RU2813939C1 - Method for surgical management of gunshot wound of maxillary sinus accompanied by epistaxis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to emergency otorhinolaryngology. Primary surgical preparation of a wound canal of tissues of the buccal region, inspection of a maxillary sinus for the presence of foreign bodies and their removal. Artificial junction of a maxillary sinus is created with a nasal cavity under an inferior nasal concha. Continuing bleeding from the wound cavity is stopped. Mucosal wound and an opening in the anterior wall of the maxillary sinus are dilated on the vestibule of the mouth. Balloon in an unfilled state is placed through the opening into the cavity of the maxillary sinus. Balloon consists of a glove rubber, inside of which there is a part of the infusion system tube one and a half centimetres with an adapter inserted into its end for the additional injections of the infusion system. Placed part of the infusion system tube is fixed to the glove rubber by tying two surgical knots with a capron suture on the distal end of the glove rubber. First of them is located in the projection of the connection of the adapter for the unit of additional injections of the infusion system with the tube of the infusion system, and the second one is in five millimetres distal from the above connection. Then, after placing the balloon in the cavity of the maxillary sinus, the free end of the tube for the infusion system is brought out by clamping from the maxillary sinus through the created artificial fistula in the lower nasal passage into the nasal cavity, and then outside it. Thereafter, a syringe with a volume of at least 20 ml filled with normal saline is connected to the brought-out end of the infusion system tube. That is followed by filling the balloon until a portion of its surface extends beyond the opening on the anterior wall of the maxillary sinus in the vestibule of the mouth. Thereafter, a free portion of the infusion system tube is clamped. Then the syringe is disconnected and the free end of the infusion system tube is tied with a simple knot. Further, the clamp is disconnected; at the point of exit of the tube of the infusion system from the vestibule of the nose, it is fixed to the crease of the wing of the nose by means of an attachment to the latter. Thereafter, the wound of the mouth vestibule mucosa is closed. On the next day, part of the physiological solution is evacuated from the balloon. If epistaxis occurs, the same amount of normal saline is introduced into the balloon that was previously evacuated. In the absence of epistaxis, the unfilled balloon is removed from the maxillary sinus cavity through the created artificial fistula.

EFFECT: method enables the surgical treatment of the gunshot wound of the maxillary sinus, accompanied by epistaxis, eliminating the anterior tamponade of the nasal cavity with early recurrent epistaxis in the postoperative period, preserve nasal breathing, exclude the block of the nasolacrimal canal outlet and the eustachian tube outlet into the nasal cavity.

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Description

The invention relates to the field of medicine, in particular to emergency otorhinolaryngology, and can be used to treat a gunshot wound of the maxillary sinus accompanied by nosebleeds.

In clinical practice, post-traumatic injuries of the maxillary sinuses are accompanied by hemosinus, and in some cases a life-threatening condition - ongoing nosebleeds from the sinus cavity [1].

To stop nosebleeds, including from the maxillary sinus, anterior nasal cavity tamponade is used [1, 2].

There are known methods for stopping nosebleeds by inserting a balloon into the nasal cavity, as described in patent RU 2722819.

The disadvantage of the above methods is the patient’s inability to breathe through the nose, closing the outlet of the nasolacrimal duct. In the latter case, the patient suffers from increased lacrimation, and conjunctivitis is also possible. With these treatment methods, patients note congestion in the ears, which is associated with the closure of the eustachian tube outlet into the nasal cavity, which can lead to a complication such as otitis media.

There is a method of hemostasis in the nasal cavity by inserting a balloon into it containing a tube inside for nasal breathing, as described in patent RU 2411918. Despite the fact that the patient’s condition is significantly alleviated compared to the methods indicated above, problems associated with closure remain nasolacrimal duct and eustachian tube.

In some cases, methods are used to stop nosebleeds by inserting adsorbent tampons into the nasal cavity, as described in patents RU 2749807, RU 2469668. These methods have the same disadvantages as with anterior nasal tamponade.

A widely known method of surgical intervention on the maxillary sinus is the Caldwell-Luc procedure [3]. It is carried out both for chronic diseases of the maxillary sinus and for its traumatic injuries. Surgical intervention consists of open surgery on the maxillary sinus with access to it in the fossa canina maxillae area, creation of an artificial anastomosis of the maxillary sinus with the nasal cavity through the inferior nasal concha and performing sinus tamponade with gauze turundas in case of significant bleeding from it. The disadvantage of this method is the presence of gauze turundas in the sinus, which can serve as a source for secondary infection, as well as the possibility of early relapse of bleeding after removal of the turundas from the sinus cavity, which leads to subsequent anterior tamponade of the nasal cavity to stop bleeding.

We took this method as a prototype.

The claimed invention is aimed at solving the problem of developing a method for surgical treatment of a gunshot wound of the maxillary sinus, which is accompanied by nosebleeds; to prevent early recurrence of nosebleeds in the postoperative period and subsequent anterior nasal tamponade; to avoid blocking the outlet of the nasolacrimal duct, the outlet of the Eustachian tube into the nasal cavity.

To achieve the above result, the invention contains the following essential features.

Primary surgical treatment of the wound canal of the tissues of the buccal region is performed, as well as an inspection of the wound cavity of the maxillary sinus for the presence of foreign bodies - bone fragments, bullets, necrotic tissue. Then a Kocher forceps, curved along a plane with closed jaws under the inferior turbinate, is inserted into the nasal cavity on the side of the injury. The lateral wall of the nasal cavity is broken in the direction of the maxillary sinus, followed by the creation of an artificial anastomosis of the maxillary sinus with the nasal cavity.

To stop bleeding from the maxillary sinus, an unfilled balloon is placed into its cavity through an opening on the anterior wall of the maxillary sinus. It consists of glove rubber, inside which a part of the infusion system tube is placed one and a half centimeters deep with an adapter inserted into its end for an additional injection unit for the infusion system. The placed part of the infusion system tube is fixed to the glove rubber by tying two surgical knots with a nylon thread at the distal end of the glove rubber. The first of them is located in the projection of the connection of the adapter for the additional injection unit of the infusion system with the tube of the infusion system, and the second is five millimeters distal from the specified connection. After placing the balloon through the hole on the anterior wall of the maxillary sinus into its cavity, the free end of the tube for the infusion system is removed by grasping it with a clamp from the maxillary sinus through the created artificial anastomosis in the lower nasal meatus into the nasal cavity, and then beyond it to the outside. A syringe with a volume of at least 20 ml is connected to the extended end of the infusion system tube. The indicated volume of the syringe is due to the fact that the volume of the maxillary sinus in the average adult is 15-20 ml [1, 2]. The syringe must be filled with saline solution in advance. Afterwards, the balloon is filled until part of its surface extends beyond the opening on the anterior wall of the maxillary sinus. Stopping balloon inflation at the specified time is necessary to prevent damage to the lower wall of the orbit. After filling the balloon has stopped, apply a clamp to the free part of the infusion system tube. Then the syringe is disconnected from the latter and the free end of the infusion system tube is tied with a simple knot, after which the clamp is removed. At the point where the infusion system tube exits from the vestibule of the nose, it is fixed to the fold of the nasal wing by suturing it to the latter. Hemostasis is monitored. Then the wound of the oral vestibule mucosa is sutured. The next day, part of the saline solution is evacuated from the balloon, and if nosebleeds occur, the same amount of saline solution that was previously evacuated from the balloon is reintroduced. In the absence of nosebleeds, the unfilled balloon is removed from the cavity of the maxillary sinus through the created artificial anastomosis.

The essential features and advantages that can be provided by the present invention are illustrated by the following figures:

Figure 1 shows a diagram of inserting the jaws of a Kocher clamp curved along a plane into the nasal cavity under the inferior turbinate with breaking through the lateral wall of the nasal cavity and inserting the jaws of the clamp into the cavity of the maxillary sinus. The dotted line indicates the sponges in the cavity of the maxillary sinus. View from the vestibule of the nose.

Figure 2 shows a diagram of inserting the jaws of a Kocher clamp curved along a plane into the nasal cavity under the inferior turbinate with breaking through the lateral wall of the nasal cavity and inserting the jaws of the clamp into the cavity of the maxillary sinus. The dotted line indicates the sponges in the cavity of the maxillary sinus. The lateral wall of the nasal cavity is shown without the nasal septum.

Figure 3 shows a diagram with a balloon filled with saline solution, which is located in the cavity of the maxillary sinus. The dotted line shows the inner surface, the maxillary, with a balloon tightly adjacent to its walls. The surface of the balloon is visualized into the opening of the anterior wall of the maxillary sinus. Through the artificial anastomosis under the inferior turbinate, the distal part of the glove rubber and the tube of the infusion system are determined.

Figure 4 shows an image of a patient with a gunshot wound to the right maxillary sinus in the postoperative period. A sutured wound in the buccal area is identified, as well as an infusion system tube coming out of the vestibule of the nose, fixed by suturing to the fold of the nasal wing.

Figure 5 illustrates a clinical example: the blue arrow indicates the part of the balloon that is visualized in the hole on the anterior wall of the right maxillary sinus.

Figure 6 shows a piece of glove rubber that is used as a cylinder.

Figure 7 shows a separate adapter for the additional injection unit of the infusion system and the tube of the infusion system.

Figure 8 shows an adapter for the additional injection unit of the infusion system, which is inserted into the tube of the infusion system.

Figure 9 shows the fixation of the adapter for the additional injection unit with the infusion system tube to the glove rubber by tying two surgical knots at the distal end of the latter with a nylon thread. The first of them is located in the projection of the connection of the adapter for the additional injection unit of the infusion system with the tube of the infusion system, and the second is five millimeters distal from the specified connection,

Figure 10 shows a syringe, an infusion system tube and a filled balloon.

Figure 11 shows a clamp applied to the infusion system tube after filling the balloon.

Figure 12 shows the free end of the infusion system tube, which is tied with a simple knot and a clamp applied to the infusion system tube.

Figure 13 shows an infusion system tube, the free end of which is tied with a simple knot, as well as a filled balloon.

The following cause-and-effect relationship exists between the essential features and the result: reliable fixation of the balloon to the infusion tube is ensured by placing in the last part of the adapter for the additional injection unit of the infusion system and tying two surgical knots with a nylon thread in the projection of the connection of the adapter for the additional injection unit of the infusion system with tube of the infusion system and five millimeters distal to the specified connection; placing the balloon in an unfilled state into the cavity of the maxillary sinus with its subsequent filling allows for reliable hemostasis, and the removal of the infusion system tube from the vestibule of the nose further facilitates the evacuation of saline solution from the balloon and its removal from the cavity of the maxillary sinus; in case of nasal bleeding from the sinus during the evacuation of saline solution from the balloon, it is possible to refill it and leave it in the maxillary sinus for a period until stable hemostasis is achieved; placing a balloon in the sinus to stop nasal bleeding allows one to avoid anterior tamponade of the nasal cavity, which helps to preserve nasal breathing and the absence of a block to the outlet of the nasolacrimal duct and the outlet of the Eustachian tube into the nasal cavity.

Conducted research on patent and scientific and technical sources of information showed that the proposed method is not known and does not follow explicitly from the studied level of technology, i.e. meets the criteria of “novelty” and “inventive step”.

The invention can be repeatedly used in medicine, in particular in emergency otorhinolaryngology, both in hospital conditions and in the military field to perform surgical treatment of a gunshot wound of the maxillary sinus accompanied by nosebleeds, which allows us to conclude that the invention meets the criterion of “industrial applicability” .

Clinical example.

Patient S, 23 years old. Diagnosis: Gunshot blind wound of the right buccal region with a comminuted fracture of the anterior wall of the maxillary sinus, foreign body (bullet) of the right maxillary sinus, hemosinus. Continued nosebleeds.

The patient was taken to a multidisciplinary hospital. Upon his arrival, an anterior nasal tamponade was performed by an otolaryngologist. Then an X-ray of the skull was performed in two projections: a depressed comminuted fracture of the anterior wall of the right maxillary sinus, a foreign body (bullet) of the right maxillary sinus, hemosinus. A CT scan of the brain was performed: a CT scan of the brain revealed no pathological changes. A depressed comminuted fracture of the anterior wall of the right maxillary sinus, a foreign body (bullet) of the right maxillary sinus, and hemosinus are detected.

After instrumental and laboratory tests, the patient was taken to the operating room.

Operation protocol:

Stage 1. Primary surgical treatment of a gunshot wound in the buccal area. Inspection of the maxillary sinus for the presence of foreign bodies.

An examination of the wound area was performed under general endotracheal anesthesia. A through wound of the tissues of the buccal region is determined. Excision of areas of necrotic tissue of the right cheek area was performed. Primary sutures were placed on the skin and mucous membrane of the inner surface of the buccal area. Hemostasis control. The mucosal wound in the area of the anterior wall of the right maxillary sinus was expanded and separated from the bone structures. Bone fragments of the anterior wall of the right maxillary sinus were removed, and the bone edges of the hole were smoothed using a bur. A foreign body – a bullet – is visualized in the sinus cavity. Deleted. Continued bleeding is observed from areas of damaged sinus mucosa. Part of the necrotic mucosa is removed.

Stage 2. Creation of an artificial anastomosis of the maxillary sinus and nasal cavity. Stopping nosebleeds from the maxillary sinus.

Gauze swabs in the nasal cavity were removed. A Kocher forceps, curved along a plane with closed jaws under the inferior turbinate, is inserted into the nasal cavity on the side of the injury. The lateral wall of the nasal cavity is broken down towards the cavity of the maxillary sinus, followed by the creation of an artificial anastomosis of the maxillary sinus with the nasal cavity.

To stop bleeding from the maxillary sinus, an unfilled balloon is placed into its cavity through an opening on the anterior wall of the maxillary sinus. The balloon was filled to 17 ml of saline until part of its surface exited the hole on the anterior wall of the maxillary sinus. The end of the infusion system tube emerging from the nasal vestibule is fixed to the fold of the nasal wing by suturing it to the latter. Hemostasis control.

Stage 3. Suturing a postoperative wound.

The wound of the oral vestibule mucosa was sutured. Hemostasis control. Alcohol bandage on the skin of the right cheek area in the projection of the wound.

The patient underwent the operation satisfactorily. Delivered to the ward.

The next day after surgery, the balloon was removed from the cavity of the right maxillary sinus. The postoperative period proceeded without complications. The patient was discharged after recovery.

Literature

1. Palchun, V.T. Otorhinolaryngology: national guidelines. 2nd ed., revised. and additional - M.: GEOTAR-Media. - 2020. – 1024 p. ISBN 978-5-9704-5007-9.

2. Otorhinolaryngology: Textbook / Military medical. academic; Ed. I. B. Soldatov, V. R. Hoffman. - St. Petersburg. : Military medical. acad., 2000. – 467 pp.: ill. ISBN 5-7733-0033-8.

3. Elantsev, B.V. Operative otorhinolaryngology. – Alma-Ata: Kazakh State Publishing House. – 1959. – P. 101-113.

Claims (1)

A method of surgical treatment of a gunshot wound of the maxillary sinus accompanied by nosebleeds, including primary surgical treatment of the wound canal of the tissues of the buccal region, inspection of the maxillary sinus for the presence of foreign bodies and their removal, creation of an artificial anastomosis of the maxillary sinus with the nasal cavity under the inferior turbinate, stopping ongoing bleeding from wound cavity, characterized in that, in the vestibule of the mouth, the wound of the mucous membrane and the hole in the area of the anterior wall of the maxillary sinus are expanded; through the hole, an unfilled balloon is placed into the cavity of the maxillary sinus, which consists of glove rubber, inside of which a part of the infusion system tube is placed one and a half centimeters with an adapter inserted into its end for an additional injection unit of the infusion system, while fixing the placed part of the infusion system tube to the glove rubber is done by tying two surgical units with a nylon thread at the distal end of the glove rubber so that the first of them is in the projection of the adapter connection for node for additional injections of the infusion system with a tube of the infusion system, and the second - five millimeters distal from the specified connection, then after placing the balloon in the cavity of the maxillary sinus, the free end of the tube for the infusion system is removed by grasping with a clamp from the maxillary sinus through the created artificial anastomosis in the lower nasal passage into the nasal cavity, and then beyond it to the outside, after which a syringe with a volume of at least 20 ml filled with saline is connected to the extended end of the infusion system tube, then the balloon is filled until part of its surface extends beyond the opening on the anterior wall of the maxillary sinus in vestibule of the mouth, after which a clamp is placed on the free part of the infusion system tube, then the syringe is disconnected and the free end of the infusion system tube is tied with a simple knot, after which the clamp is disconnected, while at the point where the infusion system tube exits from the nasal vestibule, it is fixed to the fold of the nasal wing by suturing it to the latter, after which the wound of the oral vestibule mucosa is sutured; the next day, part of the saline solution is evacuated from the balloon, and if nosebleeds occur, the same amount of saline solution is injected into the balloon that was previously evacuated from it, and if there is no nosebleed, the balloon is removed in an unfilled state from the cavity of the maxillary sinus through the created artificial anastomosis.