Treatment of chronic hypertrophic diffuse rhinitis is divided into general and local; local - for symptomatic, medical and surgical. General treatment does not differ from that in chronic catarrhal rhinitis. Symptomatic is the use of decohegants, a drop from rhinitis, drug corresponds to the local treatment of chronic catarrhal rhinitis described above. However, it should be noted that with true hypertrophy of the endonasal anatomical structures, in particular the lower and middle turbinate, local non-surgical treatment can bring only a temporary improvement in nasal breathing. The main treatment for chronic hypertrophic diffuse rhinitis is surgical, which, however, does not always lead to a final recovery, especially with the constitutional predisposition of body tissues to hypertrophic processes.
The principle of surgical treatment in chronic hypertrophic diffuse rhinitis is the thermal, mechanical or surgical effect on the hypertrophied nasal concha to restore nasal breathing, smell and achieve subsequent scarring of the wound surface, which prevents the recurrent hypertrophic process. The use of one or another type of influence is dictated by the phase of the hypertrophic process.
In the phase of “mild hypertrophy”, it is advisable to use galvanic caustic, cryosurgical effects, laser or ultrasonic destruction, intra-carcinoma mechanical disintegration. These methods are aimed at provoking the inflammatory process and the subsequent hardening of the submucosal structures (mainly vascular plexuses) of the nasal concha to reduce their volume.
Electroplating (galvanothermy, electrocautery) is a method of cauterization of tissues with the help of special metal (iridium-platinum or steel) tips heated by electric current, fixed in special handles equipped with a current switch connected to a step-down transformer. The operation is performed after application anesthesia (2-3-fold lubrication of CO 5-10% solution of cocaine + 2-3 drops of 0.1% solution of adrenaline). Instead of cocaine, you can use a 5% solution dikanna. For deeper anesthesia, intratravel anesthesia can be applied with solutions of trimecain, ultracain or novocaine at an appropriate concentration. The procedure is as follows. Under the protection of the nasal mirror, the end of the galvanic kauter is brought to the far part of the lower turbinates, put into working condition, pressed to the mucosal surface, immersed in the shell tissues and in such a position is removed outside the entire surface of the shell, resulting in a deep linear coagulated tissue burn. Usually spend two such parallel burn lines, placing them one above the other. At the end of the exposure, the galvanocauter is removed from the tissue in a hot state, otherwise, having cooled rapidly in the tissues, it sticks to them and tears off part of the coagulated surface and underlying vessels, which leads to bleeding.
The cryosurgical effect is performed using a special cryoapplicator cooled with liquid nitrogen to a temperature of -195.8 ° C. The ultralow temperature causes deep freezing of the tissue and its subsequent aseptic necrosis and rejection. This method has limited use only for diffuse polypous hypertrophy of the lower nasal conchae.
Laser destruction of the lower turbinates is carried out using a surgical laser, the radiation power of which reaches 199 watts. The factor of laser exposure to tissue is a focused laser beam of a specific wavelength in the range of 0.514-10.6 μm. The most common carbon dioxide lasers. Surgical intervention is performed under local application anesthesia and passes bloodlessly.
Ultrasonic destruction is carried out using special resonantly tuned to this frequency ultrasound sharp cone-shaped emitters (surgical instrument), vibrated with a powerful ultrasonic generator that destroys the structure of tissues and superimposed on the above-mentioned surgical instrument. In this case, oscillations with a frequency of 20-75 kHz and an amplitude of oscillation of the working part of 10-50 microns are used. Ultrasonic destruction technique: after application anesthesia, a surgical instrument is vibrated at the frequency of the ultrasound supplied and the surgical instrument is inserted into the thickness of the inferior turbinate to the depth of the supposed intraracine destruction.
Intracranial mechanical disintegration is the simplest and no less effective than the method described above. Its essence lies in making an incision along the anterior end of the inferior nasal concha, followed by inserting a raspator through this incision and damaging the parenchyma of the conch without perforation of its mucous membrane. The operation ends with anterior tamponade of the nose on the corresponding side for 1 day.
In the phase of connective tissue or fibrous hypertrophy, the above methods provide a satisfactory effect while maintaining the contractile function of the muscular system of the vascular walls. In this case, the choice of the method of disintegration is determined by the degree of effectiveness of vasoconstrictor agents. In case of severe hypertrophy of the shells and the absence of the decongestant effect, the method of resection of the concha is used. It should be noted that in addition to scissors, cutting loops are used to remove the lower turbinate, and tearing loops are used to remove nose polyps.
Partial resection of the inferior turbinate is carried out under local application and infiltration anesthesia in two steps. After lubricating the mucous membrane with an anesthetic solution, 1-2 ml of a 2% solution of novocaine in a mixture with 2-3 drops of a 0.1% solution of epinephrine is injected into the nasal shell.
The first tempo is cutting the shell from its front end to the bone base. Then on the hypertrophied area of the shell impose a cutting loop and cut it. The removal of the hypertrophied posterior end of the inferior turbinate is made by a cutting loop.
With an increased osseous base of the inferior nasal concha and hypertrophy of its soft tissues, the latter is removed, then with the help of Luke's forceps, the osseous base of the shell is removed and moved to the lateral wall of the nose, freeing the common nasal passage from it.
Often, resection of the nasal concha is accompanied by significant bleeding, especially when the posterior ends of the inferior nasal concha are removed, so the operation is completed by the anterior nasal loop on Voyachek, and in some cases it becomes necessary to have a posterior nasal tamponade. To prevent infection, swabs with a syringe and needle are impregnated with a solution of antibiotics.
Treatment of chronic hypertrophic limited rhinitis
The treatment is local drug-based and general does not differ from that in chronic hypertrophic diffuse rhinitis. Surgical treatment varies depending on the location and degree of hypertrophy. So, with hypertrophy of the posterior or anterior ends of the inferior nasal concha, diagnosed in the edema phase and satisfactory vasoconstrictor function, disintegration methods can bring good results. With these interventions, one should be afraid of damage to the nasopharyngeal mouth of the auditory tube, since its burn during galvanization and laser exposure can lead to cicatricial obliteration with serious consequences for the middle ear. Electroplating is contraindicated in hypertrophy of the middle turbinate due to the risk of damage and infection of the middle nasal passage.
In case of fibrous or polypous hypertrophy of the anterior or posterior ends of the inferior nasal concha, as well as the middle nasal conch, conchotomy is used using conchotomes, cutting loops or nasal scissors.