Rheogenic diseases of lacrimal organs: causes, symptoms, diagnosis, treatment

Very often patients with acute or chronic rhinitis, allergic rhinopathy, with paranasal sinus diseases make complaints about lacrimation, itching in the eyes or, on the contrary, on the dryness of the mucous membrane of the eyes. These complaints are due to the involvement of lacrimal nasal cavity in one or another pathological process.

Lacrimal organs - this is a fairly complex anatomical system designed for the production and removal of tear fluid, consisting of lacrimal glands and tear ducts. Anatomic and functional lacrimal organs are closely connected with the nasal cavity, providing its mucous membrane with additional moisture (tear), which enriches its own secret of the nasal mucosa with biologically active and bactericidal substances.

Anatomy and physiology. Lacrimal glands are divided into major and additional. The main gland consists of two parts - the orbital and palpebral, the additional ones are located in the transitional fold and at the junction of the eyelid conjunctiva in the conjunctiva of the eyeball. Under normal conditions, only extra glands function which, during the day, release 0.5-1 ml of a tear forming the so-called pre-corneal film on the surface of the cornea, which has a constant composition (12 ingredients), viscosity, moisture, balanced, so that it remains optically transparent . This film plays a crucial role in preserving the cornea from harmful particles of the environment, cleaning the cornea from desquamated cellular elements and serves as a medium through which gas exchange occurs between the air and the cornea. The blinking reflex serves as a kind of mechanism for the uniform distribution of tears to the anterior pole of the eyeball and its purification. The main gland begins to secrete a tear only when there is a need for increased lacrimation (presence of smoke, caustic vapors, foreign bodies in the atmosphere, psycho-emotional tearing, etc.).

The system of innervation of the lacrimal glands is of great clinical and diagnostic importance. The secretory (parasympathetic) innervation of the lacrimal glands is carried out by the lacrimal nerve due to the cells of the upper salivary nucleus. The lacrimal nerve begins in the orbital nerve - the branch of the trigeminal nerve. Its preganglionic fibers are part of the intermediate nerve, they attach to the facial nerve, the knot of the knee passes, and then in the branch of the facial nerve-the large stony nerve through the pterygoid drip-reach the ves- cular node, in which the switching of the pre-ganglionic fibers to the postganglionic fibers takes place.

Postganglionic fibers through the wing-palatine nerves enter the maxillary nerve, and then into its branch - the zygomatic nerve, from which through the connective branch they enter the tear nerve and reach the lacrimal gland. Irritation of the sensitive endings of the branches of the orbital nerve in the conjunctiva of the eye leads to increased tearing. Disturbance of lacrimation due to paralysis of the facial nerve (damage, compression by the tumor in the VSP, etc.) occurs only when the lesion of the facial nerve occurs above the knot. The center of reflex tearing is in the medulla oblongata, and the center of mental crying is in the thalamus, where the center of mimic expressive movements accompanying crying is also located. In addition to the parasympathetic innervation that comes to the lacrimal glands through the lacrimal nerves, it also receives sympathetic innervation, the fibers of which come to the lacrimal glands but the sympathetic plexus of the blood vessels originating in the sympathetic nerve originating in the upper cervical sympathetic node.

The tear ducts serve to carry the tear and the particles that are removed from the surface of the cornea into the nasal cavity and consist of a lacrimal stream, a lacrimal lake, lacrimal points (upper and lower), lacrimal canals (upper and lower), lacrimal sac and lacrimal duct .

Of greatest interest to the rhinologist are the lacrimal sac and the tear duct, as many of them possess the operation of dacryocystorhinostomy and often produce it at appropriate indications, combining it with reconstructive interventions on the nasal cavity.

The lacrimal sac is located under the skin of the inner corner of the eye in the bone cavity of the pit of the lacrimal sac between the anterior and posterior bends of the inner ligament of the eyelids. The fossa of the lacrimal sac is formed by the lacrimal groove of the lachrymal and the groove of the frontal process of the maxilla. Lacrimal bone is located in the anterior part of the medial wall of the orbit. The posterior margin of it joins with the paper plate, the upper one - with the orbital part of the frontal bone, the lower one - posteriorly with the orbital surface of the upper jaw, anterior with the tearing process of the inferior nasal shell. The tip of the lacrimal sac lies somewhat higher than the inner ligament of the eyelids, and its lower end passes into the tear-nasal duct. The lacrimal sac is located in front of the tarzorbital fascia, that is, outside the orbit; In front and outside, it is covered with fascia, starting from the periosteum near the posterior tear scallop and continuing to the front tear scallop. The vertical size of the lacrimal sac is 1 - 1.5 cm. Its walls consist of a mucosa coated with a double-layered cylindrical epithelium, and submucosal tissue.

The lacrimal duct. The upper part of the lachrymal-nasal duct lies in the bone channel, the lower part (membranous) has a bone wall only on the outside, with the mucous membrane of the nasal cavity coming to it from the other sides. The length of the membranous part of the canal is 12-14 mm. The canal is opened by a slotted mouth under the lower nasal sink at the border of its anterior and middle thirds. The opening of the canal is surrounded by the venous plexus of the nasal mucosa. In acute inflammatory or vasomotor-allergic rhinitis, when this venous plexus swells, the mouth of the tear-nasal duct closes and lacrimation arises. The same symptom arises with inflammation of the lacrimal sac - dacryocystitis.

Dacryocystitis occurs in two forms: chronic and acute - catarrhal and phlegmonous. In view of the close anatomical relationship between the nasal mucosa and the tear duct and lacrimal sac, the diseases of the latter can develop with a variety of diseases of the nasal mucosa, as well as in inflammatory processes in the areas adjacent to the lacrimal sac: in the maxillary sinus, in the bones surrounding the lacrimal sac , with purulent inflammation of the eyelids, the lacrimal gland itself, etc. Chronic dacryocystitis is manifested by persistent tear and suppuration. Simultaneously with these symptoms, blepharitis and conjunctivitis are often noted. In the area of the lacrimal sac, there is a swelling in most cases of chronic inflammation. With pressure on the tear sack from the lacrimal points, pus is secreted. The mucous membrane of the eyelids, the semilunar fold and the teardrop are hyperemic and swollen. The lacrimal nasal canal is impassable. With the prolonged existence of chronic dacryocystitis, a considerable stretching of the lacrimal sac may occur, reaching the size of a cherry, a forest or even a walnut.

Acute dacryocystitis is in most cases a complication of chronic inflammation of the lacrimal sac and manifests itself in the form of an abscess or phlegmon - a purulent inflammation of the tissue surrounding the lacrimal sac. Only in rare cases, acute dacryocystitis develops primarily. In such cases, the inflammatory process most often passes to the fiber from the maxillary sinus, the latticed maze or the mucous membrane of the nose, while in the area of the lacrimal sac and on the corresponding side of the nose and cheek severe skin flushing and extremely painful swelling are observed. Eyelids are swollen, the eye gap narrowed or completely closed. The formed abscess is spontaneously opened, and the process can be completely eliminated, or the fistula through which pus persists for a long time can be preserved.

Treatment of dacryocystitis is surgical. There are two types of operative access: endonasal and external. We will dwell on the description of the endonasal West method. The aim of the operation is to create a wide ankle between the lacrimal sac and the nasal cavity. Indications for Vesta operation are the same as for external dacryorino-cystostomy. In the opinion of FIDobromylsky (1945), the advantages of Vest's operation are her less traumatism and the absence of a postoperative scar on her face.

The operation is performed in the patient's sitting position, under local anesthesia - lubricating the nasal mucosa with 10-20% cocaine solution with epinephrine and instilling the same solution into the tear sack. The author excludes the infiltrative endonasal anesthesia, as it leads to a narrowing of an already narrow operating field, which complicates the operation. High concentration of cocaine with individual intolerance can lead to anaphylactic shock, therefore, before the main anesthesia, a test should be carried out for its tolerance by lubricating the nasal mucosa with a 1% solution of this anesthetic. It is possible to use other anesthetics for application anesthesia.

The first stage: excision of the mucosa of the lateral wall of the nose in front of the middle nasal cavity by cuts to the bone along the lines bounding the rectangle ABCD. The mucous membrane, lying in the area S, is removed and removed, exposing the underlying bone. Further, additional incisions are made to form a plastic flap from the mucosa. These incisions are also carried out to the bone along the back of the nose along the lines corresponding to the edge of the pear-shaped sinus (BE and EF). The flap of the CBEF is peeled off from the underlying bone, bent along the CF line and flipped downwards, as a result of which it occupies the position corresponding to the rectangle.

The second stage is the formation of a bone opening in the posterior part of the frontal process of the upper jaw. To remove the bone with a whole piece, make two deep incisions with a straight chisel on the bone at the previous stage, parallel to lines AE and DF at a distance of 1.5 cm from one another, then the bone is sold with the same tool perpendicular to the first two incisions from the top to the bottom and removed by bone forceps. As a result, a tear sack is exposed.

The third stage is resection of the inner wall of the lacrimal sac. Pressing on the inner corner of the eye, the tear sack is displaced into the nasal cavity and opened by its vertical section with its outer wall. Introduced through this incision into the cavity of the bag, the inner wall is resected by the cochhotom. The resulting opening in the inner wall of the lacrimal sac and there is an artificial fist between it and the nasal cavity. After that, the operating field is inspected for the presence of remaining bone fragments and their removal, the wound cavity is washed with a solution of the corresponding microbiotic antibiotic, and the detached flap B'CFE 'is put back into place (BCEF) and pressed down with a swab.

The tampon is removed after 3 days. In the postoperative period, the granulation appearing in the region of anastomosis is extinguished by 2-5% silver nitrate solution. With excessive growth of granulations, they are removed with a curette, Hartmann's nose forceps or a nose conchtome. As FSBokshtein (1924, 1956) notes, complete and persistent cure of patients suffering from chronic dacryocystitis, as a result of Vesta surgery occurs in 98% of cases, in 86% of patients there is a complete recovery of tearing.