Chronic purulent rhinoemoitis

Chronic purulent rhinoetmoiditis (synonym: chronic anterior ethmoiditis) is a disease that is treated as a subsequent pathophysiologic stage, resulting from acute rhinoemoideitis, untreated within 2-3 months after the onset. For chronic purulent rinoetmoiditis is characterized by a profound irreversible lesion of the mucosa of the anterior cells of the latticed bone with the phenomena of periostitis and osteitis (osteomyelitis) of the intercellular septa. In untimely radical treatment, the process extends to the posterior cells and the sphenoid sinus. Chronic purulent rhinoethmoiditis, as a rule, arises as a complication or a further stage of chronic sinusitis, therefore its signs and clinical course assimilate and signs of the disease of these sinuses.

The cause, pathogenesis of chronic purulent rhinoemoideitis are common to all forms of chronic inflammatory diseases of the nasal cavity. It should be emphasized that there is no purely isolated anterior ethmoidite, when other sinuses remain intact. As a rule, other, especially nearby sinuses - frontal and maxillary, as well as posterior cells of the latticed bone, are involved in the inflammatory process to some extent. The degree of involvement in the pathological process of these sinuses is different. Most often this is a kind of repercussion reaction that occurs in a single anatomical system with varying degrees of alteration of its parts. Timely sanation of the primary focus of infection leads to the rapid elimination of secondary inflammatory manifestations in adjacent sinuses, however, in advanced cases, with high virulence of microorganisms of the primary focus (anterior cells of the latticed labyrinth), a decrease in immunity, etc. In adjacent sinuses, a typical picture of acute or primary-chronic sinusitis, and then we can talk about gemisinusit, unilateral pansinusit, etc. The fact that chronic anterior etmoiditis can not "exist without corresponding signs of inflammation in the mucosa of the nasal cavity, as well as with all other anatomical forms of chronic sinusitis, and gave grounds for treating it as rhinoethmoiditis.

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

Symptoms of chronic purulent rhinoethmoiditis

The signs of a chronic purulent rhinoemoideitis of an open form are divided into subjective and objective. An open form of ethmoiditis is called the inflammatory process, which encompasses all cells (front or back) communicating with the nasal cavity or other paranasal sinuses, and characterized by the expiration of pus in the nasal cavity. The main complaints of the patient are reduced to a feeling of fullness and pressure in the depth of the nose and frontal-orbital area, one-sided or bilateral nasal congestion, worsening of nasal breathing, especially at night, constant, periodically intensifying discharge from the nose of a mucus-purulent nature, which can hardly be blown out . In the initial stage of chronic monoethmoiditis, the excretions are ungulate, viscous, mucous. As the chronic process develops, they become purulent, greenish-yellow in color, and when periostitis and osteitis occur they are characterized by putrefactive odor, which determines the presence of a subjective and objective kakosmia. The latter may indicate the presence of a combination of etmoiditis with odontogenic sinusitis. Hyposmia and anosmia are intermittent in nature and depend mainly on vasomotor, reactive-inflammatory and edematous processes in the nasal mucosa, as well as on the presence of polyps in the nasal passages. The amount of secretions sharply increases when the inflammatory process spreads to the maxillary sinus and frontal sinus.

Pain syndrome in chronic purulent rhinoemoideitis is of a complex nature and has the following properties. The pains are divided into permanent, dull, localized in the depth of the nose at the level of its root, increasing at night, In a one-sided process, several lateralize in the sore side, spreading into the corresponding orbit and frontal region; in a bilateral process, a more diffuse character without a sign of lateralization, giving in both the orbits and frontal areas, are amplified at night. With the aggravation of the inflammatory process, the pain syndrome acquires a paroxysmal pulsating character. Irradiating in the orbit and frontal region the pain sharply increases, there is photophobia and other symptoms characteristic of acute anterior ethmoiditis: increased fatigue of the organ of vision, a decrease in intellectual and physical capacity, insomnia, loss of appetite.

To the local objective symptoms include the following symptoms. When examining the patient draws attention to the diffuse injection of vessels of sclera and other tissues of the anterior part of the eyeball, the presence of dermatitis in the area of the anterior nose and upper lip. Pressing on the teardrop (a symptom of Grunwald) in the "cold" period can cause a slight soreness, which in the acute period becomes very intense and is a characteristic sign of exacerbation of chronic purulent rhinoethmoiditis. Another symptom of chronic purulent rhinoemoiditis is Gajek's symptom, which is that pressing on the base of the nose causes a feeling of dull pain in the depth of it.

Endoscopy of the nose reveals signs of chronic catarrh, swelling and hyperemia of the nasal mucosa, a narrowing of the nasal passages, especially in the middle and upper sections, often multiple polypous formations of various sizes, hanging on the legs from the upper parts of the nose. The middle shell, being a part of the anterior cells of the latticed labyrinth, is usually hypertrophied and, as it were, bifurcated - an aspect that arises in the swelling and hypertrophy of the mucous membrane of the funnel (Kaufmann's symptom).

As a result of the accumulation of pus and catabolites in the cell forming the middle nasal shell, destruction of its osseous base occurs with the preservation of soft hypertrophied tissues that are filled with inflammatory exudate, forming a kind of lacunar cyst, known as concha bullosa, which, in fact, is nothing but , as the mucocele of the middle nasal concha. Repeated diagnostic rhinoscopy is performed 10 min after anemia of the nasal mucosa. In this case, the places of the outflow of purulent discharge from the upper parts of the nose become available, which flow along the middle and lower nasal concha in the form of a yellow band of pus.

Chronic purulent rinoetmoiditis of a closed type can touch only one cell, a limited number of them or be located only in the middle nasal concha. In the latter case, cochcha bullosa, absence of purulent secretions, local hyperemia in the zone of the inflammatory process are observed. Among the signs of this form of ethmoiditis, the algic syndrome dominates, which is characterized by persistent neuralgia of the nazorbital localization, sometimes hemicrania and accommodation and convergence disorders. The patients also feel fullness and expansion in the depth of the nose or in one of its halves. The aggravation of the process is accompanied by lacrimation on the causative side, increased pain and the spread of their irradiation into the corresponding maxillofacial area.

The clinical course of chronic purulent rhinoemoideitis without comprehensive adequate treatment is long, evolving towards polyposis and cyst formation, destruction of bone tissue, the formation of large cavities in the trellis, with spreading to the posterior cells of the trellis labyrinth and other paranasal sinuses. Under adverse conditions, it is possible that both perietmoidal (eg phlegmonic orbit) and intracranial complications occur.

The prognosis for chronic purulent rhinoethmoiditis is generally favorable, however, with its timely detection and qualitative complex treatment. The prognosis is cautious in the occurrence of intraorbital or intracranial complications.

Diagnosis of chronic purulent rhinoethmoiditis

Diagnosis of chronic purulent rhinoethmoiditis is established on the basis of the subjective and objective symptoms described above, the history and, as a rule, the presence of concomitant inflammatory diseases of other anterior paranasal sinuses. An important diagnostic value is the x-ray of the paranasal sinuses, for the anterior cells of the lattice in the frontal-chin projection.

In some cases, especially in common trials or for differential diagnosis and in complicated cases, tomography, CT or MRI is used. To biopsy and determine the nature of the contents of the trellis labyrinth, remove a portion of the bulla, take its contents and perform a puncture in the asper nasi region, followed by a histological and bacteriological study of the resulting material.

Differential diagnosis is carried out in the direction of identifying concomitant inflammatory processes in the maxillary sinus and frontal sinus, in the posterior cells of the latticed labyrinth and the sphenoid sinus. With pronounced algic forms of chronic purulent rhinoemoideitis differentiate with Charlina syndromes (severe pain in the medial corner of the eye with irradiation in the back of the nose, unilateral swelling, hyperesthesia and hypersecretion of the nasal mucosa, injection of sclera, iridocyclitis, hypopion, keratitis, after anesthesia of the nasal mucosa all symptoms disappear) and Sladera. Differentiate chronic purulent rinoetmoiditis also from banal polyposis of the nose, rhinolithiasis, unrecognized chronic foreign body of the nasal cavity, benign and malignant tumors of the latticed maze, syphilitic gum of the nose.

[6], [7]

Treatment of chronic purulent rhinoethmoiditis

Effective treatment of chronic purulent rhinoethmoiditis, which, however, does not guarantee the prevention of relapses, can only be surgical, aimed at wide exposure of all affected cells of the trellis labyrinth, removal of all pathologically altered tissues, including bone intercellular septa, providing extensive drainage of the postoperative cavity , sanitation of it in the postoperative period by washing (under weak pressure!) with antiseptic solutions, administration to the postoperative period Reagents and regenerants in mixture with appropriate antibiotics. Surgical treatment should be combined with general antibiotic therapy, immunomodulating, antihistamine and restorative treatment.

With the closed form of chronic purulent rhinoemoideitis with the presence of concha bullosa, one can do with a "small" surgical intervention: the conflagration of the middle nasal conch in the direction of the septum of the nose, the opening and removal of the middle shell, the curettage of several nearby cells. In the presence of repercussion inflammatory phenomena in the maxillary sinus or frontal sinus, their non-operative treatment is performed.

Surgical treatment of chronic purulent rhinoethmoiditis

Modern achievements in the field of general anesthesia have almost completely replaced this method with local anesthesia, which, however perfect it may be, never achieves a satisfactory result. Currently, all operative interventions on the paranasal sinuses are carried out under general anesthesia; sometimes, for anesthesia of endonasal reflexogenic zones, an endo-osal application and filtration anesthesia of the nasal mucosa in the area of ager nasi, upper and middle nasal concha, nasal septum.

Indications for operation

Prolonged course of the inflammatory process and inefficiency of nonoperative treatment, the presence of concomitant chronic sinusitis and chronic pharyngitis, for which indications for surgical treatment are established, recurrent and especially deforming polyposis of the nose, the presence of orbital and intracranial complications, etc.

Contraindications

Cardiovascular failure, excluding general anesthesia, acute inflammatory diseases of the internal organs, hemophilia, endocrine system diseases in the acute stage, and others, interfering with the surgical treatment of the paranasal sinuses.

There are several ways to access the trellis labyrinth, the choice of which is dictated by the specific state of the pathological process and its anatomical localization. There are external, overmaxillary-axillary and intranasal methods. In many cases, the opening of the trellis labyrinth is combined with surgical intervention on one or more paranasal sinuses. Such a method, made possible in connection with modern advances in the field of general anesthesiology and resuscitation, was called pansinusotomy.

[8]

Intranasal method of opening a trellis labyrinth in Halle

This method is used for isolated lesions of the trellis labyrinth or its combination with inflammation of the sphenoid sinus. In the latter case, the opening of the sphenoid sinus is performed simultaneously after the opening of the trellis labyrinth.

Anesthesia, as a rule, is general (intratracheal anesthesia with a pharyngeal tamponade, which prevents blood from entering the larynx and trachea). When operated under local anesthesia, a tamponade of the nose is produced in the posterior sections to prevent blood from entering the pharynx and the larynx. The main tools for surgical intervention on the paranasal sinuses are konkhotom, Luke forceps, Chitelli and Geek forceps, sharp spoons of different configurations, etc.

The main reference points for the surgeon are the middle nasal conch and bulla ethmoidalis. If there is concha bullosa, it is removed and bullae ethmoidalis. This stage of the operation, as well as the subsequent destruction of the intercellular partitions, is carried out with the help of a conch or Luke's forceps. This stage provides access to the cavities of the trellis labyrinth. With the help of sharp spoons produce total curettage of the cellular system, achieving complete removal of intercellular partitions, granulations, polypous masses and other pathological tissues. At the same time, the movement of the tool is sent from the rear to the front, taking special care when working with the cutting part of the curette or spoon, directed upward, not moving too medially, so as not to damage the upper wall of the latticed maze and the trellis plate. You can not also direct the instrument to the side of the orbit, and, in order not to lose the correct direction of surgical action, one should constantly adhere to the middle shell.

Not all pathological tissues can be removed with the help of curettage, so their remains are removed under the control of the eyes with tweezers. The use of video endoscopic method allows the most thorough revision of both the entire postoperative cavity and individual cells that have not been destroyed. Particular attention should be paid to the inaccessible for the endonasal method of opening the latticed labyrinth in the anterior cells. The use of a curled curette by Halle in most cases allows them to perform an effective revision. In case of doubt in their thorough purification, VV Shapurov (1946) recommends that the bone mass, located in front of the middle shell in the place of the hook-shaped process, be brought down. This gives wide access to the front cells of the trellis labyrinth. Halle suggested completing the operation by cutting out a flap from the mucous membrane located in front of the middle nasal shell and laying it in the resulting operating cavity. However, many ripo-surgeons miss this stage. The bleeding that occurs during the opening of the latticed labyrinth and curettage is stopped with narrow tampons impregnated with isotonic solution in a weak dilution of adrenaline (10 ml of 0.9% solution of sodium chloride 10 drops of 0.01% solution of adrenaline hydrochloride).

The further stage of endonasal intervention on the latticed labyrinth can be completed by opening the sphenoid sinus, if there are indications to this. For this purpose, nasal forceps-Gaiker burs may be used, which, in contrast to the similar Chitelli forceps, have a considerable length, which makes it possible to reach the sphenoid sinus throughout its entire length.

The postoperative cavity is loosely plugged with a long tampon impregnated with vaseline oil and a broad-spectrum antibiotic solution. The end of the tampon is fixed near the vestibule of the nose with the help of a cotton-gauze anchor and a bandage bandage is applied. In the absence of bleeding, which, in principle, should be finally stopped in the final part of the operation, the tampon is removed after 3-4 hours. Subsequently, the postoperative cavity is washed with an isotonic sodium chloride solution, irrigated with an appropriate antibiotic. With sufficient access to the operating cavity, it is advisable to irrigate it with oil solutions of vitamins having antihypoxant and reparative properties, in abundance of sea buckthorn, crotolin, rosehip oil, and also with reparative action preparations such as solcoseryl, methandienone, nondrilon, retabolil, etc. Such The same principle of postoperative management of the patient is shown in other operative interventions on the paranasal sinuses. As our experience shows, careful care of the postoperative cavity with the use of modern reparants and regenerants ensures the completion of the wound process within 7-10 days and completely excludes the possibility of relapse.

Opening of the trellis labyrinth by Jansen - Winkler

This type of double surgical intervention is practiced if it is necessary to simultaneously repair the maxillary sinus and homolateral opening of the trellis labyrinth. The autopsy of the latter is performed after the completion of the operation by Caldwell-Luke.

A rump or spoon destroys the wall of the maxillary sinus in the upper, median corner between the ophthalmic and nasal walls. To penetrate the cavity of the latticed labyrinth through this angle, perforate the maxillary sinus wall and penetrate the orbital process of the palatine bone. This can be done quite easily due to the fragility of these bone formations. To do this, use a sharp spoon or konkhotom. The moment of penetration into the cavity of the latticed labyrinth is fixed by the crunching sound of the breaking bone septum and the sensation of falling into the cavity of the cell lying on the path. The same tools destroy the partitions between the cells, sticking to the axis of the tool and not deviating either towards the orbit, or medially upward toward the trellis plate, and also open the middle nasal shell, widen the hole that communicates it with the rest of the cells of the lattice labyrinth. This technique allows you to create a good drainage hole between the cavity of the trellis labyrinth and the middle nasal passage. Using the modern method of video microsurgery, it is possible to inspect in detail all the cells of the trellis labyrinth and, if necessary, moving medially inward and somewhat downward to penetrate the wedge-shaped sinus on the corresponding side and inspect it with video optics and the monitor screen, perform appropriate microsurgical manipulations aimed at removal pathological contents of the sphenoid sinus.

After the revision of the trellis labyrinth, the consistency of the communication of the postoperative cavity of the latticed bone with the nasal cavity is checked. This is easily achieved with video fiber optics. If it is absent, a flute probe is introduced into the middle nasal passage, which, with a sufficiently drainage opening, clearly shows all the sides of the postoperative cavity of the latticed bone. As VV Shapurov (1946) notes, the Jansen-Wiiklesra operation seems to be an easy and convenient intervention for a sufficiently complete revision of the cells of the trellis labyrinth. Thus, but after the completion of this complex operation, two drainage holes are formed - the artificial window known to us, which communicates the maxillary sinus with the lower nasal passage, and a drainage hole communicating the cavity of the latticed labyrinth with the middle nasal passage. The presence of two postoperative cavities (without considering what can be opened and the sphenoid sinus) and two drainage holes opening at different levels of the nasal cavity creates a problem of tamponade of these cavities. In our opinion, in the beginning it is necessary to produce a loose tamponade of the ethmoid cavity with a thin continuous tampon with the removal of its end through the hole in the middle nasal passage and further outwards. From it, upon completion, tamponades form a separate small anchor. Tamponade of the maxillary sinus is performed as described above under the operation of Caldwell-Luke. Tampon of the trellis labyrinth is removed after 4 hours, and a tampon from the maxillary sinus - no later than 48 hours. To remove the tampon from the trellis labyrinth, the anchor of the "antritic" tampon is "disbanded", and the end of the tampon is pushed downwards, resulting in the formation of access to the middle nasal passage and the tampon emerging from it to the cavity of the latticed bone. Removal of this tampon is produced by nasal forceps, grabbing it as close as possible to the bottom of the middle nasal passage and producing light traction downwards and forwards. The tampon is removed quite easily due to a short stay in the cavity. After its removal into the postoperative cavity in the latticed bone, it is expedient to introduce a suspension of the powder of the corresponding antibiotic, prepared ex tempore on the oil solution of vitamins "plastic exchange". Carotoline and petrolatum oil in the ratio 1: 1 can be used as the latter. In the postoperative period after removal of all tampons, the operated cavities are washed with a solution of an antibiotic and irrigated with vitamins of "plastic metabolism".

Opening of the grid maze according to Grunwadedu

This method is currently used rarely and only in cases of purulent complications from the orbit (phlegmon) when the inflammatory process of the paper plate is destroyed, the presence of a fistula maze in the inner corner of the eye, with osteomas and wounds of the medial orbit and the cells of the latticed labyrinth adjacent to it. Revision of the latticed maze can also be performed with the following interventions on the frontal sinus. This access can also be opened and the sphenoid sinus.

A single-cut arcuate incision of all soft tissues, including the periosteum, is carried out along the inner edge of the orbit, starting from the inner edge of the superciliary arc and ending with the edge of the pear-shaped opening. The vertex of the arc of the incision should be located midway between the inner corner of the eye and the front surface of the transference. Soft tissue together with the periosteum is cut off in both directions by a sharp raspator or a flat chisel of Voyachek. The resulting bleeding is quickly stopped by pressing the ball, impregnated with a solution of adrenaline. To determine the location of penetration into the trellis labyrinth, find the corresponding bone landmarks in the form of bone seams formed by the frontal, nasal, tearing bones, the frontal process of the upper jaw, and the paper plate of the trellis labyrinth. First, a seam between the nasal bone and the frontal process of the upper jaw is sought. Parallel to this, a corridor is made from below upward in the bones. Its front border should be the nasal bone, the back - the beginning of the tear-nasal passage, i.e. The depression of the CML, which, with the help of the Frey's rasporot, is isolated from its bed to avoid its traumatization. Bone in the formed corridor is removed layer by layer until the mucous membrane of the nose, which is then opened with a vertical incision to form a future drainage hole between the nasal cavity and the cavity formed after opening the cells of the trellis labyrinth. After this, the instrument for opening the trellis labyrinth is guided strictly sagittally, i.e. Parallel to the middle nasal concha, and lateral from it. This maneuver can open all the cells of the trellis labyrinth and produce a curettage of the cavity formed. The opening of the trellis labyrinth is made by a narrow spoon or rump, while strictly observing the direction of the instruments so as not to damage the paper plate. On the other hand, the opening of the latticed labyrinth, as AS Kiselev (2000) notes, can be carried out through the Riedel bone massif, lying on the border between the frontal sinus floor and the tear bone, or through a paper plate. The depth at which the appropriate instruments can be manipulated should not exceed 7-8 cm. When curettage of the operating cavity, the intercellular septa, granulations, polyps, necrotic bone fragments of the lattice bone are removed, but when manipulating in the direction of the median line, i.e. In the region the grating plate, the movements of the instrument become gentle and tangibly controlled.

To ensure wide communication of the postoperative cavity formed in the latticed bone, the bony and soft tissues located in the middle and upper nasal passages, which are the walls of the latticed labyrinth, are removed with the nose, while it should be spared the middle nasal shell, starting to play in this new anatomical configuration the role of the protective The barrier preventing direct ingress of mucus from the nose into the postoperative cavity. After the artificial canal communicating the nasal cavity with the postoperative cavity of the latticed bone is formed, the latter is loosely plugged from the side of the postoperative cavity by a long narrow tampon according to the method of Mikulich or by means of a loop tamponade according to VI Voyachek. The external wound is sutured tightly.

If before the operation there was a fistula in the region of the inner corner of the eye or somewhere in the immediate vicinity of this place, then its walls are carefully removed throughout their extent. Sutures are removed on the 5th-6th day after the operation. After removal of tampons, the postoperative cavity is washed with a warm solution of an antibiotic emulsified in carotolin, rose hip oil or sea buckthorn. The procedure is repeated daily for 3-4 days. Simultaneously, general antibiotic therapy is carried out.