Surgery for chronic sinusitis

Non-operative treatment does not always give a radical effect, and then the question arises about the use of surgical treatment according to the following indications:

• absence of the effect of nonoperative treatment, which used antibiotics, proteolytic enzymes, vaccine therapy, ostium liberation, puncture and drainage, antiallergic treatment, FTL methods, etc .;
• the presence of proliferative processes in the sinus cavity, established by methods of puncture and radiation diagnosis;
• closed forms of chronic sinusitis due to obliteration of natural anastomosis and the inability to perform nonoperative and puictic treatment;
• presence of suppurative fistula, osteomyelitic sequesters, gunshot foreign bodies, the presence of tooths that have fallen into the bosom of the teeth during their extraction;
• presence of infected cysts and various parasinous, intraorbital and intracranial complications;
• the presence of secondary complications from the internal organs, caused by a chronic purulent process in the paranasal sinuses.

These indications for surgical intervention on the maxillary sinus are also valid for other paranasal sinuses, taking into account the peculiarities of the clinical course in their diseases and the topographic and anatomical position.

Contraindications are determined by the general condition of the body, its ability to tolerate surgical intervention, the presence of systemic diseases of the blood, endocrine system, general inflammatory and infectious diseases, etc. These contraindications may be temporary or permanent. In some cases, a number of contraindications can be ignored (with adequate protective equipment) if surgical intervention on one or another paranasal sinus is to be performed but to life indications.

Operative intervention on the maxillary sinus, as in any other operation on the upper respiratory tract, rich in reflexogenic zones, is preceded by preoperative preparation of the patient, which, depending on his state of health, the chosen method of anesthesia (local or general) can take from several hours to one -2 weeks. In a particularly thorough examination, patients in need of surgical intervention under anesthesia (correction of blood pressure in hypertensive syndrome, blood glucose in diabetes mellitus, elimination of hypovolemia and metabolic disorders through infusion therapy, etc.) need a particularly thorough examination. An important place in preoperative preparation of the patient is premedication, aimed at eliminating psychoemotional stress, reducing reflex excitability, pain sensitivity, secretion of salivary and bronchial glands (with surgical interventions on the pharynx, larynx, etc.), potentiating the action of general and local anesthetics. To ensure a proper sleep before surgery for the night appoint per os tranquilizer (seduxen or fenozepam) and hypnotics from the barbiturate group (phenobarbital). In the morning for 30-40 minutes before anesthesia or before local infiltration anesthesia intramuscularly introduce seduxen, promedol and atropine. In particularly excitable patients, droperidol is added to these agents. Patients prone to allergic or anaphylactoid reactions, in premedication include antihistamines (pifolen, dimedrol, suprastin). After the onset of the premedication effect, the patient on a gurney is taken to the operating room. On the day of surgery, both before and after meals, and drinks are excluded.

[1], [2], [3], [4], [5]

Operation Caldwell-Lucas

Anesthesia is local infiltration : stem, local-regional and application, or epimucose. All three types of anesthesia are carried out consecutively in the designated order.

Stem Anesthesia : An anesthesia of the trunk of the maxillary nerve in the retrooxillary region in the immediate vicinity of the upper jawbone. The intraoral method of infiltration stem anesthesia is used: it is convenient to use a long Arteni needle, which is bent at an angle of 110 ° at a distance of 2.5 cm from the end of the needle. Such a shape of the needle facilitates the precise introduction of the anesthetic solution into the paratubular region. The needle is inserted into the alveolar-ventral cavity behind the third painter (8th tooth) concavity inward and upward by 45 °, advanced along the bone wall of the upper jaw, all the time in contact with its tubercle until the concave part of the needle (2.5 cm ) does not fully enter the tissue. In this position, the end of the needle is in the entrance to the wing of the maxillary fossa; the inclination of the needle downwards and the advance of it by another 2-3 mm corresponds to the position of its end near the trunk of the first branch of the trigeminal nerve. Having reached this position, an anesthetic is injected (4-5 ml of 1-2% solution of novocaine). Novocaine can be replaced with new anesthetic solutions, which have more pronounced anesthetic and some specific pharmacological properties.

Very effective in this respect are the "dental" combined anesthetics of ultracaine D-C and ultracaine D-C forte. The effect of the drug begins quickly - after 1-3 minutes and lasts for the first of them 45 minutes, for the second - 75 minutes. The drug provides reliable and deep anesthesia, healing of the wound proceeds without complications, due to good tissue tolerance to minimal vasoconstriction. To achieve this effect, it is sufficient to administer 1.7 ml of the solution. Ultracaine can not be administered intravenously. In some patients, the drug can cause an acute attack of suffocation, impaired consciousness, shock. In patients with bronchial asthma, the risk of developing this complication is extremely high.

The new anesthetic agent Scandinon, used in many countries under the name of carbocaine, along with a powerful anesthetic property, gives a weak vasoconstrictive effect, which makes it possible to widely apply it in local-regional surgical interventions. It is available in three versions with different indications: 3% Scandonian without vasoconstrictive action, 2% Scandinavian norepinephrine and 2% Scandinavian special. The first is used for surgical interventions in hypertensive patients, it is also an ideal tool for stem anesthesia, its pH is close to neutral, which allows for painless injections. The second is used for all types of surgical interventions, even prolonged and complex. The third contains a small dose of synthesized adrenaline, which makes its effect more localized (vasoconstriction and local concentration of the drug) and deep. It should be emphasized the special importance of the scandinavian in operations on the upper respiratory tract: it does not contain a group of paramine, which completely eliminates the risk of allergies in patients who are highly sensitive to this group.

Indications for the use of Scandinavian:

• 3% Scandonian without vasoconstrictive effect is used for stem injections, for hypertensive patients, for diabetics and for patients with coronary insufficiency;
• 2% scandonex norepinephrine can be used in any surgery, as well as in patients with heart defects of rheumatic genesis;
• for particularly heavy and prolonged operations, as well as in normal practice.

Dosage: 1 ampoule or 1 vial for normal operation; this dose can be increased to 3 ampoules with mixed anesthesia (trunk and local). This anesthetic can be used in all surgical procedures on the upper respiratory tract.

Stem anesthesia of the maxillary nerve can also be achieved by injecting an anesthetic solution into the region of the posterior palatine canal; the injection point is 1 cm above the edge of the gum, i.e., above the point of intersection of the line connecting the third molars, with the line continuing the dental arcade. At this point, inject 4 ml of 1-2% solution of novocaine or the above-mentioned anesthetics in a suitable dose.

Local regional anesthesia is performed by infiltration of soft tissues in the canine fossa and infraorbital foramen - the site of the infraorbital nerve exit. Preliminarily infiltrate 1% novocaine solution of the mucosa of the vestibule of the oral cavity of the corresponding side, by 1 cm behind the bridle on the opposite side, and up to the second-third molar of the "causative" side.

Application anesthesia is carried out by 2-3-fold lubrication or laying turundas impregnated with 5% solution of dicaine or 5-10% cocaine solution in the lower and middle nasal passages for 5 minutes.

The operation takes place in five stages :

• One-moment horizontal incision of the mucous membrane and periosteum along the transitional fold of the vestibule of the mouth starting from the 2nd incisor, receding 3-4 mm from the bridle of the upper lip and ending at the level of the second molar. The mucous membrane, together with the periosteum, is cut off by a single flap, exposing the anterior bone wall of the maxillary sinus throughout the entire canine fossa, while trying not to damage the infraorbital nerve emerging from the infraorbital fossa. Some authors suggested to make a vertical incision in the projection of the center of the canine fovea to prevent damage to the alveolar nerve branches, but this kind of the distribution section did not find.
• Autopsy of the sinus is performed in the thinnest bone part of the anterior wall, determining it according to the bluish tinge and percussion sound. Sometimes this part of the front wall is so thin that it breaks under little pressure or is completely absent, eaten by the pathological process. In this case, purulent masses can be secreted through the fistula or prolapse under pressure of granulation or polyps. The pus is immediately removed by sucking, and the tissue obstructing the scan is partially (preliminarily) removed, trying not to cause excessive bleeding.

Autopsy of the sinus can be carried out by spear-like boron according to AI Evdokimov, or gutted chisel or chisel, by which rounded nicks are made around the bone plate to be removed. The liberated bone plate is pinched from the edge by a thin rasher and removed. The dimensions of the opening in the anterior wall of the maxillary sinus can vary depending on the nature of the pathological process and its localization in the sinus.

• Surgical treatment of the cavity is the most crucial stage, and the technique of its implementation remains controversial to the present. In the classical version of Caldwell-Luc, the operation was termed "radical" because, at the suggestion of the authors, total mucosal scraping was performed irrespective of its condition, which was motivated by the assumption of relapse prevention. However, this method did not work out for many reasons:
  • the total scraping of the mucous membrane does not lead to the cure of the chronic inflammatory process, but tightens it for months and years by passing various pathomorphological stages from the lush growth of granulations and repeated surgical interventions to the cicatrical process and obliteration of the sinus and its outlet;
  • Removal, albeit pathologically altered, but capable of regeneration and reparative restoration of the islets of the mucous membrane, deprives the body of the possibility of using its adaptation-trophic functions aimed at restoring the normal mucosa of the sinus, which plays an important physiological role for the entire PNS;
  • the total scraping of the mucous membrane of the maxillary sinus leads to the destruction of the vegetative fibers preserved only in the region of viable islets, a linking link with vegetative trophic centers, which also prevents reparative processes in the sinus.

There are examples from practice, when only the formation of an effectively and long-term artificial sinus sinus with the nasal cavity and the removal of only obviously nonviable tissues, polyps and lush granulations without scraping the mucous membrane leads to complete sanation of the maxillary sinus, therefore the vast majority of modern rhinosurgery spares mucus paranasal sinuses. Total removal of the mucosa is indicated only in extremely rare cases, mainly as a palliative method of treating the "profuse" recurrent polyposis of the whole PNS, a deep destructive lesion of the entire mucosa and periosteum, the presence of osteomyelitis changes in the sinus walls. After removal of all pathological contents from the sinus, its final revision is made, paying attention to the bays, posterior and orbital walls, especially on the upper non-median angle bordering the posterior cells of the latticed labyrinth. Many authors suggest conducting an audit of this area by opening several cells. In the presence of an inflammatory process in them (chronic purulent maxilloimotitis) immediately after the opening of cells pus is released, which is the reason for the revision of all available cells with their removal and the formation of a single cavity with the maxillary sinus.

• Formation of an artificial drainage hole ("window") in the medial wall of the sinus for communication with the lower nasal passage and the implementation of drainage and ventilation functions. In the classical version of the Caldwell-Luke operation, this opening was literally cut into the nasal cavity, and the resulting flap was removed along with the mucosa of the lateral wall of the lower nasal passage. At present, this method does not apply. First, carefully cut the thin bone medial wall of the sinus and by penetrating the thin nasal raspator into the space between the bone and the mucous membrane of the lateral wall of the lower nasal passage, the bone part of the septum is fragmentarily removed to form a hole in the size of a modern 2 ruble coin. In doing so, try to extend the hole as high as possible, but no further place attachment of the bones of the lower nasal shell. This is necessary for the subsequent formation of a mucosal flap of sufficient length. Then, the remaining mucous membrane of the lateral wall of the nose is removed in the direction of the bottom of the nasal cavity, going 4-5 mm to it. Thus, a "threshold" is exposed between the bottom of the sinus and the bottom of the nasal cavity, which is an obstacle to the subsequent plasty of the nasal mucosa of the sinus floor. This threshold is smoothed with either a narrow chisel, or a sharp spoon, or a cutter, while insuring the nasal mucosa (the future flap) from damage. After smoothing the threshold and preparing the site on the bottom of the sinus in the immediate vicinity of the threshold for the flap proceed to the plastic bottom of the sinus. To do this, with the support of the mucosa (the future flap) from the lower nasal passage by any suitable instrument, for example, the nose rasher, the sharp spear-shaped eye scalpel, a rectangular flap is cut out of this mucosa by a special U-shaped incision in the following sequence: the first vertical incision is made from above down at the level of the posterior edge of the bone orifice of the "window", the second vertical incision is at the level of the front edge of the "window", the third horizontal incision is made at the upper edge window ", helping himself with the rasp, introduced in the lower nasal passage. The formed rectangular flap (which is prone to contraction) is laid through the smoothed threshold to the bottom of the sinus. Some rhinosurgeons neglect this part of the operation, believing that the epithelialisation of the sinus still occurs from the source of the nasal cavity. However, experience shows the opposite. The remaining bare tissue of the scraped threshold of the slope to lush granulation, followed by metaplasia into the scar tissue, completely or partially obliterating the newly formed "window" with all the ensuing consequences. In addition, the plastic flap is a powerful source of reparative physiological processes that accelerate the normalization of the cavity, since the secretory elements present in it release trophically active and bactericidal substances that promote healing and morphological and functional rehabilitation of the sinus.
• Tamponade of the maxillary sinus. Many practical doctors give this stage a purely formal meaning, and even in solid textbooks and manuals, its importance is reduced to the prevention of postoperative hemorrhage, formation of hemosinus, its infection, etc. Without detracting from the importance of this position, we note, however, that the fundamentally different meaning of the sinus tamponade, or rather the significance of those substances impregnated with a tampon inserted into the postoperative cavity, as a mixture with vaseline oil and antibiotics, immediately after the operation on one or another sinus , and in the postoperative period.

It's about regenerants and reparants - drugs that have the ability to stimulate reparative regeneration. This process contributes to the restoration of tissue sites and organs damaged as a result of injuries, surgical interventions, inflammatory phenomena or dystrophy. As a result of repair, either the restoration to normal state of tissues and organs in the stage of parabiosis occurs, or replacement of foci of necrosis with a specific or (and) connective tissue, which has the highest regeneration potential. It is not difficult to see that these provisions are directly related to the pathological condition under consideration; because for the organ, which we think of the maxillary sinus as an element of the system, it is not indifferent whether it will become empty and obliterated by the connective tissue, or at least 50-60 percent of its inner surface will be covered as a result of forced regeneration by multilayered cylindrical ciliate epithelium and those elements of the mucous membrane, which provide a sinus homeostasis.

The general mechanism of regenerative action includes the enhancement of the biosynthesis of purine and pyrimidine bases, RNA, functional and enzymatic cellular elements, including phospholipids of membranes, as well as stimulation of DNA reduplication and cell division. It should be noted that the process of biosynthesis in the course of both physiological and reparative (posttraumatic) regeneration requires substrate maintenance (essential amino acids and fatty acids, trace elements, vitamins). In addition, the process of biosynthesis of proteins and phospholipids is characterized by high energy intensity, and its stimulation requires adequate energy supply, i.e., appropriate energy materials. Actovegin, solcoseryl, etc. Are among the means that energetically and substrate ensure the course of repair processes. The effect of these drugs is often difficult to differentiate from the "own" regenerative action of the organism.

In accordance with the localization of action, stimulators of regeneration and repair are conditionally divided into general cell (universal) and tissue-specific stimulants. Cellular stimulants that act on any regenerating tissue include anabolic steroids, nonsteroidal anabolics - sodium deoxyribonucleate (derinat), methyluracil, inosine, etc. - and vitamins of plastic metabolism. It should not be doubted that, after removing the tampon from the wound cavity of any origin, along with the prevention of infection, it is necessary to apply topically and in the general therapeutic terms the above mentioned reparants. There is no great experience of such application, and the methods of using these drugs in otorhinolaryngology are waiting for their scientific research, but now one can recommend the use of some anabolic steroids, non-steroidal anabolics and plastic metabolism vitamins to harmonize reparative and regenerative processes in the postoperative period in operations not only on the perennial sinuses, but also on other ENT organs. For example, you can add sodium deoxyribonucleate in the proportion 1:20 or derinat (5:10) to the Vaseline oil, which is impregnated with "gaymoritic" tampons for tamponade of the sinus after surgery, - preparations with a pronounced reparative and regenerative property.

So, sodium deoxyribonucleate has immunomodulatory, anti-inflammatory, reparative and regenerating properties. It activates antiviral, antifungal and antimicrobial immunity at the cellular and humoral levels. Regulates hemopoiesis, normalizes the number of leukocytes, granulocytes, phagocytes, lymphocytes and platelets. Stimulates reparative processes in wounds, restores the structure of the mucous membrane of the upper respiratory tract and gastrointestinal tract, facilitates the engraftment of autografts (in particular, the flap of the nasal mucosa laid on the bottom of the maxillary sinus, tympanic membrane, etc.). After removing tampons from the maxillary sinus (or from the nasal cavity after septum operation), this drug can be injected into the sinus after it has been washed and emptied of the wash liquid in a mixture with carotoline in a ratio of 5 drops of the drug to 5 ml of carotolin, daily for 7 days. Instead of carotolin, you can use rose hips or sea-buckthorn oil with corn oil in the proportion of 1 ml of sea buckthorn oil per 5 ml of corn oil.

Another drug - derinat - is available in solutions for external and internal use, it is very convenient to use it in a mixture with vaseline or other vitaminized oil to impregnate tampons or use in pure form or in a mixture with carotolin, dogrose oil, sea buckthorn in the postoperative period.

Tissue-specific stimulators of the regeneration process are drugs with different mechanisms of action, combined into subgroups by selective action on a particular tissue or organ system.

Vitamins of plastic action (alfacalcidol, ascorbic acid, benfotiamine, beta-carotene, vitamin E, retinol, etc.) are of great importance for stimulating the reparative processes in the wound. Their use (local and general) significantly affects the reparative processes and must be performed compulsorily in the postoperative period within 10-14 days.

Returning to the tamponade of the maxillary sinus, we note some of its features. Before the tamponade, the final hemostasis should be achieved by any existing methods (bone-filling, scraping of bleeding pathological tissues, lacerocoagulation of the vessel). The application of epinephrine gives only a temporary effect of vasoconstriction, after which the opposite effect occurs, the dilatation phase of the vessel. Before the tamponade in the sinus, it is advisable to fill in the corresponding antibiotic, let in 5-10 drops of the hydrocortisone emulsion, 1 ml of carotoline in a mixture with the solution of deoxyribonucleate, and under the control of the vision, the mass formed in the cavity should be concentrated along the sinus bays. After this, several small pieces of the hemostatic sponge or 2-3 sponges (1x1 cm) of "Alvostase", used in dentistry for the treatment of the alveolitis, are laid in the bosom. "Alvostase" is a composite sponge, which includes eugenol, thymol, calcium phosphate butylparamino benzoate, iodoform, lidocaine, propolis; the basis is the haemostatic absorbable sponge. "Alvostat", introduced into the inflammatory cavity, quickly relieves pain and promotes healing in a very short time. After the introduction of the sponge, the sinus is tamped. The tampon impregnated with the appropriate solutions (as discussed above), the assistant holds the weight, and the surgeon gradually arranges it in the form of an accordion, starting from the farthest corners of the sinus so that when removing it in front of the extracted part, there is not that part of the tampon to be removed in the last turn. With good hemostasis tight tamponade is excluded, the tampon is laid loose, but so that it fills the entire volume of the sinus. The end of the tampon is taken to the artificial "window" into the lower nasal passage, then to the general nasal passage and outward, fixing it at the nostril with a cotton-gauze anchor and a sling-like bandage. An important step in removing the tampon from the sinus into the nasal cavity is the insurance of the flap lying on the smoothed threshold. In order not to dislodge the flap, it is pressed with the nasal raspator to the underlying bone and gently, slowly pulling the tampon into the nasal cavity and outwards. After removing the fixation of the flap, no tampon traction can be made. At the end of the tamponade, the position of the flap is verified and, if necessary, it is straightened and fixed by pressing the tampon from above. The tampon is removed after 48 hours. In order for it to slide easily, during the formation of an artificial drainage hole, make sure that its edges are smooth, without burrs, for which the gauze swab is easy to attach while removing it. 6. Suturing a wound on the threshold of the mouth - the procedure is optional and depends on the surgeon's preferences. After 3-4 h correctly aligned edges of the wound tightly adhere. Some authors recommend laying on the wound of the mouth a small gauze roll to fix the edges of the wound, which is removed after 2-3 hours. The previously applied pressure bandage on the canine fossa region supposedly to prevent swelling of the cheek is now being used less and less often due to its insolvency.

Management of the patient in the postoperative period. Meal until the next day is excluded. It is acceptable to consume a small amount (0.2-0.3 l until the next morning) of a cold sweetened and acidified lemon tea. In pain, injectable analgesics are prescribed. In addition, the patient is prescribed an appropriate antibiotic, diphenhydramine, sedative according to the indications. Mode - bedtime until the next morning. After removal of the tampon, the sinus is washed with a warm sterile isotonic solution or furacilin, and depending on its condition, composite preparations containing reparants, antibiotics, fat-soluble vitamins continue to be introduced into it for several days. Usually, with such intensive treatment, recovery comes in 2 weeks, and the patient can be discharged from the hospital for an outpatient observation 3-5 days after the operation.

Operation Kretschman-Denker

The operation was first proposed by A. Denker in 1903, then was improved by G. Krechman in 1919 by prolonging the incision for the bridle of the upper lip.

Indications, contraindications, preoperative preparation, anesthesia are identical to those for the Caldwell-Luke operation. With this surgery, you can access the nasopharynx, for example, to remove the fibroids of the base of the skull. According to VV Shapurov (1946), this operational approach has another purpose: a wide opening of the maxillary sinus with resection of the pear-shaped sinus edge creates conditions for the occlusion in the sinus of the soft tissues of the cheek and, therefore, for partial or complete obliteration, which leads to a radical cure, of course, at the cost of the remaining cosmetic defect of the face. From the toolkit there is a great need for bone forceps. This operation, as well as the previous one, consists of a number of steps:

1. the incision is extended by 1 cm beyond the bridle of the upper lip;
2. expose the pear-shaped opening and separate the soft tissues with the periosteum from the anterior parts of the lateral wall of the nose and from the anterior wall of the maxillary sinus;
3. chisels or bone pincers remove the edge of the pear-shaped aperture, part of the anterior wall of the maxillary sinus and part of the lateral wall of the nose located behind the inferior nasal shell; after sufficient opening of the maxillary sinus through the anterior medial angle, all other steps are performed as in the Caldwell-Luke operation.

With this method, direct visibility of all the bunches of the maxillary sinus with the help of a frontal reflector is difficult, for this purpose it is possible to use video fiber optics with an image output to the monitor screen; With the help of this technique it is also possible to carry out a sinus audit by the endoscopic method.

The Canfeld-Navigator operation provides for an intranasal method of opening the maxillary sinus. This method was developed by many other authors, but in previous years it was not widely used because of limited view of the maxillary sinus, high bleeding and the need in most cases to resect the anterior part of the inferior nasal shell.

Anesthesia - application in the region of the lateral wall of the nose and in the region of the lower nasal passage, infiltration anesthesia in the same area. Sin opening is carried out through the lateral wall of the nose at the level of the lower nasal passage. In the presence of modern means, this operation can be performed by video-surgical method with a minimal opening and the condition of small pathological changes in the maxillary sinus.