RU2553929C1 - Method for surgical management of chronic maxillary sinusitis through natural junction with using temporary silicone implant - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: ostio-meatal complex is locally anaesthetised. A patient is anaesthetised endotracheally. An incision 0.3-0.5 cm is made at a distance from a border of a semilunar hiatus. A free end of a hamulus is passed around. The incision is extended 0.1-0.2 cm from a base vertically downwards. And it goes further 0.4-0.6 cm along a free border of a lower nasal concha. The hamulus is pulled by blunt dissection in the lateral direction posteriorly. A view of a closed portion of bulla ethmoidalis and a natural junction of a maxillary sinus is opened. That is followed by assessing the changes of the mucous membrane within the semilunar hiatus, the closed portion of bulla ethmoidalis and the natural junction with the maxillary sinus. A microdebrider or an abrasion spoon is used to remove the changed mucous membrane up to a bony frame. The maxillary sinus is inspected through the natural junction. The pathologically involved tissues are removed. The maxillary sinus is rinsed. A temporary silicone implant is mounted. The hamulus is placed in its initial position. The incision is sutured. The sutures are removed 7 days later. The silicone implant is removed 14 days later. A middle nasal passage is endoscopically inspected. The maxillary sinus is rinsed through the natural junction with an antiseptic solution. The check-up examination is performed 6 and 12 months after the operation.

EFFECT: improving the quality of the treatment, reducing the time of staying in hospital, reducing the number of postoperative complications and recurrences by endoscopic intervention, opening the maxillary sinus within the natural junction, preserving the hamulus, and avoiding the postoperative stenosis by using the silicone implant.

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Description

The invention relates to medicine, namely otorhinolaryngology, and can be used for the surgical treatment of patients with chronic maxillary sinusitis.

In recent years, there has been great interest in the problem of endomicrosurgical treatment of diseases of the nose and paranasal sinuses. This is due to the fact that the number of patients with this pathology is large and there is no tendency to reduce them (N.A. Aref'eva, 1996). To date, there are controversial and unresolved issues of indications for various approaches in endorin surgery, the feasibility of radical removal of pathologically altered mucous membranes in the treatment of chronic sinusitis. (Benninger M.S. et al. 1994). In connection with the development of endonasal endoscopic surgery, considerable attention is paid to the condition of the osteomeatal complex, a change in the structure of which leads to the development of various pathological processes of the paranasal sinuses (Lopatin A.S., 2002). Over the past 10 years, endoscopic endonasal access has been a priority in operations on the paranasal sinuses and is increasingly replacing external access. This is facilitated by the improvement and development of new optical devices with a variable viewing angle, which allows to completely examine all departments of the paranasal sinuses and completely remove pathological contents localized even in difficult to reach areas (Klimenko K.E., 2013).

Despite the use of functional endoscopic interventions, their use is associated with the need to expand narrow areas to restore ventilation and internal drainage, which is reflected in the mandatory removal of part of the intranasal structures: the hook-shaped process, natural anastomosis, bulla ethmoidalis, etc. Violation of healing after such interventions can lead to the formation of synechia by the formation of granulations in the middle nasal passage, lateralization of the middle nasal concha, which can ultimately negate a qualitatively performed endoscopic intervention, and also lead to the appearance of a new pathological process (Gilifanov E.A., 2013).

In the majority of ENT hospitals in the Russian Federation, radical surgery is currently performed in the surgical treatment of recurrent and chronic sinusitis (V.T. Palchun et al. 2006). However, despite the present radicalism, the recovery of patients after such surgical intervention does not always occur (Angotoeva IB 2003).

In more equipped hospitals, microendoscopic operations on the maxillary sinuses are performed with an expansion of the natural anastomosis in the middle nasal passage, however, even with this approach, it is not always possible to save the patient from the problem. This method can improve drainage through the anastomosis in a natural way, but it is not always possible to examine the sinus completely and carefully remove the cyst, polyps or foreign body. In this regard, interest in micro-gyrotomy with the use of the Kozlov trocar (1997) has increased, however, this trocar has a number of design flaws that do not allow the operation to be performed under constant endoscopic control.

Endonasal access is less often complicated by trigeminal neuralgia, practically does not produce reactive swelling of the soft tissues of the face and provides reliable drainage of the operated sinus. Also, with endonasal access, integrity of healthy tissue is not required to gain access to the surgical site.

The most common endonasal opening of the maxillary sinuses is the Messerklinder endonasal endoscopic maxillary sinusotomy technique. This method consists in the following: the middle nasal concha is intraoperatively displaced medially, then under the control of the endoscope, a complete or partial resection of the hook process is performed. Further, under the control of the endoscope, the trellis bulla is opened with Blackley forceps, smaller cells of the ethmoid bone are also opened. After this, the natural anastomosis of the maxillary sinus located behind the hook-shaped process in the lower sections of the funnel is visualized and expands posteriorly and somewhat downward. Next, an examination of the cavity of the maxillary sinus is performed with a lateral 30, 45 or 70-degree endoscope. As a result of this intervention, the anastomosis of the maxillary sinus can be expanded from 0.3 to 0.6 cm, which is quite enough for full drainage. After the performed intervention, a swab is installed in the middle nasal passage for several days. We take this method as a prototype.

However, in the above method, there are a number of drawbacks: installing a tampon in the region of the middle nasal passage subsequently leads to a gaping of the front sections of the middle nasal passage, resection of the hooked process and expansion of the natural anastomosis in front allow the inhaled air stream to enter the cavity of the maxillary sinus. The result - sinus hyperventilation with unheated and untreated air, inhibition of mucociliary clearance, the inflammatory process in the sinus cavity in one form or another persists.

The aim of our invention is the development of minimally invasive microsurgical intervention with the installation of a temporary microimplant that interferes with stenosis processes in the area of the intervention, in case of recurrent and chronic maxillary sinusitis.

This goal is achieved by the fact that minimally invasive microsurgical intervention is performed on the structures of the osteomeatal complex with the opening of the maxillary sinus in the area of the natural anastomosis, examination of the sinus with endoscopes, removal of pathological material with the help of special instruments and installation of a temporary microimplant that prevents stenosis in the area of the intervention. This method of surgical treatment provides a fairly wide access to the maxillary sinus, which allows endoscopic examination of all departments of the maxillary sinus, as well as performing the necessary manipulations with endoscopic surgical instruments under visual control. Also, this method allows you to save the anatomical structures of the nose, such as the hook-shaped process in the case of applying the method according to Messerklinder or a defect in the anterior wall of the maxillary sinus when using ecstasal techniques.

For visual control when removing pathological tissues and the cyst membrane in the maxillary sinus, rigid endoscopes with a viewing angle of 0 and 30 degrees, straight and angled Blacksley forceps, micro raspers and an electric suction device are used.

Technical result: the quality of treatment is improved, the time spent by patients in the hospital is reduced, the number of postoperative complications (trigeminal neuralgia) and relapses of the disease are reduced.

Description of the method - under endotracheal anesthesia under the control of an endoscope after local anesthesia of the osteomeatal complex region, an incision of 0.3-0.5 cm is made, stepping back from the edge of the lunate cleft, bends around the free edge of the hook process. Further, the incision continues from the base vertically downward by 0.1-0.2 cm along the free edge of the inferior nasal concha 0.4-0.6 cm. The blunt posterior traction of the hook-shaped process is performed in a blunt way - the covered part of the bulla ethmoidalis and the natural anastomosis of the maxillary sinus open . Changes in the mucous membrane in the area of the lunar cleft, the covered part of bullae ethmoidalis and the natural anastomosis with the maxillary sinus are evaluated. Using a microdebridor or a curette, the changed mucous membrane is removed to the bone skeleton (crescent gap, anastomosis, bulla ethmoidalis). The maxillary sinus is examined through the natural anastomosis. The removal of pathologically altered tissues, washing of the maxillary sinus is performed. Further, in order to prevent cicatricial stenosis of the anastomosis and structures of the osteomeatal complex, a temporary silicone implant is installed. The hook-shaped process is installed in its original position, stitches are placed on the incision. On day 7, the stitches are removed. After 14 days, the silicone implant is removed. An endoscopic examination of the middle nasal passage, washing of the maxillary sinus through a natural anastomosis with an antiseptic solution is carried out. A follow-up examination is carried out 6 and 12 months after the operation.

According to our proposed method, 20 patients were operated on, including 8 patients with recurring purulent-hyperplastic sinusitis, 7 patients with chronic odontogenic sinusitis, caused by excretion of filling material in the maxillary sinus, and 5 patients with chronic polypous cystic sinusitis.

Patients suffered from two to eight years, repeatedly underwent courses of conservative therapy, consisting in general and local anti-inflammatory, antibacterial therapy, puncture of the maxillary sinuses with rinsing with antiseptic solutions.

Clinical example N 1.

Patient K., 31 years old, No. I / b 1104/13. She was admitted to the ENT department of MNPTsO with a diagnosis of Left-sided recurrent purulent-hyperplastic sinusitis.

Upon admission, she complained of frequent relapses of the disease, discharge from the nose of a mucopurulent nature, headache, nasal congestion.

According to the patient, she suffers for 1.5 years. It transfers relapses of the disease 1 time in 3-4 months. It is treated by taking antibacterial drugs, as well as by the puncture method (transferred more than 15 punctures of the left w / h sinus). During treatment, the patient noted a temporary improvement, refused surgical treatment.

When viewed in the left half of the nasal cavity, there is scanty mucopurulent discharge, the mucous membrane is swollen, hyperemic, the nasal septum is not curved, and examination of the middle nasal passage is difficult.

On a computed tomogram - dimming of the left maxillary sinus, with the presence of a liquid component, thickening of the mucous membrane in the area of the natural anastomosis of the maxillary sinus.

When the left maxillary sinus is punctured, a mucopurulent discharge is obtained.

The patient underwent surgical treatment - endonasal endoscopic opening of the left maxillary sinus through a natural anastomosis using a temporary silicone implant. Progress of the operation: under endotracheal anesthesia under the control of endoscopes 0 * and 30 * after local anesthesia of the osteomeatal complex area, a 0.5 cm incision was made, stepping back from the edge of the lunate cleft. The incision bends around the free edge of the hook-shaped process 0.2 cm. Next, the section is continued along the free edge of the lower nasal conch 0.6 cm. The blunt posterior traction of the hook-shaped process is made. The previously covered part of bulla ethmoidalis and the natural fistula of the left maxillary sinus were examined. The mucous membrane in the region of the lunar fissure on the left is pasty; the mucous membrane of bulla ethmoidalis is thickened, blocking the entrance to the natural anastomosis with the maxillary sinus. Using the curette, the altered mucosa of bulla ethmoidalis was removed to the bony skeleton. The maxillary sinus was examined through the natural anastomosis with the help of endoscopes: mucopurulent discharge in the amount of 2 ml was revealed, the mucosa of the maxillary sinus was pasty. Using a tow truck, exudate was removed from the left maxillary sinus, the sinus was washed with 40 ml of a 02% solution of chlorhexidine abigluconate. Further, in order to prevent cicatricial stenosis of the anastomosis and structures of the osteomeatal complex, a temporary silicone implant is installed. The hook-shaped process is set to its original position, sutures are made on the incision.

The sutures in the area of the surgical wound were removed on day 7. On day 14, the silicone implant was removed. Using an endoscope, the osteomeatal complex area was examined, the anastomosis area was free, passable, the maxillary sinus was rinsed through the natural anastomosis with an aqueous antiseptic solution (0.02% chlorhexidine abigluconate solution). In the washings, there is a scanty amount of mucous-sucrose discharge. A control examination of the patient was carried out after six and twelve months. At the time of inspection, there are no complaints, nasal breathing is free, the nasal mucosa is pink, moist, nasal passages are free. The anastomosis in the middle nasal passage is freely passable, the hook-shaped process in the normal position, is not separated in the maxillary sinus, radiological data showed the restoration of pneumatization of the maxillary sinus, the absence of pathological tissues.

Clinical example N 2.

Patient N., 27 years old, № and / b 1357/13. Was admitted to the ENT department of MNPTsO with a diagnosis of Chronic left-sided polypous-cystic maxillary sinusitis.

On admission, she complained of pain in the projection area of the left maxillary sinus, discharge from the left half of the nasal cavity of a light color.

From the anamnesis it is known that he suffers for 5 years, when he first suffered maxillary sinusitis on the left side. Periodically, on average, twice a year, I was on outpatient treatment, once the maxillary sinus was punctured on the left. During washing, an amber-colored cystic fluid was obtained. During treatment, the patient noted a temporary improvement, refused surgical treatment.

When viewed in the left half of the nasal cavity, the mucous membrane is scarce, the mucous membrane is swollen, hyperemic, the nasal septum is not curved, and examination of the middle nasal passage is difficult.

On the computed tomogram - dimming of the left maxillary sinus, due to a rounded formation filling 2/3 of the sinus volume, thickening, hyperplasia of the sinus mucosa in the region of the anastomosis of the left upper limb sinus.

The patient underwent surgical treatment - endonasal endoscopic opening of the left maxillary sinus through a natural anastomosis using a temporary silicone implant. Progress of the operation: under endotracheal anesthesia under the control of endoscopes 0 * and 30 * after local anesthesia of the osteomeatal complex area, a 0.5 cm incision was made, stepping back from the edge of the lunate cleft. The incision is continued along the free edge of the hook-shaped process by 0.2 cm. Next, the section is continued along the free edge of the lower nasal turbinate 0.6 cm. The blunt posterior traction of the hook-shaped process is made. The previously covered part of bulla ethmoidalis and the natural fistula of the left maxillary sinus were examined. The mucous membrane in the region of the lunar fissure on the left is pasty polypous-modified, the mucous membrane of bulla ethmoidalis is thickened, polypous-modified, blocking the entrance to the natural anastomosis with the maxillary sinus. Using a curette and a microdebrider, the altered mucosa of bulla ethmoidalis was removed to the bone skeleton and sent for histological examination, the natural anastomosis of the maxillary sinus was expanded to 1 cm in diameter. Examination of the left maxillary sinus revealed a cyst filling 2/3 of the sinus volume, coming from the area of the alveolar bay. Using curved forceps, the cyst walls were removed and sent for histological examination. Further, with the aim of preventing cicatricial stenosis of the anastomosis and structures of the osteomeatal complex, a temporary silicone implant is installed.

The hooked process is set to its original position, sutures are applied to the incision.

The sutures in the area of the surgical wound were removed on day 7. On day 14, the silicone implant was removed. Using an endoscope, the osteomeatal complex area was examined, the anastomosis area was free, passable, the maxillary sinus was rinsed through the natural anastomosis with an aqueous antiseptic solution (0.02% chlorhexidine abigluconate solution). In the washings, mucous-sucrose discharge, hemorrhagic clots were obtained. A control examination of the patient was carried out after six and twelve months. At the time of inspection, there are no complaints, nasal breathing is free, the nasal mucosa is pink, moist, nasal passages are free. The anastomosis in the middle nasal passage is freely passable, the hook-shaped process in the normal position, is not separated in the maxillary sinus, radiological data showed the restoration of pneumatization of the maxillary sinus, the absence of pathological tissues.

Claims (1)

A method for the surgical treatment of chronic maxillary sinusitis through the natural anastomosis by endonasal endoscopic surgery, characterized in that the surgery is performed under endotracheal anesthesia after local anesthesia of the osteomeatal complex region, an incision of 0.3-0.5 cm is made, departing from the edge of the lunate cleft, bend around the free edge of the hook process, the incision continues from the base vertically down by 0.1-0.2 cm, along the free edge of the lower nasal concha 0.4-0.6 cm, using a blunt method, traction of the hook-shaped process laterally posteriorly reveals the appearance of the covered part of the bulla ethmoidalis and the natural anastomosis of the maxillary sinus, assesses the change in the mucous membrane in the region of the lunate fissure, the covered part of the bulla ethmoidalis and the natural anastomosis with the maxillary , using a microdebridor or a curette, remove the changed mucous membrane to the bone skeleton, examine the maxillary sinus through the natural anastomosis, remove pathologically altered tissues, they wash the maxillary sinus, then install a temporary silicone implant, the hook-shaped process is set to its original position, stitches are cut, on the 7th day the stitches are removed, the silicone implant is removed after 14 days, an endoscopic examination of the middle nasal passage is performed, the maxillary sinus is washed through the natural anastomosis with a solution antiseptic, control examination is carried out after 6 and 12 months after surgery.