Chronic sphenoiditis

Chronic sphenoiditis (chronic inflammation of the sphenoid sinus, chronic inflammation of the main sinus, chronic sphenoidal sinusitis (sinusitis sphenaiditis chronica).

"Chronic inflammation of the sphenoid sinus - sphenoiditis - refers to diseases, the diagnosis of which often causes significant difficulties. The location of the sinus in the deep sections of the skull base, which are important in functional terms, as well as the involvement of adjacent paranasal sinuses in the inflammatory process, contribute to the appearance of an indistinct, worn out clinical symptomatology, which complicates the diagnosis. The position of the well-known otorhinolaryngologist SAProkuryakov (1939), who believes that the diagnosis of "sphenoiditis" should mature in the head of the doctor himself, does not lose relevance in our time, which requires a lot of time, experience and skill. This, apparently, explains the significant percentage of autopsy detection of cases of chronic sphenoiditis not established during life, which underlines the "reputation" of the sphenoid sinus as a "forgotten" sinus.

Chronic sphenoiditis is a chronic inflammation of the mucous membrane of the sphenoid sinus, resulting from ineffective treatment of acute sphenoiditis, estimated at 2-3 months. It is during this period of the inflammatory process in the wedge-shaped sinus that deep, often irreversible pathomorphological changes occur in the mucous membrane that often spread to the periosteum and bone tissue of the sphenoid bone. More often a chronic inflammatory process occurs in both sphenoid sinuses; according to VF Melnik (1994), bilateral damage is observed in 65% of cases, in 70% of cases of chronic sphenoiditis is combined with inflammation of other paranasal sinuses. Isolated lesion of the sphenoid sinus observed in 30% of cases appears probably due to their primary infection from the foci of infection localized in the lymphadenoid nasopharyngeal formations, for example, in chronic adenoiditis.

[1], [2]

Epidemiology

The incidence is not related to living in this or that region of the world, an important role in the emergence of chronic sphenoiditis is played by allergic processes and transmitted infections of the upper respiratory tract.

[3], [4], [5]

Causes of the chronic sphenoiditis

The cause of the development of chronic sphenoiditis is the same as in chronic inflammatory processes in other other paranasal sinuses. 

The causative agents of the disease are more often representatives of the coccal microflora. In recent years, reports have emerged that three opportunistic pathogens, Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catharrhalis, have been identified as pathogens. They note the formation of various types of aggressive associations, characterized by increased virulence. Quite often as a causative agent of the disease, mushrooms, viruses and anaerobes began to be isolated.

[6], [7], [8]

Pathogenesis

Most often in the pathogenesis of chronic sphenoiditis, the primary role is played by the chronic inflammatory diseases of other paranasal sinuses preceding it, and mainly by the chronic slow inflammation of the posterior cells of the latticed labyrinth. An important role in the pathogenesis of chronic sphenoiditis is played by the anatomical position of the sphenoid sinus and its close links with nasopharyngeal lymphadenoidal formations. The localization of the chronic foci of infection in them is an important factor in the onset of primary chronic inflammation of the mucous membrane of the sphenoid sinus. The famous French otorhinolaryngologist G.Portmann, describing chronic sphenoiditis as a disease with scant symptoms, an erased clinical picture, often masked by diseases of other other paranasal sinuses, notes that often chronic sphenoiditis manifests itself indirectly through the complications caused by it (optic neuritis, basal pachymeningitis, optico- chiasmatic arachnoiditis, etc.).

Due to the narrowness of the natural outlet opening, it closes when it spreads edema and infiltrates the inflamed mucous membrane of the nasal cavity. In this situation, the latter begins to quickly absorb oxygen and release carbon dioxide, and the oxygen content sharply decreases when a sinus exudate appears in the lumen of the sinus. The disease occurs and when exposed to adverse factors directly on the mucous membrane of the sinus.

[9], [10], [11]

Symptoms of the chronic sphenoiditis

Chronic sphenoiditis is manifested by various and uncertain symptoms, probably connected with a deep sinus location in the base of the skull, close to the diencephalic and other important structures of the brain. This becomes a frequent cause of neurological complications and the appearance of asthenovegetative symptoms: sleep disorders, loss of appetite, memory impairment, paresthesia, persistent subfebrile condition, impaired glucose tolerance. More often, chronic sphenoiditis is manifested by dull pain in the occiput and secretions to the nasopharynx, mainly in the morning hours, hyperthermia with low-grade figures and pronounced general weakness. The disease is characterized by a prolonged course with mild symptoms. The inflammatory process is more often bilateral, isolated sinus involvement is observed in 30% of cases.

Three of the most important symptoms of the disease are constant, the main one of which is the headache of permanent localization: with a small airway of the sinus - in the parietal region, and with a large spreading in the occipital. Characteristic for sphenoiditis is the irradiation of headaches in the postorbital and frontal areas with the appearance of sensations of "pulling out" or "trapping" the eyes.

A feature is also the appearance or intensification of pain in the sun and hot room, and night time. It is suggested that this is due to the active evaporation of the secret due to the high air temperature, the appearance of crusts that close the sinus outlet. Such features of a headache with chronic sphenoiditis are called "sphenoidal pain syndrome". The second important clinical sign is a subjective odor from the nose, felt only by the patient himself. The appearance of the smell is caused by the fact that the natural sinus fusion opens up in the olfactory area. The third sign is the draining of a lean and viscous exudate along the nasopharynx and posterior pharyngeal wall, which causes irritation of the mucous membrane and often side pharyngitis on the side of the lesion.

Symptomatic of chronic sphenoiditis depends mainly on the form of the process (closed, open) and the ways of distribution of humoral derivatives of the inflammatory process, which, in turn, is determined by the anatomical structure of the sphenoid sinus (its volume, bone wall thickness, the presence of digisenses, vascular emissaries, etc. .). The location of the sphenoid sinus at the base of the skull and in close proximity to important brain centers (pituitary gland, hypothalamus, other subcortical ganglia, cavernous sinus system, etc.) may cause the appearance of direct and repercussion symptoms indicative of the involvement of these formations in the pathological process. Therefore, the symptomatology of chronic sphenoiditis, although erased, hidden and masked by signs, for example, of ethmoiditis, still contains elements of "specificity" relating to the above-mentioned "repercussion" symptoms, which are not very typical for diseases of other paranasal sinuses. An example of such symptoms may be initial manifestations of optic-chiasmal arachnoiditis, paresis of the nerve, and others.

The "closed" form of chronic sphenoiditis, characterized by the absence of sinus communication with the nasopharynx (lack of drainage function), manifests itself with much more pronounced symptoms than the "open" form in which the exudate formed in the sinus loosens freely through natural drainage holes. When the form is closed (absence of secretions in the nasopharynx), patients complain of completeness and heaviness in the head, on raspiranie in the perinasal area and in the depth of the orbits; on constant, periodically exacerbated headaches, irradiating to the crown and orbits, amplified by shaking the head. For the pain syndrome with chronic sphenoiditis is a symptom of a "constant pain point", the localization of which is strictly individual for each patient, strictly repeating in the same place with each exacerbation of the inflammatory process. Headaches with closed form of chronic sphenoiditis are caused not only by pressure on sensitive nerves by accumulating exudate, but also by the characteristic for any chronic sinusitis neuritis of sensitive nerve endings, the alteration of which by inflammatory toxins leads to the occurrence of perivascular neuralgia and neuropathies characteristic of the syndromes of Slader, Charlene, Harris and etc. Such fixed pain loci can include pain radiating to the supra- and infraorbital regions, in certain teeth, in the region There are four mastoid processes and in the upper parts of the neck. With the combination of chronic sphenoiditis with chronic etmoiditis, hyposmia is possible. The closed type of the process leads to putrefactive decay of the wedge-shaped sinus tissues and to the objective and subjective cacosmia. A characteristic feature of chronic sphenoiditis is a decrease in visual acuity even in the absence of signs of optic-chiasmal arachnoiditis, and cases of temporary, until complete recovery, hypoacusia.

With the "open" form of chronic sphenoiditis, the main complaints of patients are complaints about the presence of viscous, foul-smelling secretions in the nasopharynx, which dry out into yellow-gray-green crusts. To remove these secretions and crusts, patients are forced to resort to washing the nasal cavity and nasopharynx with various solutions.

Objective local symptoms include hyperemia of the nasal mucosa and parenchymal hypertrophy of nasal concha; insufficiently effective action of vasoconstrictor; in the nasal passages - purulent discharge, drying out in hard-to-detachable crusts; in the olfactory gap, the accumulation of viscous pus and small polyps is determined, which may indicate concomitant chronic etmoiditis. On the back wall of the pharynx - flowing from the nasopharynx viscous pus and crusts; at the back of the rhinoscopy, a polyp can sometimes be found, coming out of the sphenoid sinus, covered with purulent discharge, flowing from the upper nasal passage and covering the posterior end of the middle nasal shell. The latter is hypertrophied, often polypously altered. Purulent discharge, flowing down the posterior wall of the pharynx, accumulates in the laryngopharynx and dries into hard-to-cough expectoration.

Chronic sphenoiditis, as a rule, differs sluggish course, some paucity of rhinological symptoms and basically can be characterized by the same criteria as chronic inflammatory processes in other other paranasal sinuses. However, with chronic sphenoiditis, general symptoms often appear, such as signs of neurological and asthenovegetative disorders (sleep disturbance, memory impairment, loss of appetite, increased irritability.) Gastrointestinal disorders are frequent due to the constant swallowing of purulent masses accumulating in hypopharyngs. , notes AS Kiselev (1997), in some patients a severe hypochondriacal condition requiring psychiatric treatment may develop. Eniya caused by toxigenic and patoreflektornym influence hearth chronic inflammation, in the immediate vicinity of the pituitary-hypothalamic and limbic-reticular system. This is, in particular, show signs of emotional sphere, the appearance of the central dizziness, changes in carbohydrate metabolism and others.

The evolution of chronic sphenoiditis, as in the case of chronic inflammatory processes in other paranasal sinuses, can occur both in the direction of recovery and in the direction of aggravation of the local and general manifestations of the disease, and under unfavorable conditions (general infections, reduced immunity, certain systemic diseases) (more often than with chronic inflammatory processes in other other paranasal sinuses) the occurrence of a number of severe complications (phlegmon orbit, optic neuritis, pachymeningitis skull base, optic-chiasmal arachnoiditis, cerebral abscess, thrombophlebitis of the cavernous sinus, etc.).

[12], [13]

Forms

There are two clinical forms of the disease - zksudativnuyu (catarrhal, serous, purulent) and productive (polypous and polypous-purulent).

[14], [15]

Diagnostics of the chronic sphenoiditis

A method of mass examination of a large contingent of people could be fluorography or CT of paranasal sinuses.

At the stage of collection of anamnesis it is necessary to obtain information on the duration of the disease, the peculiarities of the clinical symptomatology, which at first glance is not even related to this type of sinusitis. This concerns, first of all, neurological visual disturbances, appearing against the background of constant long-term headache and discharge into the nasopharynx.

Physical examination

It is impossible because of the peculiarities of the location of the sphenoid sinus,

[16], [17], [18],

Laboratory research

In the absence of complications, as with other types of sinusitis, general blood and urine tests are poorly informative. Obligatory is monitoring and dynamics behind the level of glucose in the blood.

Instrumental research

With posterior rinoscopy, edema and hyperemia of the mucous membrane of the nasopharynx arch, a crust on its surface, a "strip of pus" flowing down its lateral wall are revealed. In chronic sphenoiditis, hyperplasia of the mucosa of the posterior edge of the opener, the upper edge of the khoan, and the posterior ends of the upper and middle nasal concha are often found. The appearance of a "strip of pus" can be detected with repeated posterior rhinoscopy after carefully conducted anemization of the mucosa of the olfactory cleft. The majority of patients have permanent edema and hyperemia of the middle nasal concha, which creates the illusion of an infection of the posterior-superior parts of the nose.

With oropharyngoscopy, you can detect the effects of granulosis pharyngitis.

The main method of instrumental diagnosis remains radiography. Performed in the axial projection, it makes it possible to clarify the features of airway sinuses, the presence and number of chambers, the location of the interstitial septum, the nature of the decrease in the transparency of the sinuses. The introduction of a water-soluble contrast agent into the sinus through a catheter introduced during diagnostic probing of the sphenoid sinus will allow more precise localization of the changes caused by the inflammatory process.

CT and MRI when shooting in axial and coronary projections undoubtedly give a much larger amount of information, revealing the involvement of other paranasal sinuses and nearby structures of the facial skeleton in the inflammatory process

Differential diagnosis of chronic sphenoiditis

The closest to the clinical manifestations of the disease is the diencephalic syndrome, often manifested by the subjective sensation of a change in the "hot flashes" of heat and cold, which was not observed in patients with sphenoiditis.

It is necessary to differentiate the disease with the arachnoiditis of the anterior cranial fossa. Sphenoiditis, mostly chronic, from this pathology is characterized by the presence of a "spheroidal pain syndrome", a typical localization of exudate exudates and X-ray data,

[19],

Indications for consultation of other specialists

It is obligatory to observe a patient with a neuropathologist and an ophthalmologist in dynamics. It is advisable to consult an endocrinologist to clarify the condition of the glands of internal secretion, especially when the blood glucose level is elevated. Before and after surgery on the sphenoid sinus, neurologist's consultation is mandatory.

Treatment of the chronic sphenoiditis

The goals of the treatment of chronic sphenoiditis are restoration of drainage and aeration of the affected sinus, elimination of obstructive formations, removal of pathological detachment, stimulation of reparative processes,

Indications for hospitalization

The presence of sphenoidal pain syndrome ", secretions into the nasopharynx, characteristic X-ray signs, as well as the absence of the effect of conservative treatment for 1-2 days and the appearance of clinical signs of complications are indications for hospitalization. For patients with chronic sphenoiditis, such complications are considered exacerbation of the disease with a previously established diagnosis or long-term unsuccessful treatment, various and indeterminate symptoms associated with the pathology of the nose.

Non-pharmacological treatment of chronic sphenoiditis

Physiotherapeutic treatment: zondosalny electrophoresis with antibiotics of penicillin series, intraspasal irradiation with helium-neon laser beams. /

Drug treatment for chronic sphenoiditis

Before obtaining the results of the microbiological study, antibiotics of a wide range of action, amoxicillin, including in combination with clavulanic acid, cephaloridine, cefotaxime, cefazolin, roxithromycin, etc., can be used. Seed antibiotics should be prescribed as a result of inoculation; if the detachment is absent or can not be obtained, the treatment is started. In the complex of anti-inflammatory therapy, you can use the drug fenspiride. Simultaneously, hyposensitizing therapy is carried out with mebhydroline, chloropyramine, ebastin, etc. Prescribe vasoconstrictive drops in the nose (decongestants), at the beginning of the treatment of mild action (a solution of ephedrine, dimethindene in combination with phenylfripp, and instead of using night drops or a spray, a gel can be used); in the absence of effect for 6-7 days, treatment with imidazole drugs (naphazole, xylometazoline, oxymetazoline, etc.) is mandatory. The use of immunomodulators (preparations of the thymic group of U generations, azoxime) is mandatory.

Anemization of the mucous membrane of the olfactory gap is carried out with the help of various decongensants.

[20], [21], [22], [23], [24]

Surgical treatment of chronic sphenoiditis

Treatment of acute sphenoiditis involves probing the sphenoid sinus with needle-catheters. Preliminary surgical correction of the nasal cavity structures (deformities of the septum of the nose, hypertrophy of the posterior end of the middle nasal concha, synechia, adenoids), which prevent the zodiac, should be performed. Carry out a thorough stage-by-stage superficial anesthesia and anemia of the mucosa of the middle nasal passage. The anatomical landmarks are the lower edge of the pear-shaped opening, the upper edge of the choana, the middle nasal concha and the septum of the nose. The sounding is carried out along the Zuckerkandl line, which starts from the front nasal awn, passes through the middle of the middle nasal shell to the middle of the anterior wall of the sphenoid sinus. It should be remembered that the sinus outlet is 2-4 mm lateral septum of the nose and 10-15 mm above the edge of the choana. A sign of getting into the lumen of the sinus through a natural outlet hole is a feeling of "failure" and the impossibility of vertical displacement of the catheter. After aspiration of the contents, the cavity is washed with antiseptic solutions or with a warm 0.4% solution of sodium chloride. Then the patient is laid on his back with a slightly tilted head, injected into the lumen of the sphenoid sinus drug and left for 20 minutes for maximum absorption of the drug.

The tactics of treating chronic sphenoiditis are determined by the clinical form of the disease. Exudative forms (catarrhal, serous, purulent) lead conservatively with probing and long drainage, the constant introduction of drugs into the sphenoid sinuses. Productive forms (polypous and polypous-purulent) are subject to surgical treatment.

The most sparing typical way of opening the sphenoid sinus is transseptal. After a typical incision, mucoperichondria reveals quadrangular cartilage. Removed only the changed parts of it, as well as the bone part, where resect the path located on the way to the rostrum, exfoliate the mucosa and the periosteum of the anterior wall of the sphenoid sinus, which is opened by Guyek's bites. Remove pathologically altered areas of the mucosa, polyps and other formations. Complete the operation by priming the sinus with superposition of a wide ankle and tamponade of the nasal cavity.

In the endonasal opening of the sphenoid sinus by the Gayek method in the Bokshtein modification, most of the anterior part of the central nasal cavity is resected, then the posterior cells of the sinus sinus are dissected. After the removal of bone fragments, the front wall of the sphenoid sinus is visualized. The hook, inserted into its natural opening, breaks the front wall and the Guyek's forceps expands the hole.

With endoscopic dissection of the sphenoid sinus with the help of endoscopes or under the control of a microscope, the use of a microdebroder is considered more lenient.

Surgical treatment of chronic sphenoiditis is primarily aimed at creating a wide drainage hole for the sphenoid sinus, which in itself can lead to the elimination of the inflammatory process. If there are pathological tissues (polyps, granulations, areas of necrotic bone, detritus, cholesteatom masses) in the sinus, they must be removed while observing the principle of preservation of the mucous membrane capable of reparative processes.

Indications for surgical treatment of chronic sphenoiditis are determined by the duration of the disease, its combination with inflammatory processes in other other paranasal sinuses, the ineffectiveness of nonoperative and semi-surgical treatment, the presence of pronounced subjective and objective symptoms, including polyposis of the nose, signs of impaired visual function, suspicion of orbital and intracranial complications. In determining the indications for surgical treatment should also be guided by the position of the old authors that any chronic sphenoiditis is a "powder keg" on which the brain "sits" smoking a cigar with insufficient attention to this disease of both the patient and the treating doctors .

Methods of surgical treatment are many, all of them are differentiated by the nature of access to the sphenoid sinus and are divided into the following methods:

1. direct endonasal etmoidosphenoidectomy;
2. overstroke-maxillary etmoidosphenoidectomy;
3. supraorbital etmoidosphenoidectomy;
4. transseptal sphenoidectomy.

Since the isolated form of chronic sphenoiditis is extremely rare and often accompanied by the disease of other other paranasal sinuses, the most frequently and most effectively used method is Pietrantonide Lim, allowing one access through the maxillary sinus to audit all sinuses on one side, including the main one, without affecting the anatomical formations of the inner nasal are not destroyed, as, for example, in endonasal and transseptal methods. As an independent operation, the opening of the sphenoid sinus is rare; most often the sphenoid sinus is opened with a trellised labyrinth.

Method Pietrantoni - de Lima

This method provides opening and draining of all paranasal sinuses during heminansinusitis while preserving the nasal concha and restoring the physiological functions of the nasal cavity.

Indications: chronic pancinusitis (simple and complicated phlegmon orbit, optic neuritis, optic-chiasmal arachnoiditis, meningitis, cavernous sinus thrombophlebitis, abscess of the head brain - temporal and parietal lobe - and visceral toxic infections).

Operational techniques include the following stages:

1. opening of the maxillary sinus by the method of Caldwell-Luke;
2. opening of the latticed labyrinth in the region of the posterior-upper-inner corner of the maxillary sinus;
3. removal of the anterior and posterior cells of the latticed labyrinth (opening of the trellis labyrinth according to Jansen-Winkler);
4. trepanation of the anterior wall of the sphenoid sinus, beginning with the crista of the sphenoid bone;
5. endonasal opening of the frontal sinus (according to indications) and the formation of a wide drainage of all the sinuses;
6. examination of the general postoperative cavity, powdering it with a powder of a mixture of antibiotics;
7. tamponade with a single swab of all opened sinuses, starting with the deepest of their departments; the length of the tampon is calculated so that its end extends beyond the incision of the nasolabial fold on the eve of the mouth, through which it will subsequently be removed.

Transseptal opening of the sphenoid sinus according to Hirsch

This method is operationally more convenient, providing a good overview of the place of operative action in the sphenoid sinus, wide opening of both its halves, the most radical removal of pathological contents and ensuring a stable effective drainage of it. The effectiveness of surgery significantly increases when using in the final part of its video endoscopic technique, which allows to identify on the screen of the monitor and eliminate all, even the most insignificant, fragments of pathological tissues, while observing the principle of sparing the viable parts of the mucous membrane. In addition, this method allows you to reach the pituitary gland with its tumors.

Operational technique:

1. Incision and excision of mucous membrane with perichondrium, as in septum-operation up to opener, inclusive; moving the muco-perichondrium plate to the lateral side.
2. Mobilization of the cartilaginous part of the septum of the nose in the opposite direction, for which VI Voyachek suggested making incisions (fractures) on the cartilaginous part of the septum of the nose, not cutting the perichondrium and the mucous membrane of the opposite side; if it is necessary to expand access to the anterior wall of the sphenoid sinusis, it is permissible to remove only certain areas in the cartilaginous part, especially those that are curved and interfere with the orthograde access to the sphenoid sinus. In the bone part of the septum, only those areas that are on the way to the rostrum of the sphenoid sinusa are removed. AS Kiselev (1997) pays special attention to the need to preserve the upper part of the perpendicular plate of the trellised bone as a middle reference (the lower part is removed to expand access to the sphenostromus rostrum).
3. Introduction between the septum of the nose and the muco-perichondial nasal mirrors of Killian with successively elongated branches to the anterior wall of the sphenoid sinus and opening it with an elongated West chisel, forceps or boron. In the absence of a video monitoring device with fiber optics, the condition and volume of the sinus, its contents, the presence and position of the interstitial septum are checked with a button probe, successively feeling all of its walls, paying special attention to the upper and lateral.
4. Expansion of the aperture in the sphenoid sinus is carried out with tools (long chisels, spoons, long rotating gicles, etc. After removing a large part of the anterior wall of the sphenoid sinus and dissecting the underlying mucosa, most of the interstitial septum is bored.
5. Revision and curettage of the mucosa, while respecting the principle of sparing it. This stage of the operation is most effective with respect to both the preservation of viable parts of the mucous membrane and the total removal of nonviable tissues using the microvideo-surgical method with the display of the operating field on the monitor screen.
6. Reposition the parts of the septum of the nose by extracting the Killian mirror. In the sinus, insert the appropriate length of the subclavian catheter for subsequent care (rinsing with ozonized distilled water, administration of medications) and produce an anterior loop tamponade of both halves of the nose, as after septum-oneration. Tampons are removed after 24-48 h, catheter - after a week.

Postoperative treatment

During the week, general and local antibiotic therapy is carried out, daily sinus lavages with antiseptic solutions, general symptomatic treatment, prescribe drugs that increase the specific and nonspecific resistance of the organism.

Endonasal polysynsotomy

This type of operation AS Kiselev described as "modern", which probably was dictated by his own extensive experience. The operation is preceded by a detailed examination of the nasal cavity using modern endoscopic techniques. The purpose of this examination is to identify endonasal anatomical features that must be taken into account in the operation, and if there are violations that could prevent the endonasal access to the sphenoid sinus, a plan for their elimination is outlined. Such disturbances and pathological conditions include a pronounced curvature of the septum of the nose, especially in its deep sections, the presence of hypertrophic nasal concha, especially of medium, polyps, especially localization, as well as a number of dysmorphological phenomena that can significantly impede orthograde penetration of the rostrum.

In the absence of mechanical obstacles to the production of this surgical intervention, the next step is the luxation of the middle nasal concha to the septum of the nose to identify the hook-shaped process by probing it with a button probe. Behind the appendage, the anterior wall of the lattice bulla is defined, which together with it forms a half-moon slit. Then the sickle-shaped knife is cut from the top downwards by a hook-shaped process and removed by nose nippers. Removing the hook-shaped reed opens access to the bull, which is opened with the same forceps or other convenient tool. The opening of the bulla provides access to the remaining cells of the trellis labyrinth, which are successively removed, which leads to the exposure of the "roof" of the trellis. When the tool moves in the medial direction and with an excessive force directed upwards, there is a danger of damage to the grating plate and penetration into the anterior cranial fossa. Conversely, excessive tool displacement in the lateral direction can lead to damage to the paper plate and the contents of the orbit.

The next step is the enlargement of the anus of the maxillary sinus, for which end of the endoscope with a viewing angle of 30 ° is inserted into the middle nasal passage and a natural maxillary sinus sinus is found using the trigger probe. It is located behind the upper edge of the inferior nasal shell and anterior to the level of the lacrimal tubercle, its diameter is normally 5-7 mm. Further, using special nippers with a reverse bite or curette and a sharp spoon, expand natural cohust. It should be borne in mind, however, that the expansion of the anastomosis beyond the level of the lacrimal tubercle usually leads to damage to the tear ducts, and posteriorly to the level of the posterior end of the middle nasal can lead to damage to the wedge-palatal artery (a. Sphenopalatine). Excessive expansion of the anastomosis can lead to penetration into the orbit.

The next stage is the opening of the sphenoid sinus, which is produced through its front wall with the help of bone forceps. The widening of the formed hole is made with the help of Geek's clippers. After that, the sinus is examined with the help of an endoscope and its curettage is carried out, observing the principle of shading the mucous membrane.

Further, an intranasal dissection of the frontal sinus is performed, which, however, according to AS Kiselev, is the most complex kind of endonasal sinusotomy. After preliminary removal of the bone shaft and opening of the anterior cells of the latticed labyrinth forming the anterior wall of the frontal-nasal canal, the entrance to the frontal sinus becomes visible, into which the probe is inserted for the reference point. To expand the entrance to the frontal sinus, it is necessary to remove the frontal-nasal bone mass, which is fraught with danger of penetration into the anterior cranial fossa, especially in the anomalies of frontal bone development. Therefore, in the absence of the possibility of inserting the probe into the frontal sinus, it is necessary to abandon the intranasal opening of the probe and proceed, if there are appropriate indications, to external access to it.

Further management

Self-washing of the nasal cavity and nasopharynx with a warm 0.9% solution of sodium chloride using devices such as "Renolife" or "Dolphin".

Approximate terms of incapacity for acute and exacerbation of chronic sphenoiditis without signs of complications in the case of conservative treatment with sinus sounding is 8-10 days. Execution of endonasal intervention prolongs the duration of treatment for 1-2 days.

Information for Patient

• Beware of drafts.
• Carry out a vaccination against the flu.
• At the first sign of acute respiratory viral infection or influenza, consult a specialist.
• At the recommendation of the attending physician to perform a surgical sanation of the nasal cavity for the restoration of nasal breathing and correction of the anatomical structures of the nasal cavity.

Prevention

Prevention of chronic sphenoiditis is the prevention of hypothermia, control of the level of general and local immunity, careful treatment of inflammatory diseases of the upper respiratory tract, including acute sinusitis.

[25], [26], [27],

Forecast

The prognosis of chronic sphenoiditis is favorable in most cases, even with certain intracranial complications, if they are detected in time and radical treatment is carried out against them. The fastest phlegmon of orbit, optic neuritis, optic-chiasmal arachnoiditis are most dangerous in function. The prognosis is very serious, and in some cases also pessimistic with paraventricular and stem brain abscesses, rapidly progressing thrombophlebitis of cavernous sinuses with its spread to neighboring venous systems of the brain.

[28], [29], [30],