Acute ethmoidosphenoiditis: causes, symptoms, diagnosis, treatment

Acute craniobasal sinusitis (acute etmoidosphenoiditis). These diseases include inflammation of the mucosa of the posterior cells of the latticed bone and the sphenoid sinuses, which in most cases occur simultaneously, and in most cases the onset of the disease is a rhinogenic inflammation of the posterior cells of the trellis, which communicate freely with the sphenoid sinus. Therefore, in the foreign literature the term "acute etmoidosphenoiditis" was most widely used.

Acute etmoidosphenoiditis is an acute non-specific inflammation of the mucosa of the posterior cells of the latticed bone and the sphenoid sinus, arising either primarily on the basis of acute banal or influenza rhinitis, or as a consequence of (very rarely) acute transient inflammation of the anterior sinuses. Mostly adults are ill.

Etiology and pathogenesis. Most often, acute etmoidosphenoiditis is a consequence of acute epidemic rhinitis of viral or bacterial etiology, taking place on an allergic background. In this case, most often the disease acquires the character of a pansinusitis. If these rhinitis acquire a malignant clinical course characterized by high body temperature, hemorrhages, purulent ulcerous necrotic lesions of the nasal mucosa and bone tissue of the latticed maze, the infection easily penetrates the sphenoid sinus and causes its acute inflammation. The defeat of the nasal mucosa with sapa, meningococcal infection, syphilis, childhood infections can also lead to acute etmoidosphenoiditis. As AS Kiselev (1997) notes, at present, rhinoviruses, combined with bacterial microbiota, attach great importance to the development of inflammatory diseases of the paranasal sinuses. Traumatic lesions of the middle floor of the nasal cavity can also cause infection of the posterior cells of the latticed bone and the mucous membrane of the sphenoid sinus. Tumors of the rhinoemoidal and rhinopharyngeal regions, the bases of the skull, when they grow in the ethmoidosphenoidal direction and the violation of the drainage function of the outlets of the sphenoid sinus, cause the appearance in them of the transudate, which subsequently becomes infected and leads to their acute purulent inflammation.

An important factor in the pathogenesis of development of acute etmoidosphenoiditis is the degree of pneumatization of the sphenoid sinus and the posterior cells of the latticed bone. As already noted, there is a direct relationship between the incidence and severity of inflammatory diseases of the paranasal sinuses from their size. To a large extent this also applies to the sphenoid sinus.

Symptoms and clinical course. Acute etmoidosphenoiditis is classified according to the following clinical forms:

1. open and closed forms; the first is characterized by the presence of functioning outlets and a facilitated clinical course; the second - the blockade of the outlets, the accumulation of inflammatory exudate in the sphenoid sinus and a severe acute clinical course, often requiring urgent surgical intervention; it is with this form that severe intracranial complications of acute etmoidosphenoiditis occur;
2. etiological and pathogenetic forms - bacterial, viral, specific, allergic;
3. pathomorphological forms - catarrhal, serous, purulent, osteonecrotic;
4. complicated forms - basal OHA with neuritis of the optic nerve, meningoencephalitis, abscesses of the brain.

Deep bedding of the sphenoid sinus, its proximity to important anatomical formations determine the features of the symptomatology, clinical course and complications arising in acute and chronic sphenoiditis. Acute etmoidosphenoiditis is characterized by a veiled clinical course that does not manifest itself at the initial stages with bright symptoms clearly indicating the localization of the pathological process, so it is often difficult to diagnose it, which is also facilitated by not always clear X-ray data.

Occurring in acute etmoidosphenoid subjective symptoms are most often assessed as signs of acute etmoiditis, which is more clearly diagnosed during radiographic examination.

Patients with acute etmoidosphenoiditis complain about a feeling of pressure and raspiraniy in the deep sections of the nose, extending to neighboring areas and into the orbit. The pain that arises in this area is painfully burgeoning, radiating to the crown, to the region of the occipital bone, and often to the frontal region. The pain is mainly permanent, periodically sharpening, causing the occurrence of nausea and vomiting. When shaking their head, they sharply increase, synchronizing with the fluctuations of the head. The genesis of headaches in acute etmoidosphenoiditis is determined both by the inflammatory exudative process itself, which determines the accumulation of pathological contents in the cavities of the sphenoid bone, and the resulting toxic neuritis of nerve fibers innervating the sphenoid sinus: the posterior trellis nerve (from the first branch of the trigeminal nerve), the nasal nerves branches of the trigeminal nerve, which cause irradiation of pain to the frontal region) and branches of the pterygoid node).

Other important subjective symptoms of acute etmoidosphenoiditis are a decrease in the severity of smell and vision. The first is the result of an inflammatory process in the posterior cells of the latticed bone, the second is a consequence of the perivascular edema that occurs in the visual canal. With the open form of acute etmoidosphenoiditis, there is a characteristic symptom - the presence of constant discharge in the nasopharynx, provoking the patient to expectorate and spit, which is also characteristic for inflammation of the posterior cells of the latticed bone.

Objective symptoms include diffuse edema of the nasal mucosa with all the characteristic signs of acute etmoiditis, obstruction of nasal passages, "posterior" rhinorrhea, hyposmia, lacrimation, photophobia, hyperemia sclera, disruption of accommodation and visual acuity. With anterior rhinoscopy in the nasal passages, scant purulent discharge is determined, which is abundantly visible in posterior rinoscopy, covering the posterior ends of the middle and lower nasal conchae, draining along the back wall of the nasopharynx.

The nature of the clinical course is determined by the clinical forms described above. The most difficult are the so-called closed forms, in which the process most often becomes purulent and purulent-necrotic and often extends to the basal structures of the brain, causing the occurrence of OXA and other intracranial complications. Evolution of acute etmoidosphenoiditis can develop in the same directions as acute inflammatory processes develop in other paranasal sinuses. Basically, it is determined by the virulence of the microbiota, the degree of immunity, the general state of the organism, the degree of drainage of the sphenoid sinus and the latticed labyrinth, and also the timely initiated adequate treatment.

Common symptoms include moderate fever (38-39 ° C) of the ruminant type with daily fluctuations in body temperature within 1.5-2 ° C; general weakness, loss of appetite, insomnia due to headache intensifying at night. Blood analysis reveals typical changes in the general inflammatory process (neutrophilic leukocytosis, with allergy - eosinophilia, elevated ESR, etc.). Common psychoneurological signs may include increased irritability or apathy, indifference to the environment, the desire to be in a darkened room alone, unwillingness to communicate with people.

Diagnostics. In most cases, direct diagnosis is difficult and for the final diagnosis it takes weeks or even months to monitor the patient. Nowadays, in the presence of modern methods of video endoscopy, X-ray diagnostics, CT and MRI, the time of final diagnosis can be limited to several days, provided a typical clinical course. With regard to complicated forms, unfortunately, some of them are diagnosed in a number of cases only during autopsy or when irreversible organic and functional changes occur in the secondarily affected organs and systems.

Clinical diagnosis is established based on the presence in the history of acute banal, influenza or specific rhinitis immediately preceding the occurrence of a typical pain syndrome (vomiting pain in the depth of the nose, radiating to the crown, occiput and orbit). The disturbance of the sense of smell that occurred at the onset of the disease can be interpreted as a symptom of nasal congestion, however, the attachment of eye symptoms (sclera hyperemia, acute and especially visual fields) to scant discharge or lack thereof in typical loci for acute ethmoidosphenity should indicate acute exudative sphenoiditis of closed type. In the presence of secretions, they are usually detected in the upper nasal passage and drain to the posterior end of the middle nasal shell and further towards the nasopharynx. The diagnosis is confirmed by either radiography or MRI.

Differentiate acute etmoidosphenoiditis from inflammatory diseases of other paranasal sinuses, from cranioccipitocervical neuralgias such as neuralgia of the occipital nerve, from neuralgia of the internal nasal nerve, etmoidosphenoid, craniobasilar and retroorbitosphenoid tumors. The criterion for the exclusion of acute etmoidosphenoiditis in differential diagnosis is the inefficiency of non-operative and even surgical treatment of a disease that mimics acute etmoidosphenoiditis.

The prognosis of acute etmoidosfenoiditis in uncomplicated clinical forms is favorable, the condition of which is the timely and adequate treatment of the clinical stage. With protracted forms that have passed into the purulent-necrotic stage, complications from the optic nerves and meninges are possible. If, in this case, urgent surgical intervention on the sphenoid sinus is not undertaken, then there is a threat of inevitable chronization of the process in the middle cranial fossa in the form of basal leptomatitis and OXA leading to serious visual impairment. The prognosis for life is serious when complications such as thrombosis of the cavernous sinus and cerebral abscess occur.

In the vast majority of cases, the treatment of acute etmoidosfenoiditis is non-operative, medicated, local and general, using some manipulations such as the "method of movement", wedge sinus catheterization, some microsurgical interventions in the area of the outcrops of the posterior cells of the trellis, to facilitate the drainage of the sphenoid sinus through the dissected posterior cells , etc. The most important in the therapy of acute etmoidosphenoiditis is the earliest application of local and general treatment. Locally used antiphlogistics, decongestants, antiseptics, corticosteroids with the sole purpose - to reduce the severity of the inflammatory reaction in the area of the natural outlets of the sphenoid sinus and ensure their satisfactory functioning. Simultaneously, parenteral or per os antibiotics of a wide spectrum of action are applied or adapted to the specific pathogenic microbiota obtained by catheterization of the sphenoid sinus. Assign also antihistamines, intravenous calcium chloride and ascorbic acid (strengthening of barriers and cell membranes), detoxification therapy.

Very effective in the treatment of acute etmoidosphenoiditis is the catheterization of the sphenoid sinus, and the most expedient is the use of the double cannula VFMelnikova (1994), especially effective in the closed form of etmoiditis, in which the use of a single-lumen cannula and the introduction of a liquid in the sinus sharply increase the pressure in the sinus , increase pain and are fraught with the danger of fluid penetration through dehiscence, perivasal spaces and pathological usury in surrounding tissues.

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