Chronic maxillary sinusitis

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

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

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Epidemiology

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

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Causes chronic maxillary 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 the isolation of three opportunistic microorganisms as causative agents - Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catharrhalis. Fungi, anaerobes and viruses have often been isolated. The formation of various types of aggressive associations that increase the virulence of pathogens is also noted.

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Pathogenesis

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

The upper wall of the sinus, which is the lower wall of the orbit, is very thin, it has a large number of dehiscences through which the vessels and nerves of the mucous membrane communicate with similar formations of the orbit. When the pressure in the lumen of the sinus increases, pathological discharge can spread into the orbit.

It has been proven that the disease often develops in people with a mesomorphic type of facial skeleton structure. The main role belongs to one or another degree of obstruction of the natural outlet of the maxillary sinus, which causes a violation of the drainage and aeration of its mucous membrane. Of no small importance is the violation of nasal breathing associated with deformations of the nasal septum, synechia, 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, viral-viral), a decrease in the speed of mucociliary transport in the lumen of the sinus and in the nasal cavity. In addition, a predisposing factor is considered to be incomplete recovery from acute rhinitis, when inflammatory phenomena of the mucous membrane of the nasal cavity spread to the structures of the ostiomeatal complex, especially in the presence of pathology of the structure of its constituent structures. This disrupts air movement and muco-iliary transport, and contributes to the development of sinusitis. Sinusitis is often accompanied by the involvement of the nearby paranasal sinuses (ethmoid and frontal) in the inflammatory process. It is currently believed that allergy factors, the state of general and local immunity, disturbances in the microcirculation of the mucous membrane, vasomotor and secretory components, and significant disturbances in vascular and tissue permeability play a role in the development of sinusitis, including maxillary sinusitis.

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

1. chronic catarrhal maxillary sinusitis vacuo (closed form), in which the drainage function of the sinus is absent or reduced to a level that does not ensure normal ventilation; in this form, the mucous membrane of the sinus is diffusely hyperemic, thickened, there is serous transudate in the sinus; characterized by frequent exacerbations;
2. chronic purulent maxillary sinusitis; characterized by the presence in the sinus of "old" thick pus with caseous masses, extremely foul-smelling; the mucous membrane is productively thickened, gelatinous in appearance, gray in color, sometimes fleshy-red, with areas of ulceration, extensive zones of necrobiosis, at the level of which areas of exposed bone with elements of osteitis and osteomyelitis are found;
3. chronic polynous maxillary sinusitis, in which various types of natomorphological changes may be found in the mucous membrane; the most typical of these is the proliferation of the epithelium, which most often retains the multilayered cylindrical structure of the ciliated epithelium and the ability to secrete mucous glands; this type of proliferation of the multilayered cylindrical epithelium is called "saw teeth" and, given the abundant secretion of goblet cells and mucous glands, it is precisely this that forms the basis for the formation of polypous masses;
4. chronic cystic maxillary sinusitis, the occurrence of which is caused by the retention of secretions of the mucous glands; the resulting microcysts can be thin-walled, lying in the superficial layer of the mucous membrane, and thick-walled, lying in the deep layers of the mucous membrane of the sinus;
5. chronic hyperplastic maxillary sinusitis is characterized by thickening and hyalinization of the vascular plexuses, combined with fibrosis of the mucous membrane;
6. chronic caseous maxillary sinusitis is characterized by the filling of the entire maxillary sinus with foul-smelling caseous masses, which, exerting pressure on the surrounding tissues, destroy them and spread into the nasal cavity, forming extensive communications of the latter not only with the maxillary sinus, but also with the ethmoid labyrinth and frontal sinus;
7. Chronic cholesteatoma maxillary sinusitis occurs when the epidermis penetrates into the sinus cavity, which forms a kind of white shell with a pearlescent sheen (matrix), consisting of tiny epithelial scales, inside which there is a pasty, fat-like mass with an extremely unpleasant odor.

This is the pathological picture of chronic purulent maxillary sinusitis. Their various forms can occur in various combinations, but always progress in the sequence noted above.

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Symptoms chronic maxillary sinusitis

Quite often the only complaint of patients outside of an exacerbation is difficulty in nasal breathing, expressed to varying degrees, up to its absence. Nasal discharge in acute sinusitis is abundant, its nature is mucous, mucopurulent, often purulent, especially during periods of exacerbation. The pathognomonic sign is considered to be the greatest amount of discharge in the morning hours,

With sinusitis, there are often complaints of a feeling of "pressure" or "heaviness" in the area of the canine fossa and the root of the nose on the side of the inflammation, and the pain can radiate to the superciliary or temporal areas. With a chronic process, especially during periods of exacerbation, the nature of the pain is diffuse, the clinical picture is similar to trigeminal neuralgia.

Often, chronic inflammation in the maxillary sinus is accompanied by olfactory impairment in the form of hyposmia, sometimes anosmia. Lacrimation occurs quite rarely due to closure of the nasolacrimal canal.

Sinusitis is often bilateral. Exacerbation is characterized by hyperthermia with febrile numbers, malaise and general weakness with preservation of all the above-mentioned signs of the disease.

Clinical forms of chronic sinusitis are classified by some authors according to the following features:

1. by etiology and pathogenesis - rhinopathies and odontogenic sinusitis;
2. according to pathomorphological signs - catarrhal, purulent, polyposis, hyperplastic, osteomyelitic, infectious-allergic, etc.;
3. by microbiological characteristics - common microbiota, influenza, specific, mycotic, viral, etc.;
4. according to the dominant symptom - secretory, obstructive, cephalgic, anosmic, etc.;
5. according to clinical severity - latent, frequently aggravated and persistent forms;
6. by prevalence - monosinusitis, hemisinusitis, polyhemisinusitis, pansinusitis;
7. by the sign of complication - simple uncomplicated and complicated forms;
8. by age - sinusitis in children and the elderly.

It should be noted, however, that this classification is purely didactic in nature, indicating only the various aspects of a single pathogenetic process, in the development of which all or most of the indicated signs are present, and the appearance of some signs may be sequential, or may appear simultaneously.

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

Subjective local symptoms of chronic sinusitis are reflected in patient complaints of unilateral purulent nasal discharge (in monosinusitis), constant headaches, which periodically intensify with localization of the painful focus in the maxillary sinus. The pain crisis coincides with periods of exacerbation of the chronic process, the pain radiates to the temporal and orbital region. In odontogenic chronic sinusitis, pain is combined with odontalgia at the level of the diseased tooth. Patients also complain of a feeling of fullness and distension in the area of the affected sinus and surrounding tissues, an unpleasant, sometimes putrid smell from the nose (subjective cacosmia), which causes nausea and loss of appetite in the patient. One of the main subjective symptoms is a complaint of difficulty in nasal breathing, nasal congestion, deterioration of the sense of smell, which is obstructive in nature.

Objective local symptoms of chronic sinusitis. When examining the patient, attention is drawn to diffuse hyperemia and swelling of the outer membranes of the eye and the mucous membrane of the lacrimal ducts, chronic dermatitis in the area of the nasal vestibule and upper lip, caused by constant purulent discharge from the corresponding half of the nose (impetigo, eczema, excoriations, cracks, etc.), which sometimes provoke the development of sycosis and furuncles of the nasal vestibule. In exacerbations of chronic sinusitis, pain is detected upon palpation of the corresponding points: in the area of the exit of the inferoorbital nerve, in the area of the canine fossa and the inner corner of the eye. V.I. Voyachek's fluff test or rhinomanometry indicates unilateral incomplete or complete obstruction of nasal breathing. When examining a used handkerchief, yellow spots with dense caseous inclusions and streaks of blood are found. When wet, these spots emit an extremely unpleasant putrid odor, which differs, however, from the fetid odor of ozena and the sweetish-cloying odor of rhinoscleroma. In this case, objective cacosmia is also determined. Usually, with banal chronic sinusitis, the sense of smell is preserved, as evidenced by subjective cacosmia, but with the involvement of the ethmoid labyrinth cells in the process and the formation of polyps obturating the olfactory cleft, unilateral, less often bilateral hypo- or anosmia is observed. Objective signs of dysfunction of the lacrimal function are also noted due to edema of the mucous membrane in the area of the lacrimal point and disorders of the pumping function of the SM.

During anterior rhinoscopy, thick mucopurulent or creamy discharges are detected in the nasal passages of the corresponding side, often with an admixture of caseous masses, dirty yellow in color, drying into crusts that are difficult to separate from the mucous membrane. Polyps of various sizes are often found in the middle and common nasal passages; the middle and lower nasal turbinates are enlarged, hypertrophied and hyperemic. A picture of a false double middle nasal turbinate is often observed, which is caused by edema of the mucous membrane infundibulum, prolapsing from the upper part of the middle nasal passage into the common nasal passage (Kaufmann's pad). The middle nasal turbinate often has a bullous appearance, is hyperemic and thickened.

With anemia of the mucous membrane in the area of the middle nasal passage, a sign of abundant purulent discharge from the maxillary sinus is revealed, which, when the head is tilted forward, continuously flows down the inferior turbinate and accumulates at the bottom of the nasal cavity. Their removal leads to a new accumulation of pus, which indicates the presence of a voluminous reservoir of discharge in the maxillary sinus. With posterior rhinoscopy, the presence of purulent masses in the choanae is noted, which are released from the middle nasal passage to the posterior end of the middle turbinate in the direction of the nasopharynx. Often, the posterior end of this turbinate in chronic sinusitis takes the form of a polyp and increases to the size of a choanal 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.).

General symptoms of chronic sinusitis. Headaches that intensify during periods of exacerbation and when tilting the head, coughing, sneezing, blowing the nose, shaking the head. Cranio-cervical-facial neuralgic crises that occur during periods of exacerbation, most often in the cold season; general physical and intellectual fatigue; signs of a chronic source of infection.

The clinical course is characterized by periods of remission and exacerbation. In the warm season, periods of apparent recovery may occur, but with the onset of cold weather, the disease resumes with renewed vigor: general and radiating headaches occur, mucopurulent, then purulent and putrid discharge from the nose appears, nasal breathing worsens, general weakness increases, body temperature rises, signs of a general infectious disease appear in the blood.

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Forms

There are catarrhal, purulent, parietal-hyperplastic, polypous, fibrous, cystic (mixed forms), complicated and allergic sinusitis.

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Diagnostics chronic maxillary sinusitis

At the stage of assessing the anamnestic data, it is important to collect information about previous respiratory diseases, including other paranasal sinusitis, acute respiratory viral infections. The patient should be asked in detail about the presence of pain and the upper jaw area, dental examinations, possible manipulations and interventions on the teeth and structures of the alveolar process. It is necessary to ask about previous exacerbations of the disease, their frequency, features of treatment, surgical interventions on the structures of the nose and paranasal sinuses, the course of the postoperative period,

Physical examination

Palpation in the area of 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 informative enough, since a significant mass of soft tissue is located above it

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Tests

In the absence of complications of the disease, general blood and urine tests are of little information.

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Instrumental research

Anterior rhinoscopy reveals hyperemia and edema of the mucous membrane of the nasal cavity, while the lumen of the middle nasal passage is often closed. In these cases, anemization of the mucous membrane is performed. The pathognomonic rhinoscopic symptom for sinusitis is a "strip of pus" in the middle nasal passage, i.e. from under the middle of the middle nasal concha,

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

During oropharyngoscopy, attention is paid to the features of the mucous membrane of the gums, the condition of the teeth on the side of the inflamed maxillary sinus, carious teeth and fillings. If there is a filled tooth, percussion of its surface is performed; in case of pathological changes in it, it will be painful. In this case, a consultation with a dentist is mandatory.

A non-invasive diagnostic method is diaphanoscopy with a Hering lamp. In a darkened room, it is inserted into the patient's oral cavity, who then tightly grasps its base with his 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 the glow of the maxillary sinus does not always indicate the development of an inflammatory process in it.

The main method of instrumental diagnostics is radiography. If necessary, an X-ray with contrast examination of the sinus is performed during its diagnostic puncture, introducing 1-1.5 m of contrast agent into its lumen. It is best to introduce it directly in the X-ray room. It is recommended to carry out the procedure with the patient lying on his back for shooting in a semi-axial projection, and then - in the lateral, on the side of the inflamed sinus. Sometimes on X-rays with a contrast agent, you can see a rounded shadow in the area of the alveolar process, indicating the presence of a cyst, or the "serrated" symptom, indicating the presence of polyps in the sinus lumen.

CT can provide 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 provides more information if there are soft tissue formations in the lumen of the sinus.

In the absence of clear evidence of the presence of an inflammatory process in the maxillary sinus, but the presence of indirect signs, a diagnostic puncture can be performed using a Kulikovsky needle. The needle is inserted into the vault of the lower nasal passage, then turned with the curved part medially and the sinus wall is pierced.

Another method of invasive diagnostics is endoscopy, which allows to clarify the nature and characteristics of the inflammatory process by means of direct visual examination. The study is carried out after micro-maxillary antrotomy using a trocar or a cutter by inserting 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 provoked by a stressful situation or moving from a warm room to the street, where the temperature is lower. The pains are paroxysmal in nature, expressed upon palpation of the scalp, often accompanied by paresthesia and synesthesia of half of the face. Pressure on the exit points of the trigeminal nerve branches causes sharp pain, unlike in patients with sinusitis.

When local headache dominates the clinical symptoms and there is no nasal discharge, the decisive element of differential diagnosis is anemia of the mucous membrane of the middle nasal passage, after which exudate or a “strip of pus” appears in the nasal cavity, which indicates a blockage of the natural outlet of the maxillary sinus.

Indications for consultation with other specialists

The presence of dental or oral pathology requires consultation with a dentist. If necessary, sanitation measures: treatment of carious teeth, extraction of them or their roots, etc. Sometimes, consultation with a maxillofacial surgeon may be required. In case of clinical signs of trigeminal neuralgia, consultation with a neurologist is indicated for thorough differential diagnostics.

Treatment chronic maxillary sinusitis

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

Indications for hospitalization

The presence of signs of exacerbation of chronic sinusitis: severe local pain, nasal discharge against the background of hyperthermia, confirmed radiological signs of the disease, as well as the lack of effect from conservative treatment within 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 ultra-high frequencies on the sinus area, radiation from a therapeutic helium-neon laser, intrasinus phonophoresis or irradiation with a helium-neon laser.

In "fresh" forms of chronic sinusitis, which are characterized by the involvement of the sinus mucosa and limited areas of the periosteum in the pathological process, healing can be achieved by non-surgical methods (as in acute sinusitis), including punctures, drainage, introduction of proteolytic enzymes into the sinus with subsequent sinus lavage, removal of lysed pus and introduction of antibiotics mixed with hydrocortisone. Non-surgical treatment gives a quick effect with simultaneous sanitation of the causal foci of infection of odontogenic or lymphadenoid localization, with the use of medicinal effects on endonasal structures, as well as 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-surgical treatment.

S.Z. Piskunov et al. (1989) proposed an original method for treating chronic sinusitis using polymer-based drugs. The authors indicate antibiotics, corticosteroids and enzymes as drugs, and cellulose derivatives (methylcellulose, sodium salt of CMC, hydroxypropylmethylcellulose and polyvinyl alcohol) can be used as a polymer carrier.

Repeated preventive courses conducted during the cold season, when exacerbations of chronic sinusitis occur especially frequently, as a rule, do not always lead to a complete recovery, even if a number of preventive measures are taken and risk factors for this disease are radically eliminated (treatment of infection foci, strengthening the immune system, eliminating bad habits, etc.).

Thus, despite the ongoing improvement of non-surgical treatment methods for inflammatory diseases of the paranasal sinuses, their number has not decreased recently, and according to some data, has even increased. According to many authors, this is due to both the tendency to change the pathomorphosis of the microbiota as a whole and changes for the worse in the immune defense of the body. As noted by V.S. Agapov et al. (2000), an immunodeficiency state according to various indicators is observed in almost 50% of healthy donors, and its degree increases with the development of an inflammatory process in the body. This is partly due to an increase in antibiotic-resistant forms of microorganisms as a result of the widespread and sometimes irrational use of biological antibacterial drugs, as well as general changes in the body towards weakening of systemic and local homeostasis when using chemotherapeutic agents, the effects of unfavorable environmental household and industrial conditions, and other risk factors. All this leads to a decrease in the activity of immunological and non-specific reactivity, disruption of neurotrophic functions both at the level of macrosystems and in the area of cellular membranes. Therefore, in the complex treatment of patients with diseases of the paranasal sinuses and ENT organs in general, in addition to generally accepted symptomatic and antibacterial agents, it is necessary to include immunomodulatory and immunocorrective therapy.

At present, despite a fairly complete arsenal of medicinal means of influencing the reactivity of the organism as a whole and local reparative-regenerative wound processes, it is impossible to speak with certainty about the existence of a scientifically tested complex system that effectively “works” in the specified direction. In most cases, the prescription of appropriate drugs is empirical in nature and is based mainly on the “trial and error” principle. In this case, preference is given to chemical and biological drugs, and systemic enhancement of immunity and non-specific resistance is resorted to only when traditional treatment does not give the desired result. When using chemical drugs and antibiotics, as V. Sagapov et al. (2000) rightly note, they invariably enter into the metabolism in the macroorganism, which often leads to the occurrence of allergic and toxic reactions and, as a consequence, to the development of significant violations of the natural mechanisms of specific and non-specific protection of the body.

The above provisions encourage scientists to search for new, sometimes unconventional, means of treating inflammatory diseases of bacterial genesis in various organs and systems, including ENT organs and the maxillofacial system. The morphogenetic, innervational, adaptive-trophic, circulatory, etc. unity of the last two organ systems allows us to speak about the commonality and possibility of applying identical principles of therapy and identical means of treatment to them in the event of chronic purulent-inflammatory diseases.

In both dentistry and otolaryngology, herbal medicine methods are being developed using infusions, decoctions, and extracts of plant origin. However, in addition to herbal medicine, there are other possibilities for using so-called non-traditional means to treat the pathological condition considered in this section. Thus, a new promising direction in the treatment of chronic purulent processes in dentistry is being developed under the guidance of prof. V.S. Agapov, which should probably be of some interest to 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 detrimental effect on bacteria (especially effective on anaerobes), viruses, and fungi. Studies have shown that the systemic action of ozone is aimed at optimizing metabolic processes in relation to protein-lipid complexes of cell membranes, increasing the concentration of oxygen in their plasma, synthesizing biologically active substances, enhancing the activity of immunocompetent cells, neutrophils, improving the rheological properties and oxygen transport function of the blood, as well as stimulating the effect on all oxygen-dependent processes.

Medical ozone is an ozone-oxygen mixture obtained from ultrapure medical oxygen. The methods and areas of application of medical ozone, as well as its dosage, depend mainly on its properties, concentration and exposure, established at a specific stage of treatment. At higher concentrations and prolonged action, medical ozone gives a pronounced bactericidal effect, at lower concentrations - 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 antibacterial treatment.

Slow purulent inflammation is a pathological process with steady progression in a hypoergic course, which is difficult to treat with traditional non-surgical methods. Using the experience of using medical ozone in maxillofacial and plastic surgery in otolaryngology, it is possible to achieve significant success in the complex treatment of many ENT diseases, in which the effectiveness of treatment can be largely determined by the properties of medical ozone. Such diseases may include ozena, chronic purulent sinusitis and otitis in the pre- and postoperative period, abscesses, phlegmon, osteomyelitis, wound oncological processes in ENT organs, etc.

Local application of medical ozone consists of introducing ozonized isotonic sodium chloride solution into the periphery of inflammatory infiltrates, washing purulent wounds and cavities (e.g. paranasal sinuses, cavity of opened peritonsillar abscess or cavity of otogenic or rhinogenic brain abscess after surgery, etc.) with ozonized distilled water. General ozone therapy includes intravenous infusions of ozonized isotonic sodium chloride solution and minor autohemotherapy, alternating every other day.

Drug treatment of chronic sinusitis

Until the results of the microbiological examination of the discharge are obtained, broad-spectrum antibiotics can be used - amoxicillin, including in combination with clavulanic acid, cefotaxime, cefazolin, roxithromycin, etc. Based on the results of the culture, targeted antibiotics should be prescribed. If there is no discharge from the sinus or it cannot be obtained, continue treatment with the previous drug. Fenspiride can be prescribed as one of the drugs for anti-inflammatory therapy. Antihistamine treatment is carried out with mebhydrolin, chloropyramine, zbastin, etc. Vasoconstrictor nasal drops (decongestants) are prescribed, at the beginning of treatment - mild action (ephedrine solution, dimethindene with phenylephrine, and instead of taking drops or spray at night, you can use a gel), if there is no effect within 6-7 days, treatment is carried out with imidazole drugs (naphazoline, xylometazoline, oxymetazoline, etc.).

Anemization of the mucous membrane of the anterior part of the middle nasal passage is carried out using vasoconstrictor drugs (solutions of epinephrine, oxymetazoline, naphazoline, xylometazoline, etc.).

The movement of medicinal preparations is carried out after anemization of the mucous membrane for the introduction of mixtures of medicinal preparations into the sinuses, including broad-spectrum antibiotics and hydrocortisone suspension. The pressure difference, 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 nasopharynx by the soft palate when the patient pronounces a vowel sound (for example, "u") and the negative pressure in the nasal cavity created by the electric aspirator.

Using a YAMIK catheter, negative pressure is created in the nasal cavity, which allows pathological contents to be aspirated from the paranasal sinuses of one half of the nose, and their lumen to be filled with a medicinal product or contrast agent.

Surgical treatment of chronic sinusitis

Puncture treatment of sinusitis in our country is the "gold standard" and is used for both diagnostic and therapeutic purposes - to evacuate pathological contents from its lumen. If the washing fluid during the puncture of the sinus contains white, dark brown or black masses, a fungal infection can be suspected, after which it is necessary to cancel antibiotics and conduct antifungal treatment. If anaerobes are suspected as the pathogen (unpleasant odor of discharge, negative result of bacteriological examination of the contents), oxygenation of the sinus lumen should be carried out after washing its cavity with humidified oxygen for 15-20 minutes.

If long-term drainage of the sinus is required and medications are introduced into its lumen 2-3 times a day, a special synthetic drainage made of thermoplastic mass is installed through the lower nasal passage, which can be left for up to 12 days without disrupting tissue trophism.

Micro maxillary sinusotomy is performed using special trocars (Kozlova - Carl Zeiss, Germany; Krasnozhenz - MFS, Russia) in the center of the anterior wall of the sinus above the roots of the 4th tooth. After the funnel is inserted into the lumen of the sinus, it is examined with rigid endoscopes with 0° and 30° optics and subsequent therapeutic manipulations are performed, fulfilling the assigned tasks. A mandatory element of the 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. Suturing of the soft tissue wound is not performed. In the postoperative period, conventional antibacterial therapy is carried out.

Extranasal dissection according to Caldwell-Luc is performed by cutting the soft tissues in the area of the transitional fold from the 2nd to 5th teeth through the anterior wall of the sinus. An opening is formed that is sufficient for examination and manipulation in its lumen. Pathological formations and discharge are removed from the sinus, and an anastomosis with the nasal cavity is created in the area of the inner wall and in the lower nasal passage. When a significant amount of altered mucous membrane is removed, a U-shaped flap from its unchanged area is placed on the bottom of the sinus. The soft tissues are sutured tightly.

Further management

Vasoconstrictors of mild action are used for 4-5 days. In the postoperative period, gentle wound care is necessary - do not use a toothbrush for 7-8 days, rinse the vestibule of the oral cavity with astringent preparations after meals,

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

Information for the patient

• Beware of drafts.
• Conduct vaccination with anti-influenza serum in the autumn-winter period.
• At the first signs of acute respiratory viral infection or flu, consult a specialist.
• If recommended by the attending physician, perform surgical sanitation of the nasal cavity to restore nasal breathing and the normal architecture of its structures.

Prevention

Prevention is the maintenance of free nasal breathing and normal anatomy of the structures of the nasal cavity, especially the ostiomeatal complex. Prevention of the disease is the observance of the correct hygienic regime. To prevent the development of chronic sinusitis, surgical sanitation of the structures of the nasal cavity is necessary to restore nasal breathing.

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Forecast

The prognosis is favorable if the above advice and rules are followed.

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