Surgical treatment of chronic frontitis

Surgical treatment of chronic frontal sinusitis has the following objectives: opening of the frontal sinus in sufficient for its revision limits, removal of the pathologically altered mucosa and other pathomorphological formations (granulation tissue, polyps, necrotic areas of bone tissue, etc.), revision of the physiological or the formation of a new frontal-nasal persistent anastomosis to provide drainage and ventilation function of the frontal sinus. In the presence of concomitant diseases in other paranasal sinuses - one-stage surgical sanation. In all cases of the formation of a new frontal-nasal anastomia, medial laxation of the anterior end of the central nasal shell is shown and the removal of all periinfundibular cells of the latticed labyrinth, which enables the functioning of the natural canal, and also facilitates the process of forming a new frontal-nasal anastomosis.

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Surgery for chronic frontitis

All accesses in the surgical treatment of chronic frontal sinus are divided into external obstructive (trepanation of the anterior wall of the frontal sinus and Ogston-Luke, according to Kuntu - total resection of the anterior wall of the frontal sinus, the superciliary arbor and the inferior frontal sinus wall with invagination of the cutaneous flap on the posterior frontal sinus wall) ; external supraorbital (trepanation of the inferior wall of the frontal sinus according to Jansen-Jacques); (removal of the bone mass in front of the frontal-nasal canal with a preliminary insertion into the last curved point-like Houle-Wakke-Denis reference probe.) A number of other methods for opening the frontal sinus are in essence modifications of the methods listed above.It should be noted that the operation of the Kunta At present, it is not applied because of her traumatism and the resulting cosmetic defect.

The outer way of Ogston - Lucas

This operative access to the opening of the frontal sinus is a kind of analogue of the Caldwell-Luke operation for the maxillary sinus. Abroad, this method is most popular due to its delicacy, low traumatism, good access to the "interior" of the sinus, the presence of clear indications for its use and good care for the postoperative cavity.

Indication: ineffectiveness of non-surgical treatment (trepanopuncture, antibiotic therapy, decongestants, etc.); impossibility of endonasal drainage of the frontal sinus through the natural frontal-nasal canal; chronic frontal sinusitis with multichamber frontal sinus structure, polyposis frontitis, posttraumatic frontal sinus, presence of fragments of bones and foreign bodies of traumatic origin in frontal sinus, orbital complications, acute meningoencephalitis as complication of chronic frontitis, syphilitic frontal bone gum, etc.

Contraindications: acute uncomplicated frontitis, children under 14 years of age, common systemic diseases, which are a temporary or permanent contraindication to any surgical intervention. The question of surgical intervention in the frontal sinus for vital indications in the presence of certain contraindications is solved in accordance with a specific clinical case and weighing the degrees of risk.

Preoperative preparation is typical, described for the operation of Caldwell-Luke.

Infiltratioznaya anesthesia includes regional and local.

Regional anesthesia:

• anesthesia of the frontal nerve by infiltrating 3-5 ml of a 1% solution of novocaine into the area of the brow, somewhat inside from its middle; A 3 cm long needle is inserted before contact with the upper wall of the orbit;
• anesthesia of nerve lattice branches of the internal nasal nerve; The needle is injected 1 cm above the inner commissure of the eye to a depth of 2 cm before contact with the bone and after the test for the absence of needle entry into the blood vessel 3 ml of 1% solution of novocaine is administered.

Local anesthesia consists of abundant intradermal and subcutaneous infiltration of 1% novocaine with the area of the brow and surrounding tissues, the area of which should exceed the dimensions of the incision, including covering the skin 3-4 cm below the root of the nose. The procedure of anesthesia is completed with a deep application anesthetic of the corresponding half of the nose in the area of the funnel, the central nasal concha, the high parts of the septum and the olfactory gap.

Operative technique. "Simple trepanation" (by E.Eskat's definition) of the frontal sinus consists of 5 stages.

1. A one-stage incision of the skin and periosteum along the entire length of the superciliary artery is performed; carry out hemostasis by ligation of vessels or their thermocoagulation; protect the eye with a gauze pad; Separate the soft tissues together with the periosteum with a straight, wide chisel, exposing the frontal hillock and the anterior wall of the frontal sinus; expand the bone area with the help of hooks or two expanders of Jansen.
2. Treating the frontal sinus with the help of a grooved chisel or gouged chisel Voyachek, otsunya 1 cm out from the middle line; expand and smooth out the edges of the bone wound with the help of bone nippers or by gradual, small shaving, cutting the edges of the bone wound with the help of Voyatchek's chiseled chisels.
3. Examine the sinus cavity, determine the zones of pathological changes in the mucosa and the presence of pathological tissues; produce cavity of the cavity, especially cautiously in the interstitial septum, which can consist of only one duplicate of the mucous membrane, so as not to infect the opposite sinus if it is not infected; Curettage should be performed cautiously and in the area of the sinus wall; at the conclusion of the sinus revision, G.Laurens recommends that a temporary sinus tamponade be performed in the upper region of the environment.
4. The frontal-nasal drainage canal is formed; in the lower inner corner of the sinus find the upper opening of the natural frontal-nasal canal and inject into it an acute spoon with a diameter of no more than 5 mm on a long handle and produce a cautious curettage of the canal, while the sharp edge of the spoon is not directed toward the orbit to damage its walls.

The movements of the instrument are directed inward, anteriorly, posteriorly, downward, upward, destroying the tissues of the natural frontal nasal canal and the surrounding cells of the latticed bone to a size that allows the tip of the little finger to be inserted into the opening. Since this stage is accompanied by significant bleeding, it is advisable to carry out a posterior tamponade of the nose before its implementation to prevent blood from entering the pharynx and the larynx. After the formation of the artificial frontal-nasal canal, remove the temporary tampon from the sinus (see the third stage) and produce a loose frontal sinus tamponade for Mikulich, starting from the far corners of the sinus, laying the tampon in the form of an accordion so that its removal does not cause jamming in the channel other parts of the tampon. The end of the tampon is inserted into the upper (axillary) orifice of the canal with the aid of the nasal coronzanga and is reduced to the nasal cavity, from which it is withdrawn and fixed with a cotton-gauze anchor at the nostril on whose side the operation was performed. The other half of the nose is left loose. Then, remove the cholangal tampon (see step 4 of the operation).

5. Sew the skin wound 3-4 seams with an atraumatic needle with laying under the seams of the gauze bead. Sutures are removed on the 6th day after the operation. The operation is completed by the imposition of a sling and frontal bandages.

Frontal-orbital folding of the frontal sinus according to Kimshan

This method was most widely spread in the 20th century, because it combines such positive qualities as a broad approach to the operated area with the possibility, if necessary, of opening almost all the cells of the latticed maze and even the sphenoid sinus, adherence to the principles of total removal of pathologically altered tissues and a good cosmetic result , the creation of an optimal frontal-nasal artificial canal with a sufficiently effective technique for its preservation. With this method, there is the possibility of one-stage operation of another frontal sinus through the interstitial septum, without resorting to a second frontotomy. As AS Kiselev (2000) notes, this operation is preferable for medium and especially large frontal sinuses. Indications and contraindications are the same as in the Ogston-Luke method. VV Shapurov (1946) singles out the following testimony to Killian's operation on the frontal sinus:

1. chronic empyema of the frontal sinus with destruction of the bone walls, especially the cerebral wall;
2. frontal sinusitis recurring many times or not after other surgical interventions;
3. swelling of the frontal sinus;
4. foreign bodies as a result of injuries of the frontal sinus;
5. intracranial complications of acute and chronic purulent frontitis.

Anesthesia. Both local and general anesthesia are used, depending on the indications and contraindications. At present, in the absence of contraindications, all operative interventions on the paranasal sinuses are performed under general anesthesia.

Operative technique. The name of the operation (front-orbital trepanation of the frontal sinus or ophthalmic-facial frontotomy) is due to the fact that in this operative intervention, the facial wall of the frontal sinus and its orbital wall is opened, while the Killian's bone bridge is maintained between the holes in these walls, providing as a "rafters" physiological form of the frontal-orbital region. Technically, the classical operation on the frontal sinus for Killian involves several stages.

1. Single-cut incision of the skin and periosteum of soft tissues along the line, along the eyebrows from the outer edge of the soft tissue, but arcuate, but lateral surface of the external nose to the nasolabial fold (edge of the pear-shaped hole). A.S. Kiselev (2000) recommends not to make an incision of the periosteum in the region of the upper medial edge of the orbit. Before the cut VV Shapurov recommends to apply perpendicularly to the line of the future incision the guiding incisions only to the depth of the epidermis, which are necessary for cosmetically correct matching of the edges of the wound during its final sewing. Hemostasis.
2. Separation of soft tissues along the incision line upward from the upper edge of the orbit by 1-1.5 cm without detachment of the periosteum, with special attention to the periosteum at the upper medial angle of the eye remaining attached to the bone. This condition is necessary for normal nutrition of the future bone-periosteal flap.
3. The incision of the periosteum is parallel to the first incision 0.5-1 cm above it. This denotes the boundaries of the future Killian bridge.
4. Detachment of the periosteum up from its incision and exposure of the cortical layer of the front surface of the frontal bone.
5. Trepanation of the anterior wall of the frontal sinus, which is produced either by a grooved chisel, or by "flailing" the cortex and removing the spongy bone chips with the help of Voyatchek's chiseled chisels. The opening is initially small and serves to determine the size and contents of the sinus and the orientation of the upper edge of the future bridge.
6. Expansion of the trepanation hole in the facial wall of the frontal sinus is performed with the help of instruments convenient for this purpose (Geyek's nippers, bone forceps, Voyachek chisels, etc.). The dimensions of the orifice are commensurate with the volume of the sinus and its contents (polyps, cholesteatoma, granulation, tumor), the pathological condition of its walls (osteomyelitis, the presence of sequestration and fistula), the nature of the pathological process, and depending on these indicators, it is sometimes necessary to remove the entire facial wall of the frontal sinus .
7. According to Killian, the next step was the scraping of the entire contents of the frontal sinus. At present, such a radical approach to the mucous membrane of the frontal sinus is unacceptable. The attitude towards it is dictated by the considerations set forth in the description of the Caldwell-Luke operation. With intracranial complications (extra- and subdural abscess, frontal lobe abscess, meningoencephalitis, etc.), surgical intervention takes on an extended character and is determined by the type of intracranial pathological process.
8. The detachment of the periosteum is below the edge of its incision along the line, retaining the intact periosteum attached to the bone between slits 2 and 3. The detachment is made on the inferior (orbital) wall of the frontal sinus and on the lateral surface of the external nose. This detachment is made only on the inner third of the surface of the orbital wall, so as not to damage the tendon of the upper oblique muscle, which is attached more to the outside. On the lateral surface of the external nose, the excision of the periosteum is made up to the upper margin of the pit of the lacrimal sac. During the 8th stage, the eyes are protected by applying gauze napkins to it and a teaspoon that is acceptable in size. When trepanation, the bones should be careful with the paper plate.
9. Trepanation of the inferior wall of the frontal sinus begins below the incision of the periosteum in such a way as to designate the lower edge of the bridge, and continue along the frontal process of the upper jaw until it penetrates the nasal cavity. The reference point with the removal of the bone by a narrow grooved chisel is a buttoned probe inserted from the side of the sinus to the bridge through the frontal-nasal canal into the nasal cavity. Through the hole made in the bone and the mucous membrane of the nose in the posterior medial direction, it is possible, if necessary, to open the cells of the latticed labyrinth, taking care with respect to the trellis and paper plates. This same access can be opened and the sphenoid sinus.
10. Layer stitching of the wound, lower layers of catgut, skin - atraumatic needle when comparing the guide incisions.
11. The final stage of the operation is the application of a drain tube either from rubber or from a polymer material. The upper end of the tube should be at the level of the frontal sinus, if it is set higher, then on the side walls of that segment of the tube that is in the sinus, the windows are cut out so that the accumulating exudate and blood drain into the tube and are released through its lower end. The last one, extending 1 cm beyond the threshold of the nose, is stitched, tied with a silk thread and fixed to the head so that the tube does not fall out of the postoperative cavity. They impose a sling-like bandage. On the second day, the sinus is washed with an antiseptic solution, an antibiotic solution is injected into it, it is also possible to use infusion of celandine, St. John's wort, chamomile, rhodiola and other herbal preparations that promote reparative and regenerative processes in the frontal sinus. The tube is removed after 3 weeks.

Postoperative treatment. The nature of postoperative treatment is determined by the initial state of the sinus, i.e., pathological changes that appeared as indications for surgical intervention, the volume of the latter and the state of the postoperative cavity, the presence or absence of complications, including orbital and intracranial, and also used in this medical institution methodology. As a rule, with uncomplicated purulent frontitis without lesion of bone tissue from partially preserved mucosa, postoperative treatment is limited to parenteral administration of antibiotics and daily washing of the frontal sinus with one of the above solutions. In complicated cases (osteomyelitis of the frontal bone, destruction of the cerebral wall, phlegmon of the orbit, etc.), the wound is opened: daily washing with an antibiotic solution, changing its composition, loosely wrapped with a swab impregnated with solcoseryl gel or another reparant until the wound is cleansed from necrotic tissues and there will not appear normal granulations, which are the first sign of wound healing. Later, the wound is gradually filled with granulation tissue, while at the edges of the incision is formed scar tissue, which tightens them inside the cavity.

If this process is provided to the spontaneous flow, then a retracted, cosmetically inconsistent scar is formed. Therefore, if the raya is completely filled with a granulation tissue, the edges are refreshed with incisions, the scar tissue is excised and secondary seams are applied, leaving a rubber graduate for a few days in the lateral corner of the wound. To prevent obliteration of the artificial frontal-nasal canal after extraction of the tube, the granulation appearing in it is plucked or removed with a sharp spoon, or cauterized with silver nitrate, and also bougie with the help of Ritter's frontal probes. This stage of postoperative management of the patient is the most time-consuming and responsible, since the overwhelming majority of relapses of chronic frontitis and repeated operations are due to the infection of the frontal-nasal canal. This process is also facilitated by the individual ability of the tissues of some individuals when they are injured to massive and gross scarring. To prevent constriction and obliteration of the fronto-nasal canal in the postoperative period, many techniques were proposed with the use of inert polymeric materials, numerous allo- and heteromaterials, various ways of bougieering and curettage. However, as is always the case, the successful result was noted in most cases only when the method was applied by the author himself.

In this regard, our attention was drawn to the method developed in the clinic of V.T. Palchun by Gerarr Shager (1990), based on the use as a prosthesis for the fronto-nasal canal of a lyophilized artery reinforced from the inside by an alloy of titanium nickelide with a so-called structural memory in the form spiral tube. Chilled to +10 ° C, this spiral is easily stretched into a strip and in this form is inserted into the lumen of the lyophilized artery and is strengthened by catgut sutures in the prefabricated bed of the frontal-nasal canal in the form of a "drainage-graft". Heating to body temperature, the metal strip again takes the form of a spiral and reinforces the walls of the artery, not allowing them to subside. Further care for the sinister and sinus is carried out in the usual manner. After 30 days, the metal reinforcing spiral is removed, previously washing the frontal-nasal canal with a cooled antiseptic solution. Cooling the spiral gives it plastic properties, and it is easily removed by tweezers or forceps, stretching into the strip, leaving behind a well-formed suture, the walls of which acquire the necessary elasticity due to the formation of connective tissue in place of the lysed artery.

Cirrhotic dissection of the frontal sinus according to NVBelogolov. NVBelogolov called his method "Halle up," that is, as VP Shapurov (1946) writes, "... What Halle does with an intranasal scarech, according to Belogolovov, is done from the outside, but accessibility, visibility sinuses, safety of operation, simplicity is more preferable than the operation of Halle. " It is likely that under the current conditions, with the increasingly widespread use of microvideo endosurgery, the Halle's endonasal method may again acquire the status of a "method of choice" under certain conditions, for example, when the patient (mainly female) objects to the external cut.

The indications are the same as in the surgical intervention for Killian. As AS Kiselev (2000) notes, "This operation is one of the most gentle variants of the frontotomy and is especially effective in small sinuses when there is no need for an expanded trepanation of the bone walls. The originality of this is to remove the bone mass from the side of the pear-shaped hole, which greatly facilitates the technique. "

Operational techniques include the following steps.

1. Supernumerary incisions for correct matching of the edges of the wound when applying sutures. Arcuate section of Killian; stop bleeding.
2. Detachment of soft tissues and periosteum.
3. Trepanation of the orbital wall of the frontal sinus (see step 9 of the Killian operation).
4. Frontal sinus examination through an enlarged opening in the entire lower wall, especially effective in the video-surgical method. Removal of pathological contents from the sinus. Temporary tamponade.
5. A feature of the method of Belogolov is that the opening of the frontal-nasal canal is made from the side of the pear-shaped aperture, for which in the frontal process of the upper jaw a groove is cut parallel to the suture between the appendage and the nasal bone. The bone is removed to the nasal mucosa throughout the entire bone gap, and the mucous membrane is not injured.
6. From this mucosa, forming a septum between the bone gap and the nasal cavity, a special flap is cut out for laying it on the edge of the bone wound. To do this, make a section of the mucosa at the anterior or posterior edge of the groove-groove and an additional cross-section at the bottom. The formed flap easily reclines to the edge of the bone wound.
7. Through the nose in the frontal sinus insert a final rubber or other material tube, while trying not to dislodge the flap and ensure its fixation with this tube.
8. Stitches on the wound, bandages. The postoperative treatment is practically the same as that of the Killian operation. Drainage is removed after 2-3 weeks. If a lyophilized artery reinforced with a metal spiral is used, the spiral is removed after 30 days.

The eye in the morning and in the evening wipe with a cotton ball moistened in a 3% solution of boric acid, after that 1-2 drops of 1% solution of collargol or 20% solution of sulfacyl-sodium are injected into the conjunctival bag. After removal of the drainage, the condition of the artificial frontal-nasal canal is monitored and, if necessary, by medium rhinoscopy or visoscopy, some manipulations are made to prevent its obliteration (removal of granulations, bougie with Ridder builder, cauterization of 20% silver nitrate solution, etc.).

Endonasal method of opening the frontal sinus of the latticed labyrinth in Halle

Before the introduction of the endoscopic video endosurgical method into the practice of domestic rhino surgeons, Halle's method was not widely used due to technical difficulties that arise when operating in a narrow endonasal space. However, this operational access is not particularly difficult if the nasal cavity on the operable side is wide and the anteroposterior size of the frontal sinus is sufficiently large (according to the lateral radiography of the skull). Nevertheless, if it is not possible to introduce a curved probe in the frontal sinus through natural anastomosis, then, as V.Shapurov advises (1946), it is necessary to abandon the Halle method and switch to the external method. Introduced in a natural suture probe is a necessary guide for performing the bone phase of this endonasal operation. In modern conditions, the use of the method of endoscopic surgery based on the Halle method, especially when the patient objects to the external incision, acquires a certain urgency.

Indications: simple chronic empyema of the frontal sinus, unilateral frontoethmoiditis.

Operational techniques include the following stages of the operation.

1. Cutting out the mucosa from the side wall of the nose located in front of the middle nasal concha, the quadrangular flap by the U-shaped notch to the bone and cutting it back and down to the level of the anterior end of the inferior nasal shell; the introduction into the fronto-nasal canal of the trigger probe, which serves as the main reference point for the bone part of the operative intervention.
2. Churning with a grooved chisel or drilling a bony bony protrusion (agger nasi), located in front of the probe, orienting all the time to the position of the latter. With the help of a chisel or cutter, a groove forms from the edge of the pear-shaped opening to the bottom of the frontal sinus.
3. With the help of these same tools perforate the bottom of the frontal sinus and expand it to the size that allows to hold a narrow sharp spoon (flexible) or curette in the frontal sinus. When using video-fiber technology, a sinus examination is performed.
4. The mucous membrane of the frontal sinus is scraped blindly with the above instruments until the bleeding ceases, and those parts of the mucous membrane that have not undergone profound pathomorphological changes and are capable of rehabilitation, and even a healthy mucosa, are naturally destroyed. With the video-surgical method of surgery, the procedure for removing the pathological contents of the sinus is extremely gentle and helps to reduce the postoperative period, the development of reparative processes due to the preserved islets of the normal mucosa, capable of regeneration and coating of the bare bone. When scraping blindly, the "sense of the instrument" acquires great importance, with which the surgeon determines the density, consistency, volume, and other qualities of the tissue to be removed by touch. In this case, special care should be taken when acting in the region of the orbital and cerebral walls of the frontal sinus. At the end of the curettage, a narrow dry tampon is introduced into the frontal sinus and, with its help, the sinus is finally cleaned of the remnants of unremoved pathological fragments and blood.
5. A flap, cut from the mucosa, is placed in a bed formed earlier in the bone so that it forms its covering.
6. The operation is completed by insertion into the frontal sinus through the hole in the drainage tube made in it so that its end is located in the cavity of the sinus, towering over its bottom by 4-6 mm. This is achieved by an appropriate external measurement, in which the tube is applied to the face so that its lower end is below the edge of the nostril by 1 cm, and the upper one is higher by 0.5 cm of the brow. In the walls of the upper end of the tube, 2-3 small windows are cut out, 2-3 mm in diameter, for more effective drainage of the sinus. The tube from the side of the nasal cavity is fixed with a swab, which is not necessary if its outer end is taken on the ligature and fixed to the head with a silk thread. In this case, on the threshold of the nose around the tube, set the cotton filters and apply a bandage bandage.

Postoperative management of the patient - as in the operation of Belogolovov.

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