Puncture of the maxillary sinus

Puncture of the maxillary sinus for diagnosis is made only in those cases when it combines therapeutic purposes, and only when there is a suspicion of the presence of pathological contents in the sinus in the endoscopy of the nose. Some authors recommend to perform puncture in catarrhal sinusitis for the introduction of drugs into the sinus and achieve a faster therapeutic effect. To the puncture of the maxillary sinus should be treated with great care, because if a number of technical rules are not observed, various complications caused by the procedure itself or in the presence of birth defects in the structure of the facial skeleton are possible. Therefore, any puncture of the Ocellolar sinuses should be preceded by a thorough X-ray examination to identify these defects (the bicameral sinus, the absence or thinning of the orbital bone wall, the presence of dehiscence, and in the case of traumatic sinusitis - the presence of cracks and bone fragments). These phenomena determine the indications and individual approach to the implementation of the puncture of the maxillary sinus. Sometimes the bottom of the maxillary sinus is located much higher than the lower nasal passage - the traditional place for its puncture. In this case, a sinus can be probed through a natural opening or a puncture can be performed through the middle nasal passage. In the latter case, special skills are required, since it is possible to penetrate the latticework maze or into the orbit.

Often, during the puncture of the maxillary sinus, patients develop a collapoid reaction: a sharp blanching of the face, cyanotic lips, relaxation, loss of consciousness. These phenomena are caused by a sharp decrease in blood pressure due to a drop in vascular tone, a decrease in cardiac output and, as a consequence, cerebral ischemia. In this case, the patient should be sharply tipped forward so as to cause compression of the abdominal aorta and increase arterial pressure in the carotid and vertebral arteries. If the consciousness of the patient is not lost, then he is offered to inhale through his nose a pair of ammonia, causing a sharp irritation of the trigeminal nerve and a reflex increase in blood pressure. The patient is immediately placed in a horizontal position with slightly raised lower limbs, covered with a blanket, 2 ml of a 10% caffeine solution of sodium benzoate is injected subcutaneously. As a rule, these measures are enough to cause the signs of a collapoid state to be eliminated. In addition to this excess, there may be some "technical" complications arising from the wrong direction of the puncture needle or its slipping along the lateral wall of the nose in the direction of the orbit. It is also possible perforation of the upper (orbital) and posterior wall with the penetration of the needle into the KNYA, as well as the penetration of the needle into the soft tissues of the face. In these cases, the parasynous injection of rinsing fluid or air with the emergence of secondary complications (emphysema, abscess, phlegmon), the wounding of a large vessel (with artery injury - hematoma, with injuries of the vein - embolism), etc. With a puncture of the maxillary sinus, there is always a slight crunch a broken bone septum.

Anesthesia is performed by 2-3-fold lubrication of the mucous membrane of the lower and middle nasal passages with a 5% solution of dicaine in a mixture with adrenaline. Infiltration anesthesia is possible with introduction of 2 ml of 2% novocaine solution into the area of the lower nasal passage. Lubrication of the middle nasal passage with adrenaline solution facilitates the patency of the excretory duct of the maxillary sinus. The puncture is performed with a Kulikovsky needle, the features of which are a sharp, angled end curved at an angle of 20 °. The needle handle is presented in the form of a flat, thick plate of asymmetrical shape, the larger arm of which is directed towards bending the needle, the massiveness and elasticity of the needle itself, allowing it to exert considerable force on it without risking its bending. Instead of the needle Kulikovsky sometimes use a needle with a trocar for lumbar puncture.

The puncture procedure is carried out as follows. Under the control of vision, the end of the needle is injected concavity downward into the lower nasal passage to a depth of 2-2.5 cm and rest against the convex part of the end in the arch of the lower nasal passage. Then, focusing on the larger arm of the handle, unfold it so that the curved end and the general direction of the needle are directed toward the outer edge of the orbit. The most crucial moment occurs during the puncture. In the left hand, the doctor fixes the patient's head, in some cases, resting it on the headrest or wall, and with his right hand, holding the needle firmly with the palm rest, first fixes the end of the needle on the bone with a light drilling motion (prevention of needle slipping), then, the outer corner of the orbit, with the appropriate effort (produced in the course of the experiment), pierces the medial wall of the sinus, while the needle must be firmly fixed in the fingers holding it, so that at the moment of the puncture it does not go too far and injures rear or upper wall of the maxillary sinus. When installing the needle, its end should be fixed at the very arch of the lower nasal passage, where this wall is thinnest. In some cases, the medial wall of the maxillary sinus is a fairly dense and thick bone, as a result of which the puncture is performed with great difficulty or at all impossible. It should be noted that when puncturing the right maxillary sinus, the needle is more convenient to hold in the right hand, and when puncturing the left sinus - in the left hand.

After inserting the needle into the sinus, it is stretched for 2-3 mm to release its lumen from the possible fragments of the punctured tissues that have entered it. Immediately after the puncture, the fluid contained in the sinus can be released from the needle, especially if it is under pressure. The most prominent is the transudate or the contents of the cyst (cystic formation), if the needle is in their cavity. Dense pus and jelly-like masses do not stand out on their own. After a puncture the doctor makes a number of samples and manipulations. With an empty syringe, an effort is made to get the contents of the sinus with a slight suction. If this is successful, then you should not try to use this technique to completely remove the contents of the sinus, especially if obstruction is obstructed, since a vacuum created in the axillary sinus can disrupt the integrity of the vascular plexuses of the mucosa, even disrupt its connection with the periosteum, which creates conditions for hematogenous spread of infection and serious complications. Checking the functioning of the anastomosis is determined as follows. The passage of the anastomosis is preserved if the drawing of the syringe piston is possible with ease and it does not return to its original position if the liquid introduced into the sinus is released into the nasal cavity together with all the contents if, when inserted into the air sac, it easily penetrates into the nasal cavity with the corresponding characteristic sounds , but to force the introduction into the sinus of air should not be in any case, so it can be complicated by emphysema. The contents of the sinus obtained by careful aspiration, observing aseptic rules, are placed in a sterile tube and subjected to bacteriological examination. However, the contents are often sterile, which can be explained by the presence of an anaerobic microbiota.

[1], [2], [3], [4]