Chronic sinusitis

Chronic sinusitis is a chronic inflammation of the maxillary sinus, chronic maxillary sinusitis (sinusitis maxillam chronica, highmoritis chronica).

A method of mass non-invasive examination of a large contingent of people could be diaphanoscopy of the maxillary sinuses or fluorography of the paranasal sinuses.

[1], [2], [3]

Epidemiology

Epidemiology of the disease is not related to living in a particular region of the world. In various regions of Ukraine and in a number of other countries, the microbial flora in chronic paranasal sinusitis is often close in composition. Regularly recurring epidemics of influenza and respiratory viral infections cause a decrease in all factors of protection of the nasal cavity and paranasal sinuses. In recent years, the relationship between the occurrence of sinusitis and unfavorable environmental factors: dust, smoke, gas, toxic emissions into the atmosphere began to be traced.

[4], [5], [6], [7], [8], [9]

Causes of the chronic sinusitis

The causative agents of the disease are often representatives of the coccal microflora, in particular streptococci. In recent years, there have been reports of three causative organisms - Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catharrhalis, as pathogens. Often began to sow mushrooms, anaerobes, viruses. They also note the formation of various types of aggressive associations that increase the virulence of pathogens.

[10], [11], [12], [13]

Pathogenesis

The lower wall of the sinus is formed by the alveolar process: a significant number of people in the lumen of the sinus are the roots of 4 or 5 teeth, which in some of them are not even covered by the mucous membrane. In this regard, the inflammatory process from the oral cavity often extends into the lumen of the maxillary sinus. When developing a granuloma of the tooth, it can be hidden for a long time and can be detected accidentally.

The upper sinus wall, which is the bottom wall of the orbit, is very thin, and there is a large amount of dehiscence through which the vessels and nerves of the mucous membrane communicate with similar orbital structures. With increasing pressure in the lumen of the sinus, the pathological discharge can spread into the orbit.

It is proved that the disease often develops in people with a mesomorphic type of facial skeleton. The main role belongs to some degree of obstruction of the natural excretory opening of the maxillary sinus, which causes a violation of drainage and aeration of its mucous membrane. Important is the violation of nasal breathing associated with deformities of the septum of the nose, synechiae, adenoids, etc. The development of the disease is facilitated by an increase in the aggressiveness of pathogenic microorganisms, the formation of their associations (bacterial-bacterial, bacterial-viral, virus-virus), a decrease in the rate of mucociliary transport in the lumen sinuses and in the nasal cavity. In addition, the incomplete cure for acute rhinitis is considered as a predisposing factor, when the inflammatory phenomena of the mucous membrane of the nasal cavity extend to the structures of the ostiomeatal complex, especially if there are pathologies in the structure of its constituent structures. This disrupts the movement of air and fly-transport transport, contributes to the formation of sinusitis. Sinusitis is often accompanied by the involvement of nearby paranasal sinuses (latticular and frontal) in the inflammatory process. Currently, it is believed that the role of allergy, general and local immunity, mucosal microcirculation disorders, vasomotor and secretory components play a role in the development of sinusitis, including maxillary, a significant violation of vascular and tissue permeability.

Pathological anatomy. Of definite clinical interest is the classification of M.Lazeanu mentioned above, applied to chronic sinusitis, which, although not fundamentally different from the classification of B.S. Preobrazhensky, allows one to look at the problem from the point of view of concepts and interpretations adopted abroad. The author distinguishes the following pathomorphological forms:

1. chronic catarrhal maxillary sinusitis vacuo (closed form), in which the sinus drainage function is absent or reduced to a level that does not provide normal ventilation; at this form the mucous membrane of the sinus is diffusely hyperemic, thickened, in the sinus there is a serous transudate; differs frequent exacerbations;
2. chronic purulent maxillary sinusitis; characterized by the presence in the sinus of the "old" thick pus with caseous masses, extremely offensive; the mucosa is productively thickened, gelatinous, gray, sometimes fleshy-red, with ulceration, extensive areas of necrobiosis, at the level of which areas of exposed bone with osteitis and osteomyelitis are found;
3. chronic polynomial maxillary sinusitis, in which various types of natomorphological changes can occur in the mucosa; The most typical of these is the proliferation of the epithelium, which most often retains the multilayered cylindrical structure of the ciliary epithelium and the ability to secrete mucous glands; this kind of proliferation of multilayered cylindrical epithelium was called the "saw tooth" and, taking into account the abundant secretion of goblet cells and mucous glands, it forms the basis for the formation of polypous masses;
4. chronic cystic maxillary sinusitis, the occurrence of which is due to retention of the secretion of the mucous glands; the resulting microcysts can be thin-walled, lying in the surface layer of the mucous membrane and thick-walled, lying in the deep layers of the mucous membrane of the sinus;
5. chronic hyperplastic maxillary sinus is characterized by thickening and hyalinization of vascular plexuses, combined with fibrosis of the mucosa;
6. chronic caseous maxillary sinusitis is characterized by filling with fetid caseous masses of the entire maxillary sinus, which, exerting pressure on surrounding tissues, destroys them and spreads into the nasal cavity, forming extensive messages of the latter not only with the maxillary sinus, but also with the latticed labyrinth and frontal sinus;
7. chronic cholesteatomous maxillary sinusitis occurs when penetrated into the sinus cavity of the epidermis, which forms a unique shell of white with a mother-of-pearl (matrix), consisting of the smallest epithelial scales, inside which is a paste-like fat-like mass with an extremely unpleasant odor.

Such is the pathoanatomical picture of chronic suppurative maxillary sinusitis. Their various forms can occur in different combinations, but they always progress in the above sequence.

[14], [15], [16], [17], [18], [19]

Symptoms of the chronic sinusitis

Quite often, the only complaint of patients without exacerbation is the difficulty of nasal breathing, expressed in varying degrees, right up to his absence. Discharge from the nose with acute sinusitis profuse, their nature slimy, mucopurulent, often purulent, especially during periods of exacerbation. Pathognomonic attribute is the highest number of excretions in the morning,

With genyantritis, there are often complaints of a feeling of "pressure" or "heaviness" and the area of the fangs and the root of the nose on the side of the inflammation, and the pain can irradiate into the brow or temporal region. In a chronic process, especially during periods of exacerbations, the nature of pain is diffuse, the clinical picture is similar to trigeminal neuralgia.

Often the chronic inflammatory process in the maxillary sinus is accompanied by a violation of the sense of smell in the form of hyposmia, sometimes anosmia. Rarely does it appear tearing due to the closure of the nasal canal.

Sinusitis is often bilateral. The exacerbation is characterized by hyperthermia with febrile digits, malaise and general weakness, while maintaining all the indicated signs of the disease.

Clinical forms of chronic sinusitis are classified by some authors on the following grounds:

1. on etiology and pathogenesis - rhinopathy and odontogenic sinusitis;
2. on pathomorphological signs - catarrhal, purulent, polypous, hyperplastic, osteomyelitic, infectious-allergic, etc .;
3. on the microbiological basis - banal microbiota, influenza, specific, mycotic, viral, etc.;
4. on the basis of a dominant symptom - secretory, obstructive, cephalic, anosmic, etc .;
5. on the basis of clinical severity - latent, often exacerbated and persistent forms;
6. on the basis of prevalence - monosynusitis, hemisinusitis, polygamisinusitis, pansinusitis;
7. on the basis of complication - simple uncomplicated and complicated forms;
8. on the basis of age - sinusitis of children and senile age.

It should be noted, however, that this classification is purely didactic in nature, referring only to the different aspects of a single pathogenetic process, in the development of which all or most of the indicated features are present, and the appearance of certain features may be consistent or may occur simultaneously.

Symptoms of chronic sinusitis are divided into local subjective, local objective and general.

Subjective local symptoms of chronic sinusitis are reflected in patients' complaints about unilateral purulent discharge from the nose (with monosynusitis), on permanent headaches, which are periodically amplified with localization of the lesion in the maxillary sinus. The painful crisis coincides with the periods of exacerbation of the chronic process, the pain radiates to the temporal and orbital region. In odontogenic chronic sinusitis, the pain is combined with odontalgia at the level of the aching tooth. Patients complain also of a feeling of fullness and bursting in the affected sinus and surrounding tissues, an unpleasant, sometimes putrid odor from the nose (subjective kakosmia), which causes the patient to feel sick and lose appetite. One of the main subjective symptoms is a complaint of difficulty in nasal breathing, nasal congestion, and an olfactory impairment that is obstructive.

Objective local symptoms of chronic sinusitis. When examining the patient, attention is drawn to the diffuse hyperemia and swelling of the outer shells of the eye and the mucous membrane of the lacrimal ways, the phenomena of chronic dermatitis in the area of the anterior nose and upper lip caused by persistent purulent discharge from the corresponding half of the nose (impetigo, eczema, excoriation, etc.), which sometimes provoke the appearance of sycosis and furuncles of the vestibule of the nose. With exacerbations of chronic sinusitis, soreness is revealed on palpation of the corresponding points: in the region of the exit of the lower nerve head, in the region of the dog fossa and the inner corner of the eye. A test with a V.Voyachek fluff or rhinomanometry indicates a one-sided incomplete or complete obstruction of nasal breathing. When examining the used handkerchief, yellow spots with dense caseous inclusions and blood veins are found. In wet conditions, these spots produce an extremely unpleasant putrefactive odor, differing, however, from the fetid odor of the lake and the sweetish-sugary smell of the rhinosclerome. In this case, an objective kakosmia is also determined. Usually, with banal chronic sinusitis, the sense of smell is preserved, as evidenced by the subjective kakosmia, however, when a grid maze cells are involved in the process and the olfactory slit of the polyps is formed, a one-sided, rarely bilateral hypo- or anosmia is observed. Objective signs of disturbance of the function of tear-excreting function due to edema of the mucous membrane in the area of the lacrimal point and violations of the pump function of CML are also noted.

With anterior rhinoscopy in the nasal passages of the corresponding side, thick mucopurulent or creamy discharges are detected, often with an admixture of caseous masses, dirty-yellow, drying out into the crusts that are difficult to separate from the mucous membrane. Often in the middle and common nasal passages polyps of different sizes are found; the middle and lower nasal conchaes are enlarged, hypertrophied and hyperemic. Often there is a picture of a false double middle nasal concha, which is caused by the edema of the mucous membrane of the infundibulum, prolapse from the upper part of the middle nasal passage to the common nasal passage (Kaufmann's pad). The average nasal shell often has a bullous appearance, is hyperemic and thickened.

When the mucous membrane is anemic in the area of the middle nasal passage, a sign of profuse discharge of suppurative discharge from the maxillary sinus is revealed, which, when the head tilts forward, continuously flow down the inferior nasal concha and accumulate at the bottom of the nasal cavity. Their removal leads to a new accumulation of pus, which indicates the presence of a bulky reservoir of secretions in the maxillary sinus. With posterior rhinoscopy, there is a presence of purulent masses in the khoans, which stand out from the middle nasal passage to the posterior end of the middle nasal conch in the direction of the nasopharynx. Often, the posterior end of this shell in chronic sinusitis acquires the appearance of a polyp and increases to the size of a choana polyp.

Examination of the teeth of the corresponding half of the alveolar process can reveal their diseases (deep caries, periodontitis, apical granuloma, fistula in the gum area, etc.).

Common symptoms of chronic sinusitis. Headaches that intensify during exacerbations and when the head is tilted, coughing, sneezing, blowing, shaking his head. Cranio-cervico-facial neuralgic crises that occur during periods of exacerbations, most often in the cold season; general physical and intellectual fatigue; signs of a chronic foci of infection.

The clinical course is characterized by periods of remission and exacerbations. In the warm season there may be periods of apparent recovery, but with the onset of cold weather the disease resumes with renewed force: general and irradiating headaches appear, mucopurulent, then purulent and putrefactive discharge from the nose, nasal breathing worsens, general weakness increases, temperature rises body, signs of a common infectious disease appear in the blood.

[20], [21], [22], [23]

Forms

Distinguish catarrhal, purulent, parieto-hyperplastic, polyposis, fibrous, cystic (mixed forms), complicated and allergic sinusitis.

[24], [25], [26]

Diagnostics of the chronic sinusitis

At the stage of assessing anamnestic data, it is important to collect information about previous respiratory diseases, including other perinasic sinusitis, ARVI. It is necessary to ask the patient in detail about the presence of pain and the area of the upper jaw, examinations of the dentist, possible manipulations and interventions on the teeth and structures of the alveolar process. It is obligatory to question the preceding exacerbations of the disease, their frequency, the peculiarities of the treatment of surgical interventions on the structures of the nose and paranasal sinuses, the course of the postoperative period,

Physical examination

Palpation in the projection of the anterior wall of the maxillary sinus in a patient with chronic sinusitis causes a slight increase in local pain, which is sometimes absent. Percussion of the anterior wall of the sinus is not sufficiently informative, as it is surrounded by a large array of soft tissues

[27], [28], [29], [30]

Analyzes

In the absence of complications of the disease, general blood and urine tests are poorly informative.

[31], [32], [33], [34]

Instrumental research

Anterior rhinoscopy reveals flushing and edema of the mucous membrane of the nasal cavity, with this lumen of the middle nasal passage often closed. In these cases, mucosal anemia is produced. Pathognomonic rhinoscopic symptom for sinusitis is a "strip of pus" in the middle nasal passage, ie from under the middle of the middle nasal concha,

The presence of polyps in the nasal cavity indicates the cause of the violation of the drainage function of the natural outlets of one or more sinuses. The polypous process is rarely isolated and almost always bilateral.

During oropharyngoscopy, attention is drawn to the features of the mucosa of the gums, the state of the teeth from the inflamed maxillary sinus, carious teeth and seals. In the presence of a sealed tooth, percussion of its surface is carried out, in the case of pathological changes in it, it will be painful. In this case, consultation of the dentist is mandatory.

A non-invasive method of diagnosis is diaphanoscopy by Goering's bulb. In a darkened room, it is injected into the mouth of the patient, which then tightly clamps her base with her lips. The transparency of the inflamed maxillary sinus is always reduced. The method is mandatory for use in pregnant women and children. It should be remembered that a decrease in the intensity of luminescence of the maxillary sinus does not always indicate the development of an inflammatory process in it.

The main method of instrumental diagnosis is radiography. If necessary, perform an x-ray about contrasting examination of the sinus during its diagnostic puncture, introducing into its lumen 1-1,5 mi of contrast preparation. It is best to implement it directly in the X-ray room. It is recommended to perform the procedure in the position of the patient lying on the back for shooting in the floor of the axial projection, and then in the lateral, on the side of the inflamed sinus. Sometimes, on radiographs with a contrast agent, one can see a rounded shadow in the region of the alveolar process indicative of the presence of a cyst, or a symptom of a "denticle," indicating the presence of polyps in the lumen of the sinus.

With the help of CT it is possible to obtain more accurate data on the nature of the destruction in the walls of the maxillary sinus, the involvement of other paranasal sinuses and nearby structures of the facial skeleton in the inflammatory process. MRI gives more information when there are soft tissue tissues in the lumen of the lumen.

In the absence of clear evidence of the presence of an inflammatory process in the maxillary sinus, but the presence of indirect symptoms, it is possible to conduct a diagnostic puncture with the help of Kulikovsky's needle. The needle is inserted into the arch of the inferior nasal passage, then unfolds the curved part medially and pierces the sinus wall.

Another method of invasive diagnosis was endoscopy, which allows us to clarify the nature and characteristics of the inflammatory process through direct visual examination. The study is carried out after micro-hemorrhoid with a trocar or cutter by introducing an optical endoscope with a certain angle of view.

Differential diagnosis

First of all, it is necessary to differentiate the disease from trigeminal neuralgia, in which the pains are of a "burning" nature, appear suddenly, their appearance can be triggered by a stressful situation or transition from a warm room to a street where the temperature is lower. The pains are paroxysmal, expressed by palpation of the scalp, often accompanied by paresthesia and synesthesia of the half of the face. Pressing on the exit points of the branches of the trigeminal nerve causes a sharp pain unlike the patients with sinusitis.

When there is no local headache in clinical symptoms, and nasal discharge is absent, the anatomy of the mucosa of the middle nasal passage becomes the crucial element of differential diagnosis, after which an exudate or "pus of the pus" appears in the nasal cavity, which indicates a block of the natural opening of the maxillary sinus.

Indications for consultation of other specialists

The presence of a pathology of the teeth or oral cavity requires consultation of the dentist. If necessary, sanation measures: treatment of carious teeth, extraction of their or their roots, etc. Sometimes it may be necessary to consult a specialist in maxillofacial surgery. With clinical signs of neuralgia of the trigeminal nerve for a thorough differential diagnosis, a consultation of a neurologist is shown.

Treatment of the chronic sinusitis

The goals of chronic chronic sinusitis: restoration of drainage and aeration of the affected sinus, removal of pathological detachment from its lumen, stimulation of reparative processes.

Indications for hospitalization

The presence of signs of exacerbations of chronic sinusitis: severe local pain, nasal discharge in the background of hyperthermia, confirmed radiographic signs of the disease, as well as the absence of the effect of conservative treatment for 2-3 days, the appearance of clinical signs of complications.

Non-drug treatment of chronic sinusitis

Physiotherapeutic treatment: electrophoresis with antibiotics on the anterior wall of the sinus, phonophoresis of hydrocortisone, including in combination with oxytetracycline, exposure to ultrasound or superhigh frequencies in the sinus area, radiation from the therapeutic helium-neon laser, intraspecific phonophoresis or irradiation with helium-neon laser.

With the "fresh" forms of chronic sinusitis, which are characterized by involvement of the sinus in the pathological process and the limited parts of the periosteum, can be achieved by non-operative methods (as in acute maxillary sinusitis), including puncture, drainage, insertion of proteolytic enzymes into the sinus, followed by sinus washing, removal of lysed pus and administration of antibiotics in a mixture with hydrocortisone. Non-operative treatment gives a quick effect with simultaneous sanation of the causative foci of infection of odontogenic or lymphadenoid localization, with the use of medicamentous action on the endonasal structures, and the removal of polypous formations from the nasal cavity to improve the drainage function of the remaining paranasal sinuses. Anti-allergic measures with the use of antihistamines are of great importance in non-operative treatment.

S.Z. Piskunov et al. (1989) proposed an original method for the treatment of chronic sinusitis with the use of drugs on a polymer basis. As drugs, the authors refer to antibiotics, corticosteroids and enzymes, and cellulose derivatives (methylcellulose, CMC sodium, hydroxypropylmethylcellulose and polyvinyl alcohol) can be used as a polymeric carrier.

Repeated preventive courses in the cold season, when exacerbations of chronic sinusitis occur especially often, do not always lead to complete recovery, even with a number of preventive measures and radical elimination of risk factors for the disease (sanation of foci of infection, strengthening of immunity, exclusion bad habits, etc.).

Thus, despite the ongoing improvement in the methods of nonoperative treatment of inflammatory diseases of the paranasal sinuses, recently their number has not decreased, and according to some data, even increases. This, according to many authors, is due to both a tendency to change the pathomorphism of the microbiota in general, and changes not in the best direction of the body's immune defense. As noted by VS Agapov and co-authors. (2000), immunodeficiency in various indicators is observed in almost 50% of healthy donors, and the degree of it increases with the development of the inflammatory process in the body. This is partly due to the increase in antibiotic-resistant forms of microorganisms as a result of widespread and sometimes irrational use of biological antibacterial drugs, as well as general changes in the body towards weakening systemic and local homeostasis with the use of chemotherapeutic agents, the effects of adverse environmental household and industrial conditions, and other risk factors. All this leads to a decrease in the activity of immunological and nonspecific reactivity, the violation of neurotrophic functions both at the level of macrosystems and in the field of cell membranes. Therefore, in the complex treatment of patients with diseases of the paranasal sinuses and ENT organs in general, in addition to the conventional symptomatic and antibacterial agents, it is necessary to include immunomodulating and immunocorrecting therapy.

At present, despite the rather full arsenal of medicamental means of influencing the reactivity of the organism as a whole and the local reparative-regenerative wound processes, it is impossible to say with certainty about the existence of a scientifically tested system of a complex, effectively "working" system in this direction. In most cases, the purpose of the respective drugs is empirical in nature and is based mainly on the principle of "trial and error". Preference is given to chemo-and biological drugs, but to systemic immunity and non-specific resistance are resorted only when traditional treatment does not produce the desired result. When using chemotherapy drugs and antibiotics, as rightly noted V.Sagapov et al. (2000), they are invariably included in the metabolism in the macroorganism, which often leads to the emergence of allergic and toxic reactions and as a result - to the development of significant violations of the natural mechanisms of specific and nonspecific defense of the body.

These provisions encourage scientists to find new, sometimes non-traditional means of treating inflammatory diseases of bacterial genesis of various organs and systems, including ENT organs and the maxillofacial system. Morphogenetic, innervation, adaptation-trophic, blood, etc., the unity of the last two organ systems allows us to talk about the commonality and the possibility of applying identical therapies to them and the same remedies for the occurrence of chronic purulent-inflammatory diseases.

Both in stomatology, and in otorhinolaryngology methods of phytotherapy with application of infusions, broths, extracts of a phytogenesis are developed. However, in addition to phytotherapy, there are other possibilities for using so-called non-traditional drugs to treat the pathological condition discussed in this section. So, a new perspective direction in the treatment of chronic purulent processes in dentistry is developed under the guidance of prof. VS Agapova, which probably should be of some interest for ENT specialists. We are talking about the use of ozone in the complex treatment of chronic sluggish purulent infectious and inflammatory diseases of the maxillofacial region. The therapeutic effect of ozone is determined by its high oxidation-reduction properties, which, when applied locally, have a harmful effect on bacteria (especially on anaerobes), viruses and fungi. Studies have shown that the systemic effect of ozone is aimed at optimizing metabolic processes with respect to protein-lipid complexes of cell membranes, increasing in their plasma oxygen concentrations, synthesizing biologically active substances, enhancing the activity of immunocompetent cells, neutrophils, improving the rheological properties and oxygen transport function of blood, and also stimulating effect on all oxygen-dependent processes.

Medical ozone is an ozone-oxygen mixture obtained from ultrapure medical oxygen. The methods and fields of application of medical ozone, as well as its dosage, depend mainly on its properties, concentration and exposure, established at a particular stage of treatment. At higher concentrations and prolonged action, medical ozone produces a pronounced bactericidal effect, at lower concentrations - it stimulates reparative and regenerative processes in damaged tissues, contributing to the restoration of their function and structure. On this basis, medical ozone is often included in the complex treatment of patients with sluggish inflammatory processes, including purulent diseases and insufficient effectiveness of antibiotic treatment.

Under low-grade purulent inflammation is meant a pathological process with steady progression under hypoergic flow, which is difficult to give in to traditional non-operative treatment. Using the experience of using medical ozone in the maxillofacial and plastic surgery in otorhinolaryngology, it is possible to achieve significant success in the complex treatment of many ENT diseases, in which the effectiveness of treatment can be determined in many respects precisely by the properties of medical ozone. To such diseases can be referred ozena, chronic purulent sinusitis and otitis in the pre- and postoperative period, abscesses, phlegmon, osteomyelitis, wound cancer processes in the ENT organs, etc.

The local application of medical ozone consists in the introduction of ozonized isotonic sodium chloride solution along the periphery of inflammatory infiltrates, washing of purulent wounds and cavities (eg, paranasal sinuses, open peritonsillar abscess cavity or cavity of otogenic or rhinogenic cerebral abscess after surgery, etc.) with ozonized distilled water. General ozonotherapy includes intravenous infusions of the ozonized isotonic sodium chloride solution and a small autohemozon therapy alternating every other day.

Medical treatment of chronic sinusitis

Before receiving the results of the microbiological examination of the isolate, antibiotics of a wide range of action, amoxicillin, including in combination with clavulanic acid, cefotaxime, cefazolin, roxithromycin, etc., can be used. As a result of the planting, antibiotics of directed action should be administered. If the discharge from the sinus is absent or can not be obtained, continue treatment with the same drug. As one of the preparations of anti-inflammatory therapy, fenspiride can be administered. Antihistamine treatment with hydrobromoline, chloropyramine, zbastin, etc. Is prescribed. Vessel desiccants are prescribed in the nose (decongestants), at the beginning of treatment - soft action (ephedrine solution, dimethindene with phenylephrine, and gel can be used instead of nighttime administration of drops or spray), in the absence of effect in for 6-7 days are treated with imidazole drugs (nafazoline, xylometazoline, oxymetazoline, etc.).

Anemization of the mucous membrane of the anterior part of the middle nasal passage is carried out with the help of vasoconstrictive preparations (solutions of epinephrine, oxymeteolin, naphazoline, xylometazoline, etc.).

The transfer of drugs is carried out after anemia of the mucous membrane for the introduction into the sinuses of mixtures of drugs, including broad-spectrum antibiotics and hydrocortisone suspension. The pressure drop, due to which the mixture moves into the lumen of the sinus, is created as a result of the isolation of the nasal cavity and the nasopharynx with a soft palate when the patient receives a vowel sound (for example, "y") and a negative pressure in the nasal cavity created by the electroaspirator.

With the help of the YAMIK catheter, a negative pressure is created in the nasal cavity, which allows aspirating pathological contents from the paranasal sinuses of one half of the nose, and their lumen is filled with a drug or contrast agent.

Surgical treatment of chronic sinusitis

Puncture treatment of sinusitis in our country is a "gold standard" and is used both for diagnostic and therapeutic purposes - for evacuation of pathological contents from its lumen. If you get a washing liquid during a sinus puncture, white, dark brown or black masses can be suspected fungal infection, after which it is necessary to cancel antibiotics and perform antifungal treatment. If anaerobes are supposed to be the causative agent (an unpleasant smell of detachable, negative result of bacteriological examination of the contents), oxygenation of the lumen of the sinus should be performed after washing its cavity with moistened oxygen for 15-20 minutes.

In case of necessity of long drainage of the sinus and introduction of medicines into its lumen 2-3 times a day, a special synthetic drainage from the thermoplastic mass is installed through it through the lower nasal passage. Which can be left for up to 12 days without disrupting trophism of tissues.

Microgeymorotomy is carried out with the help of special trocar (Kozlova - Karl Zeise, Germany, Krasnozhenz - MFS, Russia) in the center of the anterior wall of the sinus over the roots of the 4th tooth. After the introduction of the funnel into the lumen of the sinus, it is inspected by rigid endoscopes with optics of 0 ° and 30 ° and carries out subsequent medical manipulations, carrying out the assigned tasks. An obligatory element of intervention is the removal of formations that interfere with the normal functioning of the natural outlet, and the restoration of full drainage and aeration of the sinus. The application of sutures to the wound of soft tissues does not produce. In the postoperative period, usual antibiotic therapy is carried out.

Extranasal opening by Caldwell-Lucas is performed by cutting soft tissue in the area of the transitional fold from the 2nd to 5th teeth through the anterior wall of the sinus. Form a hole, sufficient for inspection and manipulation in its lumen. From the sinus remove pathological formations and detachable, in the region of the inner wall and in the lower nasal passage impose an ankle with the nasal cavity. When removing a significant amount of the altered mucosa to the bottom of the sinus, a U-shaped flap is placed from its unchanged site. Soft fabrics are sewed tight.

Further management

For 4-5 days, soft-acting vasoconstrictors are used. In the postoperative period, sparing care of the wound is necessary - 7-8 days do not use a toothbrush, after a meal rinses are performed on the threshold of the oral cavity with astringent preparations,

Approximate terms of incapacity for exacerbation of chronic sinusitis without signs of complications in the case of conservative treatment with sinus punctures are 8-10 days. The use of extranasal intervention lengthens the time by 2-4 days.

Information for Patient

• Beware of drafts.
• To carry out vaccination with anti-influenza serum in the autumn-winter period.
• At the first sign of acute respiratory viral infection or influenza, consult a specialist.
• At the recommendation of the attending physician to perform a surgical sanation of the nasal cavity for the restoration of nasal breathing and normal architectonics of its structures.

Prevention

Prevention is the preservation of free nasal breathing and normal anatomy of the structures of the nasal cavity, especially the ostiomeatal complex. Prevention of disease - compliance with the correct hygienic regime. To prevent the development of chronic sinusitis, surgical sanation of the nasal cavity structures is necessary to restore nasal breathing.

[35], [36], [37], [38], [39]

Forecast

The forecast is favorable if you follow the above tips and rules.

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