Chronic purulent rhinoethmoiditis.

Chronic purulent rhinoethmoiditis (synonym: chronic anterior ethmoiditis) is a disease interpreted as a subsequent pathophysiological stage that occurs as a result of acute rhinoethmoiditis that has not been cured within 2-3 months after its occurrence. Chronic purulent rhinoethmoiditis is characterized by deep irreversible damage to the mucous membrane of the anterior cells of the ethmoid bone with periostitis and osteitis (osteomyelitis) of the intercellular septa. If radical treatment is not timely, the process spreads to the posterior cells and the sphenoid sinus. Chronic purulent rhinoethmoiditis, as a rule, occurs as a complication or a further stage of chronic sinusitis, therefore its signs and clinical course assimilate the signs of the disease of these sinuses.

The cause and pathogenesis of chronic purulent rhinoethmoiditis are common to all forms of chronic inflammatory diseases of the nasal cavity. It should be emphasized that there is no purely isolated anterior ethmoiditis, when other sinuses remain intact. As a rule, other sinuses, especially the nearby ones - the frontal and maxillary, as well as the posterior cells of the ethmoid bone, are involved to one degree or another in the inflammatory process. The degree of involvement of these sinuses in the pathological process varies. Most often, this is a kind of repercussion reaction that occurs in a single anatomical system with varying degrees of alteration of its sections. Timely sanitation of the primary focus of infection leads to rapid elimination of secondary inflammatory manifestations in the adjacent sinuses, however, in advanced cases, with high virulence of microorganisms of the primary focus (anterior cells of the ethmoid labyrinth), decreased immunity, etc., a typical picture of acute or primary-chronic sinusitis can develop in the adjacent sinuses, and then we can talk about hemisinusitis, unilateral pansinusitis, etc. The fact that chronic anterior ethmoiditis cannot "exist" without corresponding signs of inflammation in the mucous membrane of the nasal cavity, as well as in all other anatomical forms of chronic sinusitis, gave reason to interpret it as rhinoethmoiditis.

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Symptoms of chronic purulent rhinoethmoiditis

The signs of chronic purulent rhinoethmoiditis of the open form are divided into subjective and objective. The open form of ethmoiditis is called an inflammatory process that covers all the cells (anterior or posterior), communicating with the nasal cavity or other paranasal sinuses, and is characterized by the outflow of pus into the nasal cavity. The main complaints of the patient are reduced to a feeling of fullness and pressure in the depth of the nose and frontal-orbital region, unilateral or bilateral nasal congestion, deterioration of nasal breathing, especially at night, constant, periodically increasing mucopurulent nasal discharge, which is difficult to blow out. In the initial stage of chronic monoethmoiditis, the discharge is not abundant, viscous, mucous. As the chronic process develops, they become purulent, greenish-yellow in color, and when periostitis and osteitis occur, they have a putrid odor, causing the presence of subjective and objective cacosmia. The latter may indicate a combination of ethmoiditis with odontogenic sinusitis. Hyposmia and anosmia are intermittent in nature and depend mainly on vasomotor, reactive-inflammatory and edematous processes in the nasal mucosa, as well as on the presence of polyps in the nasal passages. The amount of discharge increases sharply when the inflammatory process spreads to the maxillary sinus and frontal sinus.

The pain syndrome in chronic purulent rhinoethmoiditis is complex and has the following properties. Pains are divided into constant, dull, localized deep in the nose at the level of its root, increasing at night. In a unilateral process, they are somewhat lateralized to the affected side, spreading to the corresponding eye socket and frontal region; in a bilateral process, they are more diffuse in nature without a sign of lateralization, radiating to both eye sockets and frontal regions, increasing at night. With an exacerbation of the inflammatory process, the pain syndrome acquires a paroxysmal pulsating character. The pain radiating to the eye socket and frontal region sharply increases, photophobia and other symptoms characteristic of acute anterior ethmoiditis appear: increased fatigue of the visual organ, decreased intellectual and physical performance, insomnia, loss of appetite.

The local objective symptoms include the following signs. When examining the patient, attention is drawn to the diffuse injection of the vessels of the sclera and other tissues of the anterior part of the eyeball, the presence of dermatitis in the area of the nasal vestibule and upper lip. Pressure on the lacrimal bone (Grunwald's symptom) in the "cold" period can cause mild pain, which in the acute period becomes very intense and is a characteristic sign of exacerbation of chronic purulent rhinoethmoiditis. Another pain sign of chronic purulent rhinoethmoiditis is Gaek's symptom, which consists in the fact that pressure on the base of the nose causes a feeling of dull pain deep in it.

Endoscopy of the nose reveals signs of chronic catarrh, swelling and hyperemia of the nasal mucosa, narrowing of the nasal passages, especially in the middle and upper sections, often multiple polypous formations of various sizes, hanging on legs from the upper sections of the nose. The middle concha, being part of the anterior cells of the ethmoid labyrinth, is usually hypertrophied and as if bifurcated - an aspect that occurs with swelling and hypertrophy of the mucous membrane of the funnel (Kaufmann's symptom).

As a result of accumulation of pus and catabolites in the cell forming the middle nasal concha, destruction of its bone base occurs with preservation of soft hypertrophied tissues, which are filled with inflammatory exudate, forming a kind of lacunar cyst, known as concha bullosa, which, in fact, is nothing more than a mucocele of the middle nasal concha. Repeated diagnostic rhinoscopy is performed 10 minutes after anemization of the nasal mucosa. In this case, the places of outflow of purulent discharge from the upper parts of the nose become visible, which flow down the middle and lower nasal concha in the form of a yellow strip of pus.

Chronic purulent rhinoethmoiditis of the closed type may concern only one cell, a limited number of them, or be localized only in the middle nasal concha. In the latter case, concha bullosa, absence of purulent discharge, local hyperemia in the area of the inflammatory process are observed. Among the signs of this form of ethmoiditis, the algic syndrome dominates, which is characterized by persistent neuralgia of the naso-orbital localization, sometimes hemicrania and accommodation and convergence disorders. Patients also feel fullness and distension in the depth of the nose or in one of its halves. Exacerbation of the process is accompanied by lacrimation on the causal side, increased pain and the spread of its irradiation to the corresponding maxillofacial area.

The clinical course of chronic purulent rhinoethmoiditis without comprehensive adequate treatment is long, evolving towards polypo- and cyst formation, destruction of bone tissue, formation of extensive cavities in the ethmoid bone, with spread to the posterior cells of the ethmoid labyrinth and other paranasal sinuses. Under unfavorable conditions, both periethmoidal (for example, orbital phlegmon) and intracranial complications may occur.

The prognosis for chronic purulent rhinoethmoiditis is generally favorable, but with timely detection and high-quality complex treatment. The prognosis is cautious if intraorbital or intracranial complications occur.

Diagnosis of chronic purulent rhinoethmoiditis

The diagnosis of chronic purulent rhinoethmoiditis is established on the basis of the subjective and objective symptoms described above, anamnesis data and, as a rule, the presence of concomitant inflammatory diseases of other anterior paranasal sinuses. Radiography of the paranasal sinuses is of great diagnostic importance, for the anterior cells of the ethmoid bone in the frontomental projection.

In some cases, especially in widespread processes or for differential diagnosis and complicated cases, tomographic examination, CT or MRI are used. For biopsy and determination of the nature of the contents of the ethmoid labyrinth, part of the bulla is removed, its contents are taken and a puncture is made in the asper nasi area with subsequent histological and bacteriological examination of the obtained material.

Differential diagnostics are carried out in the direction of identifying concomitant inflammatory processes in the maxillary sinus and frontal sinus, in the posterior cells of the ethmoid labyrinth and sphenoid sinus. In severe algic forms of chronic purulent rhinoethmoiditis, it is differentiated from Charlin syndrome (severe pain in the medial corner of the eye radiating to the bridge of the nose, unilateral swelling, hyperesthesia and hypersecretion of the nasal mucosa, scleral injection, iridocyclitis, hypopyon, keratitis; after anesthesia of the nasal mucosa, all symptoms disappear) and Slader syndrome. Chronic purulent rhinoethmoiditis is also differentiated from banal nasal polyposis, rhinolithiasis, unrecognized old foreign body in the nasal cavity, benign and malignant tumor of the ethmoid labyrinth, syphilitic gumma of the nose.

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Treatment of chronic purulent rhinoethmoiditis

Effective treatment of chronic purulent rhinoethmoiditis, which, however, does not guarantee prevention of relapses, can only be surgical, aimed at wide opening of all affected cells of the ethmoid labyrinth, removal of all pathologically altered tissues, including bone intercellular septa, ensuring wide drainage of the resulting postoperative cavity, its sanitation in the postoperative period by washing (under low pressure!) with antiseptic solutions, introduction of reparants and regenerants into the postoperative cavity in a mixture with appropriate antibiotics. Surgical treatment should be combined with general antibiotic therapy, immunomodulatory, antihistamine and restorative treatment.

In the case of a closed form of chronic purulent rhinoethmoiditis with the presence of concha bullosa, it is possible to get by with a "minor" surgical intervention: luxation of the middle nasal concha in the direction of the nasal septum, opening and removal of the middle concha, curettage of several nearby cells. In the presence of repercussion inflammatory phenomena in the maxillary sinus or frontal sinus, their non-surgical treatment is carried out.

Surgical treatment of chronic purulent rhinoethmoiditis

Modern advances in general anesthesiology have almost completely replaced local anesthesia with this method, which, no matter how perfect its execution, never achieves a satisfactory result. At present, all surgical interventions on the paranasal sinuses are performed under general anesthesia; sometimes, for anesthesia of endonasal reflexogenic zones, endo-nasal application and infiltration anesthesia of the nasal mucosa in the area of the ager nasi, the upper and middle nasal concha, and the nasal septum are performed.

Indications for surgery

Long-term course of the inflammatory process and ineffectiveness of non-surgical treatment, the presence of concomitant chronic sinusitis and chronic pharyngitis, for which indications for surgical treatment have been established, recurrent and especially deforming nasal polyposis, the presence of orbital and intracranial complications, etc.

Contraindications

Cardiovascular insufficiency, which excludes general anesthesia, acute inflammatory diseases of internal organs, hemophilia, diseases of the endocrine system in the acute stage and others that prevent surgical treatment of the paranasal sinuses.

There are several ways to access the ethmoid labyrinth, the choice of which is dictated by the specific state of the pathological process and its anatomical localization. There are external, transmaxillary sinus and intranasal methods. In many cases, opening the ethmoid labyrinth is combined with surgical interventions on one or more paranasal sinuses. This method, which has become possible due to modern achievements in the field of general anesthesiology and resuscitation, is called pansinusotomy.

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Intranasal method of opening the ethmoid labyrinth according to Halle

This method is used in isolated lesions of the ethmoid labyrinth or in combination with inflammation of the sphenoid sinus. In the latter case, the opening of the sphenoid sinus is performed simultaneously with the opening of the ethmoid labyrinth.

Anesthesia is usually general (intratracheal anesthesia with pharyngeal tamponade, which prevents blood from entering the larynx and trachea). When operating under local anesthesia, tamponade of the nose is performed in the posterior sections to prevent blood from entering the pharynx and larynx. The main instruments for surgical intervention on the paranasal sinuses are a conchotome, Luke's forceps, Chitelli and Gaek's forceps, sharp spoons of various configurations, etc.

The surgeon's main landmarks are the middle nasal concha and bulla ethmoidalis. If concha bullosa is present, it and bullae ethmoidalis are removed. This stage of the operation, as well as the subsequent destruction of the intercellular septa, is performed using a conchotome or Luke's forceps. This stage provides access to the cavities of the ethmoid labyrinth. Using sharp spoons, total curettage of the cellular system is performed, achieving complete removal of the intercellular septa, granulations, polypous masses and other pathological tissues. In this case, the movement of the instrument is directed from back to front, observing special caution when working with the cutting part of the curette or spoon directed upward, without advancing too much medially, so as not to damage the upper wall of the ethmoid labyrinth and the ethmoid plate. It is also impossible to direct the instrument towards the orbit, and in order not to lose the correct direction of the surgical action, it is necessary to constantly adhere to the middle concha.

Not all pathological tissues can be removed by curettage, so their remains are removed under visual control with forceps. The use of the videoendoscopic method allows for a more thorough revision of both the entire postoperative cavity and individual, remaining undestroyed cells. Particular attention should be paid to the anterior cells, which are difficult to access with the endonasal method of opening the ethmoid labyrinth. The use of a curved Halle curette in most cases allows for their effective revision. In case of doubt about their thorough cleaning, V.V. Shapurov (1946) recommends knocking down the bone mass located in front of the middle turbinate at the site of the uncinate process. This provides wide access to the anterior cells of the ethmoid labyrinth. Halle proposed completing the operation by cutting out a flap from the mucous membrane located in front of the middle nasal turbinate and placing it in the resulting surgical cavity. However, many rip surgeons skip this stage. Bleeding that occurs during opening of the ethmoid labyrinth and curettage is stopped using narrow tampons soaked in an isotonic solution in a weak dilution of adrenaline (10 drops of 0.01% adrenaline hydrochloride solution per 10 ml of 0.9% sodium chloride solution).

The next stage of endonasal intervention on the ethmoid labyrinth can be completed by opening the sphenoid sinus, if there are indications for this. For this purpose, the Gajek nasal forceps-punchers can be used, which, unlike the similar Chitelli forceps, have a significant length, allowing the sphenoid sinus to be reached along its entire length.

The postoperative cavity is loosely tamponed with a long tampon soaked in Vaseline oil and a broad-spectrum antibiotic solution. The end of the tampon is fixed at the nasal vestibule using a cotton-gauze anchor and a sling-like bandage is applied. In the absence of bleeding, which, in principle, should be finally stopped in the final part of the operation, the tampon is removed after 3-4 hours. Subsequently, the postoperative cavity is washed with an isotonic sodium chloride solution and irrigated with an appropriate antibiotic. With sufficient access to the surgical cavity, it is advisable to irrigate it with oil solutions of vitamins that have antihypoxic and reparative properties, abundantly contained in sea buckthorn oil, crotolin, rosehip oil, as well as such reparative drugs as solcoseryl, methandienone, nondralone, retabolil, etc. The same principle of postoperative patient management is also indicated for other surgical interventions on the paranasal sinuses. As our experience shows, careful care of the postoperative cavity using modern reparants and regenerants ensures the completion of the wound process within 7-10 days and completely eliminates the possibility of relapse.

Opening of the ethmoid labyrinth according to Jansen-Winkler

This type of dual surgical intervention is practiced when it is necessary to perform simultaneous sanitation of the maxillary sinus and homolateral opening of the ethmoid labyrinth. Opening of the latter is performed after completion of the Caldwell-Luc operation.

The wall of the maxillary sinus is destroyed by a conchotome or a spoon in the superoposterior medial angle between the orbital and nasal walls. In order to penetrate the cavity of the ethmoid labyrinth through this angle, it is necessary to perforate the wall of the maxillary sinus and penetrate through the orbital process of the palatine bone. This is achieved quite easily due to the fragility of these bone formations. A sharp spoon or conchotome is used for this. The moment of penetration into the cavity of the ethmoid labyrinth is recorded by the crunching sound of the breaking bone septum and the sensation of the cell lying on the way falling into the cavity. The same instruments are used to destroy the septa between the cells, adhering to the axis of the instrument and not deviating either towards the orbit or medially-upwards towards the ethmoid plate, and also to open the middle nasal concha, widening the opening communicating it with the rest of the mass of cells of the ethmoid labyrinth. This technique allows creating a good drainage opening between the cavity of the ethmoid labyrinth and the middle nasal passage. Using a modern method of video microsurgery, it is possible to revise in detail all the cells of the ethmoid labyrinth and, if necessary, moving medially deep and slightly downwards, penetrate the sphenoid sinus on the corresponding side and examine it using video fiber optics and a monitor screen, perform appropriate microsurgical manipulations aimed at removing the pathological contents of the sphenoid sinus.

Upon completion of the revision of the ethmoid labyrinth, the consistency of the communication of the postoperative cavity of the ethmoid bone with the nasal cavity is checked. This is easily achieved with video fiber optics. If it is not available, a grooved probe is inserted into the middle nasal passage, which, with a sufficient drainage hole, clearly shows all sides of the postoperative cavity of the ethmoid bone. As V.V. Shapurov (1946) notes, the Jansen-Wickelsra operation seems to be an easy and convenient intervention for a fairly complete revision of the cells of the ethmoid labyrinth. Thus, upon completion of this complex surgical intervention, two drainage holes are formed - the artificial "window" known to us, connecting the maxillary sinus with the inferior nasal passage, and the drainage hole connecting the cavity of the ethmoid labyrinth with the middle nasal passage. The presence of two postoperative cavities (without taking into account that the sphenoid sinus may also be opened) and two drainage holes opening at different levels of the nasal cavity creates the problem of tamponade of these cavities. In our opinion, first a loose tamponade of the ethmoid cavity should be performed with a thin continuous tampon, with its end being brought out through the opening in the middle nasal passage and then outward. A separate small anchor is formed from it at the end of the tamponade. Tamponade of the maxillary sinus is performed as described above in the Caldwell-Luc operation. The tampon from the ethmoid labyrinth is removed after 4 hours, and the tampon from the maxillary sinus - no later than 48 hours. To remove the tampon from the ethmoid labyrinth, the anchor of the "sinusitis" tampon is "disbanded" and the end of the tampon is moved downwards, as a result of which access is formed to the middle nasal passage and the tampon coming out of it to the cavity of the ethmoid bone. This tampon is removed with nasal forceps, grasping it as close as possible to the bottom of the middle nasal passage and producing light traction downwards and forwards. The tampon is removed quite easily due to its short stay in the cavity. After its removal, it is advisable to introduce a suspension of the powder of the corresponding antibiotic into the postoperative cavity in the ethmoid bone, prepared ex tempore in an oil solution of "plastic metabolism" vitamins. As the latter, carotolin and vaseline oil in a 1:1 ratio can be used. In the postoperative period, after removal of all tampons, the operated cavities are washed with an antibiotic solution and irrigated with “plastic metabolism” vitamins.

Opening of the ethmoid labyrinth according to Gruenwaded

This method is currently rarely used and only in cases of purulent complications from the orbit (phlegmon) with destruction of the paper plate by the inflammatory process, the presence of ethmoidal labyrinth fistulas at the inner corner of the eye, osteomas and wounds of the medial region of the orbit and adjacent cells of the ethmoidal labyrinth. Revision of the ethmoidal labyrinth can also be performed during the interventions on the frontal sinus described below. The sphenoid sinus can also be opened using this approach.

A one-stage arcuate incision of all soft tissues, including the periosteum, is made along the inner edge of the orbit, starting from the inner edge of the superciliary arch and ending with the edge of the pyriform opening. The apex of the arc of the incision should be located midway between the inner corner of the eye and the anterior surface of the bridge of the nose. The soft tissues together with the periosteum are separated in both directions with a sharp raspatory or a flat Voyachek chisel. The resulting bleeding is quickly stopped by pressing a ball soaked in an adrenaline solution. To determine the point of penetration into the ethmoid labyrinth, the corresponding bone landmarks are found in the form of bone sutures formed by the frontal, nasal, lacrimal bones, the frontal process of the maxilla and the paper plate of the ethmoid labyrinth. First, the suture between the nasal bone and the frontal process of the maxilla is found. Parallel to this suture, a corridor is made in the bone from the bottom up. Its anterior border should be the nasal bone, the posterior border should be the beginning of the nasolacrimal duct, i.e. the fossa of the SM, which is isolated from its bed using Frey's raspatory to avoid traumatizing it. The bone in the formed corridor is removed layer by layer to the nasal mucosa, which is then opened with a vertical incision to form a future drainage hole between the nasal cavity and the cavity formed after opening the cells of the ethmoid labyrinth. After this, the instrument for opening the ethmoid labyrinth is directed strictly sagittally, i.e. parallel to the middle nasal concha, and laterally from it. This maneuver can open all the cells of the ethmoid labyrinth and curettage of the resulting cavity. Opening the ethmoid labyrinth is performed with a narrow spoon or conchotome, while it is necessary to strictly monitor the direction of the instruments so as not to damage the paper plate. On the other hand, opening of the ethmoid labyrinth, as noted by A.S. Kiselev (2000), can be carried out through the Riedel bone massif, lying on the border between the bottom of the frontal sinus and the lacrimal bone, or through a paper plate. The depth at which manipulations with the appropriate instruments can be performed should not exceed 7-8 cm. During curettage of the operating cavity, intercellular septa, granulations, polyps, necrotic bone fragments of the ethmoid bone are removed, but when manipulating in the direction of the midline, i.e. in the area of the ethmoid plate, the movements of the instrument become gentle and palpably controlled.

To ensure wide communication of the postoperative cavity formed in the ethmoid bone with the nose, the bone and soft tissues located in the middle and upper nasal passages, which are the walls of the ethmoid labyrinth, are removed, while sparing the middle nasal concha, which begins to play the role of a protective barrier in this new anatomical configuration, preventing direct entry of mucus from the nose into the postoperative cavity. After the artificial canal communicating the nasal cavity with the postoperative cavity of the ethmoid bone has been formed, the latter is loosely tamponed from the side of the postoperative cavity with a long narrow tampon according to the Mikulich method or using a loop tamponade according to V.I. The external wound is sutured tightly.

If before the operation there was a fistula in the area of the inner corner of the eye or somewhere in the immediate vicinity of this place, then its walls are carefully removed along their entire length. The stitches are removed on the 5th-6th day after the operation. After removing the tampons, the postoperative cavity is washed with a warm solution of antibiotic emulsified in carotolin, rosehip or sea buckthorn oil. The procedure is repeated daily for 3-4 days. At the same time, general antibiotic therapy is administered.