Paranasal sinus injuries - Treatment

Goals of Treatment for Sinus Trauma

Eliminate the cosmetic defect resulting from the injury and restore the functional state of the paranasal sinuses and nose in order to prevent post-traumatic inflammatory diseases of the paranasal sinuses, leading to formidable intracranial and intraorbital complications.

Indications for hospitalization

Isolated or combined lesions of the paranasal sinuses.

Non-drug treatment of paranasal sinus injuries

In case of closed lesions of the paranasal sinuses, ice is applied to the area of injury in the first 5-6 hours after the injury; in case of nosebleed, anterior loop or posterior nasal tamponade may be used. In case of damage to the ethmoid labyrinth and sphenoid sinus, hemosinus resolves with conservative treatment. In case of hemosinus of the frontal sinus without cosmetic defect and displacement of bone fragments, conservative treatment is indicated.

Drug treatment of paranasal sinus injuries

In case of concussion, bed rest in an elevated position (semi-sitting), dehydration agents (intravenous administration of 40% dextrose solution, hypertonic solutions of calcium chloride and sodium chloride, as well as furosemide, acetazolamide), sedatives and a diet with limited fluid intake are prescribed. Non-narcotic analgesics (metamizole sodium, tramadol), sedatives (oxazepam, phenobarbital) are also prescribed. To combat wound infection and prevent secondary complications, general antibacterial therapy is used, preference is given to cephalosporins of the II-III generation. Hemostatic and symptomatic therapy are also carried out. The introduction of antitetanus serum according to the scheme is mandatory.

Surgical treatment of paranasal sinus injuries

Treatment tactics depend on the nature and depth of the injury, the severity of general and neurological symptoms. All surgical interventions on damaged paranasal sinuses must be performed in the early stages after the injury (1-14 days). In case of injury with damage to soft tissues and bone structures of the facial part of the skull, primary surgical treatment is performed.

In case of a penetrating wound of the frontal sinus with a small bone defect of its anterior wall, revision and endoscopic examination of the sinus are performed through the wound channel. In case of integrity of the frontal sinus aperture, the mucous membrane of the sinus is preserved, the wound is sutured with a cosmetic suture and drainage (catheter) is installed in the sinus through the wound channel, through which the sinus is washed with antiseptic solutions for 3-4 days.

In case of a closed fracture of the anterior, inferior, and even posterior wall of the frontal sinus without signs of rhinoliquorrhea and brain damage, it is recommended to perform plastic surgery of the walls of the frontal sinuses. Access to the damaged walls is provided by minimal skin incisions in the area of the greatest recession of the walls. Next, a revision of the damaged area is carried out and through a small opening, using an elevator, a traction movement is used to reposition the conglomerate of bone fragments to their original place. Through the opening, an examination of the sinus is carried out using an endoscope and, if there is no damage to the aperture of the frontal sinus (always revealed in the case of a fracture of only the anterior and, in most cases, the anterior-inferior wall) and the stability of the repositioned wall, the operation is completed by applying a cosmetic suture to the wound. In case of mobility, and especially separation of fragments from each other, it is necessary to fix them to each other and to the surrounding carinae of the whole frontal bone. To do this, a surgical burr is used to make milling holes along the edges of the fragments and the intact frontal bone, through which the fragments are fixed to the edges of the defect and to each other with a non-absorbable thread. In some cases, in order to avoid further collapse of the formed wall, it is necessary to additionally fix the fragments to the skin of the frontal region with a non-absorbable thread. In case of severe traumatic edema of the mucous membrane of the sinus, even with a functioning frontal sinus aperture, a sinus drainage is installed, through which the sinus is washed with antiseptic solutions for 2-5 days.

In case of significant open injuries of the frontal sinus, in most cases a radical operation is performed, which consists of removing the mucous membrane and bone fragments with the formation of the frontal sinus aperture and fixation of drainage according to B.S. Preobrazhensky for 3 weeks (a rubber tube with a diameter of 0.6-0.8 cm, connecting the frontal sinus and the nasal cavity, is fixed with a roller on the skin next to the incision). With careful examination and probing of the posterior wall of the frontal sinus, it is possible to detect its fracture, requiring exposure of the dura mater. Detection of liquorrhea in this place serves as an indication for suturing the rupture with plastic surgery of the defect.

In case of penetrating injury of the maxillary sinus with a small defect of the anterior wall, an endoscopic examination of the sinus is also performed with preservation of the mucous membrane and installation of drainage through the lower nasal passage. The wound is sutured with a cosmetic suture if possible.

In case of open damage to the maxillary sinus with fragmentation of the anterior, upper and other walls, a radical operation is indicated, which consists in forming an apex of the sinus with the nasal cavity under the inferior turbinate. In case of damage to the orbital wall with prolapse of the orbital tissue into the sinus, taking into account that in the future a cosmetic defect (drooping of the eyeball) and diplopia may develop, plastic surgery of this wall is performed using artificial materials (titanium plates, etc.). In case of damage to the orbital wall, it is recommended to preserve the bone fragments and reposition them by inflating a liquid rubber balloon in the sinus. Additionally, the anterior wall is formed from large bone fragments fixed to each other and to the intact edges of the anterior wall with a non-absorbable thread. The balloon is filled with 15-20 ml of radiopaque substance, which allows for further radiographic control of complete filling of the sinus with the balloon and sufficient reposition of the walls. The balloon tube is brought out through the artificial anastomosis and fixed to the cheek. The balloon should remain in the sinus for 10-14 days.

Further management

The length of hospitalization of patients depends on the degree of damage to the paranasal sinuses and the presence of combined damage to other important organs. If primary surgical treatment of facial wounds was performed, the sutures are treated daily with a solution of brilliant green or iodine and removed after 7-8 days. Patients who underwent radical surgery on the maxillary sinus, in the postoperative period (7-10 days), the sinuses are washed with antiseptic solutions through the formed artificial anastomosis. Patients who underwent radical surgery on the frontal sinus, the frontal sinus is washed daily through a drainage tube, which is removed after 21 days. In case of gentle plastic surgery on the frontal sinus, fixing sutures on the skin are removed after 3-7 weeks. After discharge from the hospital, the patient is monitored by an otolaryngologist at a polyclinic at the place of residence.

The patient should be informed that he/she should follow a gentle regimen for a month after the injury, take care of and not touch the injury area or the site of the operation on his/her own, and should not blow his/her nose too much (prevention of subcutaneous emphysema). Physical activity, visiting a bathhouse, or sauna are excluded. It is advisable to use vasoconstrictor nasal drops for 7-10 days. For one month after the injury, it is recommended to take Sinupret according to the scheme and perform an independent nasal douche using a 0.9% sodium chloride solution, seawater preparations, etc.

Forecast

In case of isolated closed damage to the paranasal sinuses, the prognosis is favorable; in case of severe combined trauma, it depends on the degree of damage to the brain, eye socket and other structures, as well as possible purulent complications. Approximate periods of disability are 20-30 days from the moment of surgical intervention.

Prevention

It is necessary to avoid blows to the face during sports, road accidents, etc.

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