after surgery is achieved through infiltration anesthesia of the nose from three points according to Weisblat, which allows you to successfully implement the principle of the multimodal strategy of the Fast Track program - surgery, contributing to the early mobilization of the patient.

 

About the authors

Lyudmila S. Korobova

Blokhin Scientific Research Institute of Pediatric Oncology and Hematology

Author for correspondence.
Email: lydmil@bk.ru
ORCID iD: 0000-0003-3047-412X
SPIN-code: 6197-8273

Cand. Sci. (Med.), Anesthesiologist-Intensivist

Russian Federation, 24, Kashirskoye highway, Moscow, 115478

Nune V. Matinyan

Blokhin Scientific Research Institute of Pediatric Oncology and Hematology; Pirogov Russian National Research Medical University

Email: n9031990633@yandex.ru
ORCID iD: 0000-0001-7805-5616
SPIN-code: 9829-6657

Dr. Sci. (Med.), Professor

Russian Federation, Moscow; Moscow

Oleg A. Merkulov

Blokhin Scientific Research Institute of Pediatric Oncology and Hematology

Email: 9166718244@mail.ru
ORCID iD: 0000-0002-8533-0724
SPIN-code: 1492-1083
Scopus Author ID: 382666

Dr. Sci. (Med.)

Russian Federation, Moscow

Vladimir A. Korolev

Blokhin Scientific Research Institute of Pediatric Oncology and Hematology

Email: korolev4@yandex.ru
ORCID iD: 0000-0003-1079-7589
SPIN-code: 9953-6402

Cand. Sci. (Med.)

Russian Federation, Moscow

Vladimir V. Lazarev

Pirogov Russian National Research Medical University

Email: lazarev_vv@inbox.ru
ORCID iD: 0000-0001-8417-3555
SPIN-code: 4414-0677
ResearcherId: P-6234-2015

Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Tatiana A. Ovchar

Morozov Children’s Hospital

Email: Shadum@yandex.ru
ORCID iD: 0000-0001-5764-4016
SPIN-code: 8387-5141

Anesthesiologist-Intensivist, Neonatologist

Russian Federation, Moscow

Vasily P. Akimov

Blokhin Scientific Research Institute of Pediatric Oncology and Hematology

Email: akimovvp87@gmail.com
ORCID iD: 0000-0002-2064-1716
SPIN-code: 5603-4790

Anesthesiologist-Intensivist

Russian Federation, Moscow

Ekaterina A. Kovaleva

Blokhin Scientific Research Institute of Pediatric Oncology and Hematology

Email: mel_amory@mail.ru
ORCID iD: 0000-0001-9492-034X
SPIN-code: 7122-7508

Anesthesiologist-Intensivist

Russian Federation, Moscow

References

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