Endoscopy on the maxillary sinuses Endoscopic sinus surgery can help cure sinusitis

Endoscopic nose surgery- one of the methods of treatment of diseases of the sinuses and nasal cavity.

According to statistics, the risk of various diseases of the nasal cavity begins to increase dramatically in people aged 25 years and older.

The specialists of our clinic have many years of successful experience in the treatment of various pathologies of the nose and paranasal sinuses. We will tell you in detail what endoscopic surgery of the paranasal sinuses is, how and why it is performed, how postoperative rehabilitation takes place, we will select a comprehensive and effective method treatment individually for each patient.

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How is endoscopic nasal surgery performed and what are its advantages

The main instrument of the endoscopic method for the treatment of nasal pathologies is the endoscope and special micro-instruments. An endoscope is a device consisting of a tube filled with fiber optics and equipped with an eyepiece on one side and a camera on the other. There are about 15-20 microinstruments for each operation, each of which allows for a low-traumatic action on one or another structure of the nasal cavity. The smaller the injury, the faster and safer everything will heal.

The endoscope is inserted into nasal cavity the patient, which allows the specialist to personally observe the state of the tissues of the nose, sinuses and mucous membranes, determine the source of infection, and also remove pathological formations.

Endoscopic sinus surgery has many advantages over traditional sinus surgery. surgical treatment. In order to remove the focus of pathology, the specialist does not need to make external incisions. As a result, the period of rehabilitation of the patient after endoscopy is much shorter (1-2 days of hospitalization), and his mucous membrane heals much faster. In addition, this technique is less painful. After such an operation, there are no stitches, which means that there are no scars. The risk of infection is also minimal, because there are no open wounds. It should be noted the absence of postoperative edema or their insignificance, so you can quickly return to your normal lifestyle, go to work.

Endoscopic nasal surgery has another important advantage. Most of these operations are performed without anesthesia. This means that you don't have to think about possible allergies on anesthetic drugs and the damage they cause to the patient's body. Often the price of endoscopic operations is lower than the cost of interventions using laser radiation.

Endoscopic surgeries are performed only under general anesthesia, but the latter is well tolerated by all age groups without exception.

The endoscope does not change the shape of the nose, as, for example, a viewing mirror, and therefore is an accurate diagnostic tool. Examination with its help delivers minimal discomfort to the patient, even if it is a child, because this instrument almost does not come into contact with the mucous membrane. Initially, the nasal cavity is examined with an endoscope with direct optics, and then with an instrument with the possibility of angular vision. Modern endoscopes are computer-navigated, which makes it possible to obtain a three-dimensional image of the nasal valve and increase the accuracy of the operation.

Indications for endoscopic sinus surgery

One of the reasons when surgery may be needed is the proliferation of mucosal tissue, or hypertrophy. That is why polyps appear in the nasal cavity and sinuses, and if they are large and protrude into the nasal cavity, a person practically cannot breathe through the nose. Since polyps grow slowly, nasal breathing is also broken slowly, and its violation often attracts attention when the process is seriously started.

Also, the need to use endoscopic surgery can cause infections. The paranasal sinuses communicate with the nasal cavity through thin bony canals that are covered with a mucous membrane. The mucous membrane expands with any infections respiratory tract and blocks sinus ventilation. That is why we feel nasal congestion, and the process of breathing through the nose is difficult, headaches also appear, pain in the sinuses, and snoring may appear.

The purpose of endoscopic surgery is not only to treat any pathology of the nasal cavity, but, more often, to widen the bony canal of the sinuses. If in the future the patient develops infections of the cavity, including allergic edema, the sinus canal will be opened and ventilation will be maintained.

Contraindications for endoscopic surgery are chronic diseases airways, disease of cardio-vascular system and epileptic pathologies in the stage of decompensation.

If you feel pain or discomfort in the paranasal sinuses, experience problems with nasal breathing, this may indicate a pathology of the nose or paranasal sinuses. The specialists of our clinic will complete diagnostics, will accurately determine the cause of these symptoms and say whether there is a need for an operation on the paranasal sinuses. Remember that nasal pathologies in the initial stages are practically asymptomatic! Be attentive to your health!

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Complications after endoscopic sinus surgery

In rare cases, endoscopic operations may have complications, such as bleeding. As a rule, to prevent them, the operated area is plugged. However, if the patient has poor blood clotting or is taking drugs that affect this factor, bleeding will be due to this. In any case, before the operation, it is necessary to tell the doctor about the characteristics of the body and the medications taken.

To eliminate inflammation in the nasal cavity and paranasal sinuses ah, drug therapy, washings and surgical manipulations are used. All these methods are aimed at eliminating the swelling of the mucous membranes and improving the outflow of secretions. In our article we will talk about a modern surgical method for the treatment of sinusitis - functional endoscopic surgery.

intranasal medicines, represented by sprays, drops, inhalations, have anti-inflammatory, vasoconstrictive or antibacterial action. They facilitate nasal breathing, prevent the reproduction of pathogens on the surface of the mucous membranes and relieve inflammation. Preparations with astringent action envelop the nasal cavity and prevent it from drying out. Washing saline solutions – good way remove accumulated mucus from the sinuses. However, this method is applicable for adults and children over 5 years of age (the younger the child, the greater the likelihood of otitis media).

Nasal lavage

The most inaccessible place for washing can be called maxillary sinuses . Due to the anatomical location, conventional manipulations do not affect the mucus accumulated in the maxillary region. In the hospital and outpatient settings, three methods are used:

• displacement ( vernacular name"cuckoo");
• use of a sinus catheter;
• sinus piercing (for medical language- puncture).

In most cases, combinations drug therapy with one or more methods of clearing the sinuses of mucus, it is enough to significantly alleviate the patient's condition and subsequent complete recovery. However, the hope of many patients on “maybe it will pass by itself” often leads to the fact that ordinary inflammation, which, with adequate actions and timely medical assistance, would pass in a week, goes into more serious conditions, causing damage to other organs.

The ears most often at risk (otitis media), oral cavity(dental diseases), lungs (pneumonia, bronchitis) and even the brain (meningitis, encephalitis). Missed sinusitis from the acute stage may well turn into chronic form, providing a person with constant headaches, periodic nasal congestion, snoring and other unpleasant phenomena.

In situations where conservative methods of therapy are powerless, doctors resort to surgical intervention. One of the most common methods of the last century, successfully used to this day, is open operation, allowing you to visually examine the sinuses and thoroughly clean them of pus and mucus. But the complexity of the process and the need general anesthesia led to the fact that an increasing number of surgical interventions in the nasal cavity are performed internally. Such manipulations are called functional endoscopic operations in the nasal cavity. For the first time, this method was tested in the 50s of the last century, and since the 60-70s it has been successfully used in otolaryngology all over the world.

Advantages of endoscopy

In states with a high level of medicine, endoscopic practice is considered a kind of "gold standard" in the treatment of chronic forms of inflammation of the sinuses and conditions that are resistant to conservative therapy. One of the clear advantages of such manipulations, especially in comparison with the traditional approach, is no visible postoperative defects because tissue incisions are not required.

Endoscopic surgery

Another advantage - possibility of detailed diagnostics. An endoscope inserted into the nasal cavity is a light-conducting device, with which you can not only qualitatively examine the affected sinuses, but also assess the extent of inflammation, understand anatomical features and to identify "surprises" in advance. And most importantly - to find and neutralize the focus of the disease, thereby speeding up the recovery time, reducing the risk of injury and possible complications. After such an intervention, a scar does not form, pain at the stage of rehabilitation are less pronounced, although swelling of the mucous and soft tissues may persist for several days.

The paranasal sinuses are equipped with thin canals made of bone, which are covered with mucous tissue. With any inflammation, be it allergies or viral rhinitis, these tissues swell and block the passage. Endoscopic surgery on the maxillary sinus (see the video in the gallery of the site) is aimed precisely at expanding the bone canal. Another plus of this intervention is that even if the patient encounters lesions of the nasal cavity again in the future, the lumen in the sinuses will not close, which gives an advantage in the treatment of subsequent acute conditions.. In addition to the main task of increasing the bone canal with the help of endoscopic techniques, it is possible to eliminate a variety of unnecessary tissues in the nasal cavity: cysts, polyps, growths.

Advantages of endoscopic surgery

Since the surgical field during such operations is located close enough to the vital organs, safety and precision of manipulations are of paramount importance. In this regard, the endoscopic technique is constantly being improved and studied.

One of the key updates in recent years is the use of imaging control: a computer program that receives data from CT processes the incoming information in a special way and recreates a three-dimensional image of the patient's nasal cavity.

In such a layout, the entire structure of the sinuses and adjacent soft tissues is displayed, moreover, using such a program, it is easy to track each surgical instrument and calculate further actions. Such a technique involving visual control is more often used in complex cases: with severe damage to the paranasal sinuses, ineffectiveness of conventional operations, with a non-standard structure of the patient's nasal cavity.

Preoperative preparation

The first and one of the most important stages before the intervention is diagnostics, which allows you to determine the cause of the development of the disease, the characteristics of the disease, the condition of the air passages and outline a treatment plan. For this, X-ray, CT, olfactory analysis, cytology and rhinomanometry data are used, revealing thickened walls of the mucous membranes, cysts, polyps, localization of blockage of the nasal lumens and other elements of the disease. Accurate knowledge allows you to decide on the tactics of treatment in general and the strategy of surgical intervention in particular.

Carrying out endoscopic procedures

If earlier in the surgical practice of ENT doctors it was believed that the complete elimination of severe and chronic forms of sinusitis requires a major elimination of the mucous membranes of the nasal sinuses, then the modern technique of FEHP (functional endoscopic sinus surgery) completely refutes this opinion. The technical base and updated instruments used in endoscopic operations provide a sparing intervention mode with preservation of mucous tissues . At the same time, the outflow of purulent mass and mucus improves, the air passages are restored, and the shells themselves get the opportunity to regenerate and self-correct.

Sinus cleaning

Cleaning of the maxillary sinuses - an operation carried out under the influence of local anesthesia, which reduces the time of manipulation and accelerates the rehabilitation of the patient. First, an endoscope equipped with microvideo cameras is inserted into the nasal cavity. It allows surgeons to visually assess the amount of work, structural features of the sinuses and detect the primary focus of the disease. Then, after the endoscope, special microinstruments are introduced into the affected area, ensuring high accuracy of each movement of the doctor. As a result, the affected tissues are removed without any harm to healthy cells, which has a beneficial effect on postoperative recovery.

This method minimally injures the mucous membranes and, since most interventions are performed by access through the nostril openings, it does not leave external defects in the form of scars or scars. After endoscopic procedures, there may be slight swelling, soft tissue swelling and slight discomfort.

Foreign body in the nose

Along with pathogens, inflammation of the maxillary sinuses can cause a foreign body to enter the nasal cavity. If in young children this happens due to accidental inhalation of small objects or particles of food and with one's own hand stuffing elements of toys into the nostrils, then in conscious adulthood, dental procedures are most often the cause. Another way for foreign particles to enter the sinuses is an open wound. A sign of foreign elements in the nasal passages can be a copious secretion of mucus from one nostril. But there are cases when an object that has entered the nasal cavity at first does not cause inconvenience, but over time it necessarily provokes inflammation.

Removal of a foreign body by endoscopic surgery

With the development of minimally invasive techniques, the operation to remove a foreign body from the maxillary sinus began to be carried out using an endoscope, which allows you to carefully eliminate the stuck object without harm to healthy tissues. In some cases, the extraction of particles is carried out through access under upper lip. The size of the hole does not exceed 4 mm, which ensures the safety of the anastomosis of the maxillary sinus.

Unfortunately, endoscopic equipment is quite expensive, so such operations are not performed in all medical institutions, moreover, for a flawless intervention, knowledge and practical experience surgeon.

There are many diseases of the nasal cavity and maxillary sinuses, which are accompanied by the accumulation of purulent exudate and the formation of pathological growths on the mucous membrane. And if they can be removed from the nasal cavity quite easily, in the case of the maxillary sinuses, complicated procedure maxillary sinusectomy. Previously, it was performed by a rather traumatic method, until endoscopic maxillary sinusotomy appeared. This procedure allows you to eliminate pathological contents in the sinuses through small incisions or punctures, which minimizes the risk of complications and shortens the rehabilitation period.

The maxillary sinus is located above the upper jaw and is connected to the nasal cavity by a small fistula, the diameter of which does not allow full drainage and sanitation. If we consider the older methods of removing pathological tissues (cysts, polyps, etc.) and exudate from the sinuses, it turns out that they were all rather traumatic procedures. A long study of the problem and the creation of endoscopic instruments made it possible to get away from old methods and increase the efficiency of the procedure.

To date, experts have almost completely switched to endoscopic micromaxillary sinus surgery, a procedure in which all manipulations are performed through small punctures in the walls of the maxillary sinuses. There are alternatives to performing surgical endoscopy of the sinuses, but they are not always as effective and affordable.

Radical maxillary sinusectomy

The method is considered radical and quite traumatic, since for access to maxillary cavity a fairly wide (about 10-15 mm in diameter) hole is needed in the wall of the sinus. The most common surgery according to the Caldwell-Luc method, in which an incision is made on the gums of the upper jaw and the mucosal flap is pushed back. The exposed bone tissue is pierced with a drill or pierced with a chisel, after which the hole is expanded with forceps and penetrated into the sinus for further manipulations.

Compared with endoscopic removal of the maxillary sinus cyst, the radical method has significant drawbacks.

For example, the doctor does not have sufficient visibility to remove all pathological fragments. In addition, the wound after the intervention is large enough, which favors its infection and complications.

laser method

According to the type of access, laser maxillary sinusotomy does not differ from the classical radical intervention. The only difference is that to remove a cyst from the sinus, not classic instruments (forceps, loops, etc.) are used, but a laser emitter. The method remains the same traumatic, but the risk of recurrence is reduced due to better elimination of pathological foci.

Endoscopic maxillary sinusectomy

Access to the sinus cavity during endoscopic maxillary sinusectomy is carried out through small punctures:

• in the anterior wall of the maxillary sinus (in the mouth);
• through natural fistulas;
• through oroantral perforations (most often these are fistulas formed during the pathological process);
• through the lower nasal passage.

When accessing, not large instruments are used, but small-diameter trocars. The doctor gets the maximum view thanks to a miniature camera, and the removal of pathological is carried out mechanically, but laser or wave emitters are more often used.

Puncture

Puncture is considered the most affordable method, which is used if a full-fledged surgical intervention is impossible due to the abundance of purulent contents in the maxillary sinus or an effusion of unclear origin. Also, the method has justified itself in case the necessary manipulations with sinusitis did not give a result.

The essence of the puncture is the removal of the contents from the sinus by means of a special needle, which is inserted through the nasal septum under local anesthesia. After reaching the sinus needle, the doctor attaches a syringe to it and pumps out the contents of the cavity. After that, it is washed with antiseptics and antibiotic solutions.

Advantages and disadvantages of maxillary sinus endoscopy

When removing a cyst in the maxillary sinus or eliminating a pathological effusion, the ratio of effectiveness and safety of the procedure is evaluated. In this regard, the classical method is significantly inferior to endoscopic sinus surgery.

The main advantages of intervention using an endoscope:

• absence of extensive damage to the mucous membranes and bones;
• wide view of the sinus;
• full access to the maxillary cavity;
• low risk of complications and relapses;
• short recovery period;
• the method allows for a variety of manipulations, including the removal of a foreign body, cysts, effusion, polyps from the sinuses.

The operation is performed in a hospital and is the most acceptable for patients who are contraindicated in classic maxillary sinusectomy.

There are practically no disadvantages of endoscopic maxillary sinusectomy. The only "minus" of such an operation is higher than that of a puncture and radical operation, price.

Indications and contraindications for

Maxillary sinusectomy is indicated in the presence of diseases of the upper respiratory tract with involvement of the membranes of the maxillary sinus in the pathological process, especially if during the development of inflammation a purulent exudate, effusion or cyst forms in its cavity.

Doctors call unconditional indications for the procedure:

• chronic process with sinusitis;
• chronic sinusitis and nasal congestion, which are characterized by the presence of inflammatory processes;
• the presence of polyps and other neoplasms in the sinuses of the nose;
• accession of a purulent infection during the development of sinusitis;
• inefficiency conservative treatment with sinusitis, sinusitis and other pathologies.

To endoscopic removal cysts of the maxillary sinus, its release from purulent accumulations, do not resort to exacerbation of the chronic process. If the risk of spreading the infection is high, a puncture is prescribed for drainage and sanitation of the cavities.

In addition, the main contraindications to sinusectomy using endoscopic equipment include systemic diseases:

• poor blood clotting;
• malignant processes in the field of intervention;
• conditions in which general anesthesia cannot be used.

It is undesirable to perform this type of intervention to correct breathing problems in children under 3 years of age.

How is an endoscopic sinusectomy performed?

Before removal of a cyst in the maxillary sinus by an endoscope, the patient undergoes full examination. In the presence of acute inflammatory processes, preparation for sinusectomy includes a course of antibiotics and local anti-inflammatory drugs.

An operation is performed to eliminate the pathologies of the maxillary sinuses in a hospital. The patient is seated in a chair in a semi-recumbent position. The next step is application vasoconstrictor drops, due to which the swelling of the mucous membranes subsides and facilitates the manipulation. After that, the doctor applies anesthesia. Its type is discussed before the start of the operation, but in most cases local anesthesia is used for adult patients, and short-term general anesthesia is indicated for children.

After the anesthesia takes effect, the operation begins to remove the cyst and the contents of the maxillary sinus. The doctor makes a hole with a trocar that leads to the sinus, and inserts endoscopic equipment through it. First of all, it is a flexible endoscope tube with a camera and a light source and manipulators.

It is interesting! Modern endoscopes are so miniature that they can even be inserted through a canal in the tooth, the root of which goes into the maxillary sinus.

After assessing the condition of the sinus, the doctor, if necessary, rinses the cavity with sterile saline and performs the necessary manipulations: excised cysts or polyps, removes foreign bodies, takes pinches for histology. After that, the doctor re-processes the cavity, if necessary, coagulates the vessels and removes endoscopic instruments from the nasal cavity and, if necessary, places filling materials.

On average, the entire procedure takes about 20-30 minutes. Hospitalization takes no more than 3 days after the operation. During this time, the patient's edema subsides, full breathing through the nose is restored.

How long does recovery and rehabilitation take?

Recovery after endoscopic sinus surgery takes no more than two weeks. The initial recovery period is the hardest. At this stage, there is noticeable swelling of the face, and the risk of infection remains high. Therefore, in the first week, the patient is recommended various procedures and methods for restoring the mucous membranes and other structures of the nose:

• sanitation of the nasal cavity with saline solutions up to 10 times a day;
• instillation into the nose of drops with a vasoconstrictor and anti-edematous effect;
• it is recommended to do inhalations with a nebulizer so that the mucous membrane does not dry out;
• taking antibiotics for a week in dosages determined by the doctor;
• oral hygiene.

If the operation was through the teeth and the removal of the filling material was required, a visit to the dentist may be required to restore the filling. The temporary “patch”, which was installed at the end of the manipulations, is recommended to be removed after 3-5 days.

For at least two weeks, the patient is contraindicated physical exercise, stresses, including hypothermia and overheating. The diet must include vegetables and fruits. To strengthen the immune system, it is useful to take vitamins in combination with trace elements.

Possible Complications

Experts say that complications after sinusotomy are rare. Their appearance is due to non-compliance with the recommendations of the doctor during the rehabilitation period. So, a hot bath, sauna, ice cream or too hot tea can cause complications. Therefore, to prevent any problems, you need to follow the advice of a doctor, even if they seem frivolous or optional.

The most common possible complications after this type of intervention:

• swelling on the cheek and pain in the teeth - this species complications appear if during the manipulations affect the roots of the teeth, but may also indicate a re-infection, which requires repeated intervention;
• headache - most often this is a consequence of the action of anesthesia;
• facial deformity - may indicate injury to the trigeminal nerve, requires surgical correction and therapy;
• an increase in temperature indicates a resumption of inflammation.

In the presence of severe symptoms, the doctor may refer to sinusoscopy and repeated endoscopic maxillary sinusotomy. However, this happens extremely rarely. In most cases, after a couple of weeks, a person returns to a normal lifestyle.

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Endoscopic methods of surgery are associated with the risk of various injuries and complications typical for surgery of the paranasal sinuses. Serious complications occur, fortunately, extremely rarely, but in those cases when they occur, they can be dramatic: such complications should include, first of all, damage to the orbit and intraorbital structures, optic nerve, the dura mater of the anterior part of the base of the skull and the periosteum of the cranial cavity adjacent to it, as well as the internal carotid artery and other venous sinuses of the brain.

Intraorbital bleeding caused by retraction of the severed anterior ethmoid artery into the orbit can lead to dangerous bulging and vasodilatation with vascular compression and possibly local ischemia, whereby patients may be at risk of narrowing the field of vision and deterioration, even loss of vision. Like any method of sinus and skull base surgery, endoscopic methods should be used only after appropriate preparation and careful study of the anatomy and anatomical options. The "single surgeon" must either be able to cope with the complications that arise, or have contact with a nearby clinical institution that has all the necessary prerequisites for this.

In more than 10,000 patients operated on at the Otorhinolaryngological University Hospital in Graz over the past 20 years, only 6 cases developed an iatrogenic cerebrospinal fluid fistula. In all cases, this defect was eliminated, and there were no complications or irreversible damage. In connection with the endoscopic interventions, there were no cases of damage to the optic nerve, impaired eye mobility, not to mention death. The world of specialists has long overcome the initial skepticism. Today, all residents in the 4th year of training attend an introduction to endoscopic surgery, while endoscopic diagnostics is included in the main training program from the very beginning.

Rice. 1. Surgical interventions in the ethmoid bone and in the area of ​​the nasal cavity are associated with risk serious complications. This damage to the dura mater with the formation of a cerebral hernia occurred during surgery on the nasal septum.

A thorough knowledge of endoscopic technique and skill in handling endoscopes and instruments should eliminate the risk of injury to the patient. On fig. 2 schematically depicts a case of a serious complication documented in the medical literature: a surgeon with basic knowledge of the anatomy of the nose and its paranasal sinuses should know that a straight, rigid endoscope with a length of approx. 18 cm cannot be simply "immersed" in the nose to the lens.

Summary

The Messerklinger method is primarily an endoscopic diagnostic concept based on an understanding of the pathophysiology of sinusitis. In this concept, the large paranasal sinuses are considered as "subordinate" cavities, the diseases of which in the vast majority of cases are rhinogenic and therefore are of a secondary nature. At the same time, the key role of bottlenecks is highlighted. anterior section ethmoid bone in normal and pathophysiology of PPN. This concept also confirms that conventional rhinoscopy, as well as plain radiography of PPN, is in most cases insufficient to identify the cause of acute or recurrent sinusitis. The combination of diagnostic endoscopy of the lateral wall of the nasal cavity using rigid endoscopes with conventional or computed X-ray tomography with coronary reconstruction of the obtained sections turned out to be ideal for diagnosing inflammatory diseases of PPN.

Based on the experience gained in endoscopic diagnosis, the concept of endoscopic surgery has been developed, aimed not at eliminating the symptoms, but at treating the diseases that cause them and pathological changes in key places of the ethmoid bone. Sanitation of diseased areas of the ethmoid bone is carried out by small and short-term targeted surgical interventions. At the same time, the frontal and maxillary sinuses themselves are affected only in rare cases. This is not a routine sphenoethmoidectomy, although the Messerklinger method allows it to be performed. and always individual surgical intervention, carried out taking into account this pathology.

In cases where it is necessary to expand the opening of the maxillary sinus, it is carried out at the expense of fontanelles. Thus, we get a wide opening in a physiologically predetermined place, to which the secret will move along genetically determined paths. In addition, the physiological pathways of ventilation and drainage are restored. There is no need to subject the medium turbinate- except when it is pneumatized (bullous) - surgical intervention, in particular, does not need to completely or partially resect it

The key to the successful application of the Messerklinger method is accurate preoperative diagnosis and atraumatic surgical treatment under the superficial and local anesthesia with little bleeding. Any unnecessary damage to the mucous membranes and, above all, the creation of opposing wound surfaces should be avoided. The same care and precision is required as in middle ear surgery. In most cases, the duration of the operation and, accordingly, the burden on the patient is relatively small.

This method can be used in a wide range of indications, not only for massive nasal polyposis, but due to the low burden created by gentle surgery under local anesthesia, also in patients in whom (e.g. due to their advanced age) intervention under general anesthesia would be associated with great risk.

The mucous membranes of the paranasal sinuses have a high regenerative capacity, as evidenced by the fact that the frontal and maxillary sinuses, even with massive pathological changes, in the vast majority of cases are completely cured after the sanitation of the ethmoid bone, without being themselves affected.

Messerklinger method as the first stage surgical treatment inflammatory diseases PPN practically does not know the indications for radical intervention from the outside. The Messerklinger method has its limits and specific difficulties. With its help, not all problems arising in connection with inflammatory diseases PPN. Although this method can achieve a marked improvement in patients in some cases of allergies, asthma, cystic fibrosis and diffuse polyposis, it does not provide a definitive solution to these problems. But since radical methods operations do not bring the best treatment results in the long term, we also prefer the patient-friendly Messerklinger method for these diseases.

Today, using the improved FESS method, low-traumatic endoscopic surgical interventions can be performed for numerous additional indications: from cerebrospinal fluid fistulas and encephalomeningoceles, compression of the orbit and optic nerve to tumors of the skull base, pituitary gland, and, in some cases, nasopharyngeal fibromas. In these cases, the concept of endoscopic surgery we present is not new; it uses the possibilities of a less traumatic intervention, based on well-known, well-proven methods of operation, which until now required surgical access from the outside.

The described method requires thorough preparation and proper training. It is associated with the same risk and the same complications. which are also found in other methods of endonasal ethmoid surgery. But clinical results have shown that this method correct application experienced surgeons has a very low complication rate.

Heinz Stammberger

Endoscopic diagnostics and surgery for diseases of the paranasal sinuses and anterior part of the skull base

Optical methods for examining the paranasal sinuses in last years are becoming more widespread. In combination with other diagnostic methods, they help the doctor to make an accurate diagnosis and carry out the necessary treatment. Endoscopy is indispensable in complex diagnostic cases, with discrepancies in clinical picture disease and results.

Despite the fact that the procedure is relatively safe and minimally invasive, it is still traumatic (for the insertion of the endoscope, the sinus wall is punctured, as with a conventional puncture), and general anesthesia is often used for its implementation. That is why there are certain indications for endoscopic examination, which the doctor takes into account when prescribing this type of examination. Currently, otorhinolaryngologists perform endoscopy of the maxillary and frontal sinuses.

Modern devices are complex technical devices equipped with special optics with a wide viewing angle, video recorders, digital video signal converters, and various auxiliary tools. Thanks to this device, the doctor can directly examine the sinuses by receiving an image on the monitor screen. In otorhinolaryngology, rigid endoscopes are commonly used to examine the paranasal sinuses, which retain their shape during the procedure.

Goals of endoscopic examination of the sinuses

The paranasal sinuses are located in the human body in such a way that it is impossible to examine them without the help of special devices. It is endoscopy that helps to solve this problem. Typically, a specialist performs this procedure to achieve the following goals:

• early detection of the pathological process in the sinuses;
• resolving issues differential diagnosis and taking the contents of the sinus for analysis (to isolate the pathogen and determine its sensitivity to antibacterial drugs);
• biopsy of suspicious areas and morphological examination;
• preparation for surgery or control of treatment after it.

Indications for use

When prescribing an endoscopic examination, the ENT doctor carefully examines the patient and studies the history of the disease, and then determines the need for the procedure. Indications for diagnostic endoscopy are limited, consider the main ones.

1. Clarification of the diagnosis in case of damage to the sinuses of the unknown origin (when using simpler methods it is not possible to establish the cause of the disease).
2. Sinus injuries.
3. Anomalies in the development of the paranasal sinuses.
4. Polyposis.
5. Carrying out various medical procedures.

Methodology

Preparation of the patient for endoscopic examination includes the toilet of the nasal cavity and anesthesia. Penetration into the paranasal sinuses can be performed under general intubation anesthesia or local anesthesia in combination with low-dose tranquilizers or barbiturates.

For endoscopy of the maxillary sinus, in most cases, access through its anterior wall is used. This is due to the peculiarities of its structure.

• To do this, using a special trocar, a hole is drilled between the third and fourth teeth with rotational movements.
• Then, an endoscope with an optical resolution of 0 to 70 degrees is inserted into the resulting hole through the trocar sleeve.
• The specialist examines the walls of the sinus, evaluates the color and relief of the mucous membrane, identifies the affected area (if any) and performs all the necessary manipulations (tissue sampling for analysis, opening of the cyst, etc.).
• At the end of the procedure, the trocar is carefully removed.
• The perforation site is not sutured.

The doctor also receives important information during the examination of the anastomosis of the sinus with the nasal cavity. At the same time, its dimensions, the presence or absence of polyposis growths and other pathological changes in the mucosa of the anastomosis are determined. The data thus obtained make it possible to determine the tactics of managing the patient. If during endoscopy there is an opportunity to eliminate a limited pathological process or to free and expand the anastomosis, then the procedure ends there. If the specialist reveals extensive changes, then this may be an indication for a wider surgical intervention.

Conclusion

Endoscopic examination of the paranasal sinuses is an original diagnostic method, which makes it possible to inspect with an increase in all details of a complex configuration. By conducting a study from different angles of view, the doctor receives information about all hard-to-reach or anatomically narrow places of the sinuses and can assess not only their condition, but, if necessary, perform microsurgical intervention.