Surgical treatment of chronic frontitis

Surgical treatment of chronic frontal sinusitis has the following goals: opening the frontal sinus to the extent necessary for its revision, removal of pathologically altered mucous membrane and other pathomorphological formations (granulation tissue, polyps, necrotic areas of bone tissue, etc.), revision of the physiological or formation of a new persistent frontonasal anastomosis to ensure drainage and ventilation function of the frontal sinus. In the presence of concomitant diseases in other paranasal sinuses - their one-stage surgical sanitation. In all cases of formation of a new frontonasal anastomosis, medial luxation of the anterior end of the middle nasal concha and removal of all periinfundibular cells of the ethmoid labyrinth are indicated, which ensures the possibility of functioning of the natural canal, and also facilitates the process of formation of a new frontonasal anastomosis.

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Operations for chronic frontal sinusitis

All approaches in surgical treatment of chronic frontal sinusitis are divided into external transfrontal (trepanation of the anterior wall of the frontal sinus according to Ogston-Luc, according to Kunt - total resection of the anterior wall of the frontal sinus, superciliary arch and inferior wall of the frontal sinus with invagination of the skin flap to the area of the posterior wall of the frontal sinus); external transorbital (trepanation of the inferior wall of the frontal sinus according to Jansen-Jacques); transnasal (removal of the bone mass in front of the frontonasal canal with preliminary insertion into the latter of a curved button-shaped probe-guide according to Halle-Wacquet-Denis. Many other methods of opening the frontal sinus, in fact, are modifications of the above methods. It should be noted that Kunt's operation is currently not used due to its traumatic nature and the cosmetic defect that arises after it.

External Ogston-Luke method

This surgical approach to opening the frontal sinus is a kind of analogue of the Caldwell-Luc operation for the maxillary sinus. Abroad, this method is most popular due to its delicacy, low trauma, good access to the "interior" of the sinus, the presence of clear indications for its use and good conditions for caring for the postoperative cavity.

Indications: ineffectiveness of non-surgical treatments (trepanopuncture, antibiotic therapy, decongestants, etc.); impossibility of endonasal drainage of the frontal sinus through the natural frontonasal canal; chronic frontal sinusitis with a multi-chamber structure of the frontal sinus, polypous frontal sinusitis, post-traumatic frontal sinusitis, the presence of bone fragments and foreign bodies of traumatic origin in the frontal sinus, orbital complications, acute meningoencephalitis as a complication of chronic frontal sinusitis, syphilitic gumma of the frontal bone, etc.

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

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

Infiltration anesthesia includes regional and local.

Regional anesthesia:

• anesthesia of the frontal nerve by infiltration of 3-5 ml of 1% novocaine solution into the area of the superciliary arch slightly inward from its middle; a 3 cm long needle is inserted until it touches the upper wall of the orbit;
• anesthesia of the ethmoidal nerve branches of the internal nasal nerve; the needle is inserted 1 cm above the internal commissure of the eye to a depth of 2 cm until contact with the bone and after testing for the absence of the needle entering a blood vessel, 3 ml of 1% novocaine solution is injected.

Local anesthesia consists of abundant intradermal and subcutaneous infiltration with 1% novocaine solution of the superciliary arch and surrounding tissues, the area of which should exceed the size of the incision, including covering the skin 3-4 cm below the root of the nose. The anesthesia procedure is completed by deep application anesthesia of the corresponding half of the nose in the area of the funnel, middle nasal concha, high parts of the nasal septum and olfactory cleft.

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

1. A single-stage incision is made in the skin and periosteum along the entire length of the superciliary arch; hemostasis is achieved by ligating the vessels or by thermocoagulating them; the eye is protected with a gauze pad; the soft tissues are separated together with the periosteum using a straight wide chisel, exposing the frontal tubercle and the anterior wall of the frontal sinus; the bone surface is expanded using hooks or two Jansen expanders.
2. The frontal sinus is trepanned using a grooved chisel or grooved Voyachek chisels, moving 1 cm outward from the midline; the edges of the bone wound are widened and smoothed using bone nippers or by gradually cutting off the edges of the bone wound with small shavings using grooved Voyachek chisels.
3. The sinus cavity is examined, areas of pathological changes in the mucous membrane and the presence of pathological tissues are determined; curettage of the cavity is performed, especially carefully in the area of the intersinusal septum, which may consist of only one duplication of the mucous membrane, so as not to introduce infection into the opposite sinus if it is not infected; curettage should be performed carefully in the area of the medullary wall of the sinus; upon completion of the revision of the sinus, G. Laurens recommends performing temporary tamponade of the sinus in the upper outer region.
4. A frontonasal drainage canal is formed; in the lower inner corner of the sinus, the upper opening of the natural frontonasal canal is found and a sharp spoon with a diameter of no more than 5 mm on a long handle is inserted into it and careful curettage of the canal is performed, while the sharp edge of the spoon is not directed towards the eye socket so as not to damage its walls.

The instrument is moved inwards, forwards, backwards, downwards, upwards, destroying the tissues of the natural frontal-nasal canal and the surrounding ethmoid bone cells to a size that allows the tip of the little finger to be inserted into the hole made. Since this stage is accompanied by significant bleeding, it is advisable to perform a posterior nasal tamponade before its implementation to prevent blood from entering the pharynx and larynx. After the artificial frontal-nasal canal is formed, the temporary tampon is removed from the sinus (see stage 3) and a loose tamponade of the frontal sinus is performed according to Mikulich, starting from the far corners of the sinus, placing the tampon in the form of an accordion so that its removal does not cause other parts of the tampon to jam in the canal. The end of the tampon is inserted into the upper (sinus) opening of the canal using nasal forceps and lowered into the nasal cavity, from where it is brought out and fixed with a cotton-gauze anchor at the nostril on the side where the operation was performed. The other half of the nose is left free. Then the choanal tampon is removed (see stage 4 of the operation).

5. The skin wound is sutured with 3-4 stitches using an atraumatic needle, with a gauze roll placed under the stitches. The stitches are removed on the 6th day after the operation. The operation is completed by applying a sling and forehead bandage.

Fronto-orbital trepanation of the frontal sinus according to Kimshan

This method has become most widespread in the 20th century, since it combines such positive qualities as a wide approach to the operated area with the possibility, if necessary, of opening almost all the cells of the ethmoid labyrinth and even the sphenoid sinus, adherence to the principles of total removal of pathologically altered tissues and a good cosmetic result, creation of an optimal frontonasal artificial canal with a fairly effective method of preserving it. With this method, there is the possibility of simultaneous operation of the other frontal sinus through the intersinusal septum, without resorting to a second frontotomy. As A.S. Kiselev (2000) notes, this operation is preferable for medium and especially large frontal sinuses. Indications and contraindications are the same as for the Ogston-Luke method. V.V. Shapurov (1946) identifies the following indications for the Killian operation on the frontal sinus:

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

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

Surgical technique. The name of the operation (fronto-orbital trepanation of the frontal sinus or orbitofacial frontotomy) is due to the fact that during this surgical intervention the facial wall of the frontal sinus and its orbital wall are opened while preserving the Killian bone bridge between the openings in these walls, which provides the physiological shape of the fronto-orbital region as a "rafter". Technically, the classic operation on the frontal sinus according to Killian involves several stages.

1. A single-stage incision of the skin and periosteum of soft tissues along the line, along the eyebrow from its outer edge, arched, but the lateral surface of the external nose to the nasolabial fold (edge of the piriform opening). A.S. Kiselev (2000) recommends not to make an incision of the periosteum in the area of the superomedial edge of the orbit. Before the incision, V.V. Shapurov recommends making perpendicular guide notches to the line of the future incision only to the depth of the epidermis, necessary for cosmetically correct matching of the edges of the wound during its final suturing. Hemostasis.
2. Separation of soft tissues along the incision line upwards from the upper edge of the orbit by 1-1.5 cm without detachment of the periosteum, with special attention to ensuring that the periosteum at the superomedial angle of the eye remains attached to the bone. This condition is necessary for normal nutrition of the future bone-periosteal flap.
3. An incision of the periosteum parallel to the first incision, 0.5-1 cm above it. This marks the boundaries of the future Killian bridge.
4. Detachment of the periosteum upward from its incision and exposure of the cortical layer of the facial surface of the frontal bone.
5. Trepanation of the anterior wall of the frontal sinus, which is performed either with a grooved chisel or by "plowing" the cortex and removing spongy bone chips using Voyachek grooved chisels. The opening is initially small in size and serves to determine the size and contents of the sinus and orientation in relation to the upper edge of the future bridge.
6. The expansion of the trepanation hole in the facial wall of the frontal sinus is performed using convenient instruments (Haek's nippers, bone forceps, Voyachek chisels, etc.). The size of the hole is measured by the volume of the sinus and its contents (polyps, cholesteatoma, granulation, tumor), the pathological condition of its walls (osteomyelitis, presence of sequesters and fistulas), the nature of the pathological process, and depending on these indicators, sometimes it is necessary to remove the entire facial wall of the frontal sinus.
7. According to Killian, the next stage was scraping out all the 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 out in the description of the Caldwell-Luc operation. In case of intracranial complications (extra- and subdural abscess, frontal lobe abscess, meningoencephalitis, etc.), the surgical intervention acquires an extended character and is determined by the type of intracranial pathological process.
8. The periosteum is detached below the edge of its incision along the line, preserving the periosteum attached to the bone between incisions 2 and 3 intact. The detachment is performed on the lower (orbital) wall of the frontal sinus and on the lateral surface of the external nose. The said detachment is performed only on the inner third of the surface of the orbital wall, so as not to damage the tendon of the superior oblique muscle, which is attached more outwardly. On the lateral surface of the external nose, the periosteum is separated to the upper edge of the fossa of the lacrimal sac. During stage 8, the eye is protected by applying gauze napkins and a teaspoon of suitable size to it. During bone trepanation, care is taken with respect to the paper plate.
9. Trepanation of the lower wall of the frontal sinus begins below the incision in the periosteum so as to mark the lower edge of the bridge, and continues along the frontal process of the maxilla until it enters the nasal cavity. A button probe inserted from the sinus side under the bridge through the frontonasal canal into the nasal cavity serves as a guide when removing the bone with a narrow grooved chisel. Through an opening made in the bone and mucous membrane of the nose in the posteromedial direction, it is possible, if necessary, to open the cells of the ethmoid labyrinth, being careful with respect to the ethmoid and paper plates. The sphenoid sinus can also be opened through the same approach.
10. Layer-by-layer suturing of the wound, the lower layers with catgut, the skin with an atraumatic needle while matching the guide notches.
11. The final stage of the operation is the application of a drainage tube made of either rubber or polymer material. The upper end of the tube should be at the level of the bottom of the frontal sinus, but if it is installed higher, then windows are cut on the side walls of the section of the tube that is in the sinus so that the accumulating exudate and blood flow into the tube and are released through its lower end. The latter, extending 1 cm beyond the nasal vestibule, is stitched, tied with a silk thread and fixed to the head so that the tube does not fall out of the postoperative cavity. A sling bandage is applied. On the second day, the sinus is washed with an antiseptic solution, an antibiotic solution is introduced into it, it is also possible to use infusions 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 condition of the sinus, i.e. pathological changes that were used as indications for surgical intervention, the volume of the latter and the condition of the postoperative cavity, the presence or absence of complications, including orbital and intracranial, as well as the technique used in a given medical institution. As a rule, in uncomplicated purulent frontal sinusitis without damage to bone tissue with partially preserved mucous membrane, postoperative treatment is limited to parenteral administration of antibiotics and daily lavage of the frontal sinus with one of the above solutions. In complicated cases (osteomyelitis of the frontal bone, destruction of the cerebral wall, orbital phlegmon, etc.), the wound is treated openly: daily rinsing with an antibiotic solution, changing its composition, loosely tamponed with a tampon soaked in solcoseryl gel or another reparant until the wound is cleared of necrotic tissue and normal granulations appear in it, which are the first sign of wound healing. Subsequently, the wound is gradually filled with granulation tissue, while scar tissue is formed along the edges of the incision, drawing them into the cavity.

If this process is left to its own devices, a retracted, cosmetically insolvent scar is formed. Therefore, when the area is sufficiently filled with granulation tissue, the wound edges are refreshed with incisions, the scar tissue is excised, and secondary sutures are applied, leaving a rubber drain in the lateral corner of the wound for several days. To prevent obliteration of the artificial frontal-nasal canal after the tube is removed, the granulations that appear in it are pinched or removed with a sharp spoon, or cauterized with silver nitrate, and also bougienaged with Ritter frontal probes. This stage of postoperative patient management is the most labor-intensive and responsible, since the overwhelming majority of relapses of chronic frontal sinusitis and repeated operations are caused by the overgrowth of the frontal-nasal canal. This process is also facilitated by the individual ability of tissues in some people to massive and rough scarring when they are injured. To prevent narrowing and obliteration of the frontonasal canal in the postoperative period, many methods have been proposed using inert polymeric materials, numerous allo- and heteromaterials, various methods of bougienage and curettage. However, as is always observed, a successful result was noted in most cases only when one or another method was used by the author himself.

In this regard, our attention was drawn to the method developed in the V. T. Palchun clinic by Gerard Schager (1990), based on the use of a lyophilized artery reinforced from the inside with titanium nickelide alloy, which has the so-called structural memory, in the form of a spiral tube as a prosthesis for the frontal-nasal canal. Cooled 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, as a "drainage graft", is strengthened with catgut sutures in a pre-prepared bone bed of the frontal-nasal canal. Heating to body temperature, the metal strip again takes on the shape of a spiral and reinforces the walls of the artery, preventing them from collapsing. Further care of the anastomosis and sinus is carried out in the generally accepted manner. After 30 days, the metal reinforcing spiral is removed, after first washing the frontal-nasal canal with a cooled antiseptic solution. Cooling the spiral gives it plastic properties, and it is easily removed with tweezers or forceps, stretching into a strip, leaving behind a well-formed anastomosis, the walls of which acquire the necessary elasticity due to the formation of connective tissue at the site of the lysed artery.

Transorbital opening of the frontal sinus according to N.V. Belogolovov. N.V. Belogolovov called his method "Halle's vzryachuyu", i.e., as V.P. Shapurov (1946) writes, "...what Halle does with an intranasal gun, Belogolovov does externally, but the accessibility, visibility of the sinus, safety of the operation, simplicity make it more preferable than the Halle operation." Probably, in modern conditions, with the increasingly widespread use of microvideoendosurgical technology, the endonasal Halle method can, under certain conditions, again acquire the status of "the method of choice", for example, if the patient (mainly a woman) objects to an external incision.

The indications are the same as for the Killian operation. As A.S. Kiselev (2000) notes, "This operation is one of the most gentle variants of frontotomy and is especially effective for small sinuses, when there is no need for extended trepanation of the bone walls. Its originality lies in the removal of the bone mass from the side of the piriform opening, which significantly simplifies the technique."

The operational technique includes the following stages.

1. Brow notches for proper alignment of wound edges when suturing. Killian arcuate incision; stopping bleeding.
2. Detachment of soft tissue and periosteum.
3. Trepanation of the orbital wall of the frontal sinus (see stage 9 of the Killian operation).
4. Revision of the frontal sinus through an enlarged opening in its lower wall, especially effective with the video surgical method. Removal of pathological contents from the sinus. Temporary tamponade.
5. The peculiarity of Belogolovov's method is that the opening of the frontal-nasal canal is performed from the side of the piriform opening, for which a groove is cut in the frontal process of the upper jaw parallel to the suture between the process and the nasal bone. The bone is removed to the mucous membrane of the nose along the entire length of the formed bone gap, while trying not to injure the mucous membrane.
6. A special flap is cut out from the said mucous membrane, which forms a partition between the bone gap and the nasal cavity, to place it on the edge of the bone wound. To do this, an incision is made in the mucous membrane along the anterior or posterior edge of the gap-groove and an additional transverse incision below. The resulting flap is easily folded back onto the edge of the bone wound.
7. A rubber or other material tube is inserted through the nose into the frontal sinus, trying not to displace the flap and ensuring its fixation with this tube.
8. Application of wound sutures, dressings. Postoperative treatment is practically no different from that in 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 is wiped in the morning and evening with a cotton ball soaked in a 3% solution of boric acid, after which 1-2 drops of a 1% solution of collargol or a 20% solution of sodium sulfacyl are introduced into the conjunctival sac. After the drainage is removed, the condition of the artificial frontal-nasal canal is monitored and, if necessary, certain manipulations are performed using the method of middle rhinoscopy or vidusoscopy to prevent its obliteration (removal of granulations, bougienage using Ridder bougies, cauterization with a 20% solution of silver nitrate, etc.).

Endonasal method of opening the frontal sinus of the ethmoid labyrinth according to Halle

Before the introduction of the endoscopic videoendosurgical method into practice by domestic rhinosurgeons, the Halle method was not widely popular due to technical difficulties arising during surgery in a narrow endonasal space. However, this surgical approach does not present any particular difficulties if the nasal cavity on the operated side is wide and the anteroposterior size of the frontal sinus is large enough (according to lateral skull radiography). Nevertheless, if it is not possible to insert a curved probe into the frontal sinus through the natural ostium, then, as V.V. Shapurov (1946) advises, it is necessary to abandon the Halle method and switch to the external method. The probe inserted into the natural ostium is a necessary reference point for performing the bone stage of this endonasal operation. In modern conditions, the use of the endoscopic surgery method based on the Halle method, especially when the patient objects to an external incision, is becoming somewhat relevant.

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

The surgical technique includes the following stages of the operation.

1. Cutting out a quadrangular flap from the mucous membrane of the lateral wall of the nose, located in front of the middle nasal concha, by making a U-shaped incision to the bone and separating it backwards and downwards to the level of the anterior end of the inferior nasal concha; inserting a button probe into the frontal-nasal canal, which serves as the main reference point during the bony part of the surgical intervention.
2. Knocking down with a grooved chisel or drilling out with a bur the bony protrusion (agger nasi) located in front of the probe, orienting all the time on the position of the latter. Using a chisel or cutter, form a groove from the edge of the pyriform opening to the bottom of the frontal sinus.
3. Using the same instruments, the bottom of the frontal sinus is perforated and expanded to a size that allows a narrow, sharp spoon (flexible) or curette to be inserted into the frontal sinus. Using video fiber technology, the sinus is examined.
4. The mucous membrane of the frontal sinus is scraped blindly with the above-mentioned instruments until the bleeding stops, and, naturally, those areas of the mucous membrane that have not undergone deep pathomorphological changes and are capable of rehabilitation, and even the healthy mucous membrane, are destroyed. With the video-surgical method of operation, 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 islands of normal mucous membrane capable of regeneration and covering the exposed bone. When blind scraping, the "feeling of the instrument" is of great importance, with the help of which the surgeon determines by touch the density, consistency, volume, and other qualities of the tissue being removed. In this case, special care should be taken when acting in the area of the orbital and cerebral walls of the frontal sinus. After completing the curettage, a narrow dry swab is inserted into the frontal sinus and used to finally cleanse the sinus of any remaining pathological fragments and blood.
5. A flap cut from the mucous membrane is placed in the previously formed bone bed so that it forms a covering.
6. The operation is completed by inserting a drainage tube into the frontal sinus through a hole made in it so that its end is in the sinus cavity, rising above its bottom by 4-6 mm. This is achieved by the appropriate external measurement, in which the tube is applied to the face so that its lower end is 1 cm below the edge of the nostril, and the upper end is 0.5 cm above the superciliary arch. In the walls of the upper end of the tube, 2-3 small windows are cut, 2-3 mm in diameter, for more effective drainage of the sinus. The tube is fixed on the side of the nasal cavity with a tampon, which is not necessary if its outer end is taken on a ligature and fixed to the head with a silk thread. In this case, cotton filters are installed in the vestibule of the nose around the tube and a sling-like bandage is applied.

Postoperative care of the patient is the same as for the Belogolovov operation.

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