Treatment of the nasal cavity after endoscopic surgery. Endoscopic surgery for chronic sinusitis

Currently, endoscopic sinus surgery is developing rapidly and has already won the status of minimally invasive surgery, functional surgery, etc. in otorhinolaryngology and in head and neck surgery.

Most of the work on endoscopic surgery at pathological conditions nasal cavity and its paranasal sinuses, concerns its use in inflammatory diseases. D. Kennedy and B. Senior state that the use of endoscopic technologies in such conditions of the nasal cavity and its paranasal sinuses is a progressive method that allows limiting the volume of surgical intervention with sufficient access.

In addition to the improvement and development of diagnostic methods, an important role in the achievements of endoscopic surgery in general and surgical interventions in the nasal cavity and paranasal sinuses in particular is played by the progress of scientific and technical thought in the creation of new tools.

Development of methods for diagnosing and treating paranasal sinuses

Article by N. Krouse et al. contains a general discussion of mechanical-power instrumentation, which has gained popularity in otorhinolaryngology due to its safety and effectiveness in sinus surgery. Understanding the principles and techniques of mechanical-power dissection in the paranasal sinuses, exposure, installation and management of instruments, pre- and postoperative care is necessary for otorhinolaryngologists involved in the treatment of such patients. More detailed and important information on the question of interest are available in the works considered below.

It is known that during endoscopic operations, stereoscopic vision and tactile information about tissue consistency are not always available to the surgeon. To overcome this shortcoming, P. Plinkert and H. Lowenheim propose a method for characterizing various tissues with an electromechanical sensor that determines their resonant frequencies. In the future, an electromechanical sensor is supposed to be connected to a surgical instrument, providing the surgeon with information about the tactile properties of tissues. The authors used this method to study the density of tissues removed during surgery (nasal polyps, The lymph nodes, cartilage, bone), as well as various bone structures of the skull.

The studies were carried out under conditions of experimental simulation and subsequently with a prototype of a tactile sensor. The authors concluded that the resonant frequencies increase with increasing tissue density. Measurements on the experimental model showed that the resonant frequencies for soft tissues are in the range of 15-30 Hz, for the bone septum of the ethmoid labyrinth - 240-320 Hz, and for denser bone structures of the base of the skull - 780-930 Hz. Characteristics of the tumor tissue of the upper sections respiratory tract and primary departments of the digestive tract indicate the possibility of distinguishing between healthy mucosa, tumor-infiltrated mucosa, and tumor-infiltrated tissue under the mucosa. In the latter cases, the resonant frequencies of the tumor were 1/3 higher than those of the healthy mucosa. The results obtained in the experiment were reproduced using a sensor prototype. The authors emphasize that the use of information about the tactile characteristics of tissues in endoscopic otorhinolaryngological surgery can improve the differentiation of tissue structures during surgery in the future. In addition, it will increase the safety of minimally invasive interventions in head and neck surgery.

Instruments for removing pathological tissues in sinus surgery have also improved.

So, G. McGarry et al. reported the invention of a microdebrider (microforceps) for endonasal surgery, which allows accurate and precise tissue removal without damaging the surrounding mucosa. However, it should be emphasized that a conventional instrument may render the removed tissues unsuitable for histological examination. This problem is made even more evident by the fact that the Hummer microdebrider does not have a mechanism to collect the removed tissue pieces. Using a microdebrider, 21 people were operated on for paranasal sinus polyposis. During the intervention, the removed preparations were collected in a special trap. At the same time, tissue biopsy from the surrounding areas was performed for comparison. Pathological anatomical diagnosis was established in all patients. Transitional cell papilloma was revealed in one observation, inflammatory polyposis in the remaining 20, and granuloma in 2 of them. Traces of injury were limited to the respiratory epithelium. Subepithelial tissues were not affected, metaplastic epithelium was intact.

The use of a microdebrider makes it impossible histological examination. The removed tissues have minor “artifacts” and are preserved for pathoanatomical diagnosis.

The work of D. Becker discusses the engineering and technical aspects of the problem of cutting devices - "razors" for soft tissues and drills for bone. An in-depth understanding of the principles of their work will allow the surgeon to optimize the effectiveness of the instruments used. These mechanical instruments can be used not only within the boundaries of the sinuses, but also for submental lipectomy (“razor” for soft tissues), reshaping of the nasal wall (drill for bone tissue). The authors touch upon the issues of changing the design of tools for these and other purposes.

Some aspects of these issues concerning children's practice are covered by M. Mendelsohn and S. Gross. They presented the latest examples of mechanical instruments for various areas of nose and paranasal sinus surgery, especially in children. Anatomical spaces in children are smaller and much closer to vital structures. The advantage of the “razor” apparatus for soft tissues is the possibility of simultaneous suction, which increases the accuracy of manipulation.

J. Chow and J. Stankiewicz used similar mechanical instruments to decompress the orbit and optic nerve. This toolkit helps to carry out operations as safely, functionally and in full as possible. The use of a microdebrider and a drill under conditions of endoscopic imaging makes it possible to achieve the necessary drainage and decompression in cases of orbital abscesses, ophthalmopathy, and optic nerve injury.

J. Bernstein et al. studied the effect of microdebrider on tissue healing after use in endoscopic surgery of the paranasal sinuses. The formation of synechia, often observed after endoscopic operations on the paranasal sinuses, can cause exudative manifestations in the sinus region. To reduce the frequency of this complication, various approaches are used: careful and accurate surgical technique, partial resection of the middle turbinate, insertion of tampons or stents into the middle nasal passage, postoperative debridement. The microdebrider is a mechanically rotating cutting device for precise tissue removal, minimizing mucosal injury and crushing. The authors presented the experience of 40 endoscopic operations on the paranasal sinuses performed using a microdebrider. The patients were followed up for 5 months. Rapid healing of the mucosa, minimal formation of scabs and crusts, as well as a low frequency of adhesions - synechia were noted. These initial results suggest certain advantages of microdebriders in chronic sinusitis surgery.

W. Richtsmeier and R. Scher used Hopkins angled endoscopes, in particular in the larynx and laryngopharynx area, to expand surgical options during endoscopic surgery. Usually surgical interventions in these areas are carried out directly, under the naked eye, or under an operating microscope. We analyzed 48 cases in which solid endoscopes were used. The authors found significant advantages of endoscopic systems when operating on surfaces that are not in the direct line of sight of the surgeon, such as, for example, the walls of the hypopharynx, the base of the epiglottis, the ventricles, and the posterior commissure. Endoscopes with viewing angles of 30° and 70° are recognized as convenient to use, however, in these cases, appropriate instruments were required. To remove lesions on vertical surfaces, the use of a laser (titanium phosphate oxide) through a flexible fiber optic conductor has an advantage. Endoscopes also allow the use of large instruments proposed for intra-abdominal and intra-thoracic surgery, blocking the view through the operating microscope. Telescopic imaging of the larynx and laryngopharynx lends surgical manipulations a more traditional form of endoscopic surgery.

Anesthesia in endoscopic nasal surgery

A certain place in the organization of interventions in endoscopic surgery of the nasal cavity and its paranasal sinuses, in addition to providing instruments, is occupied by the issues of adequate anesthesia. Its form - local or general - is determined by the localization and prevalence of the object of surgical intervention and the type of pathological focus.

For the nasal cavity and its paranasal sinuses are often used local anesthesia. M. Jorissen et al. studied the possibilities of such anesthesia and contraindications to its use. When performing endoscopic surgical interventions in the paranasal sinuses, the authors make one intramuscular injection as a systemic premedication (pethidine and promethazine) and conduct local anesthetic treatment (a few drops in the nose, cocaine lubrication, lidocaine infiltration). Such anesthesia is well tolerated by 95% of patients. Blood loss is minimal with adequate anesthesia.

Long-term results of endoscopic interventions

Analysis of long-term results and complications of mini-endoscopic interventions on all paranasal sinuses in chronic polypous sinusitis was carried out by R. Weber et al. The study included 170 patients who underwent bilateral endonasal mini-endoscopic sinus surgery or ethmoidectomy. The follow-up period ranged from 20 months. up to 10 years old. A study conducted by grading results, i.e. comparison of clinical findings and the surgical material to be evaluated showed the effectiveness of the intervention in 92% of cases. In the analysis of complications, the frequency of injuries of the dura mater ranged from 2.3 to 2.55%, periorbital formations - from 1.4 to 3.4%. In 2 cases, there was bleeding from the internal carotid artery. According to the authors, the problem of vascular complications should be carefully studied and discussed. In conclusion, the work emphasizes that more than 90% of patients with chronic polypous sinusitis can achieve satisfactory long-term results after endonasal ethmoidectomy using a microscope and endoscope. To minimize the risk of injury to the optic nerve or internal carotid artery, it is necessary to carry out in the preoperative period computed tomography. A special training and education program is also recommended.

The issues of healing of the mucous membrane of the paranasal sinuses after endoscopic intervention in the experiment were dealt with by D. Ingrams et al.

Y. Guo et al. investigated the effect of functional endoscopic surgical treatment sinuses on the epithelial lining of the mucous membrane maxillary sinus. We studied biopsy samples of the mucous membrane of the supralateral wall and the area of the bone foramen, which were taken during the operation and after 6 and 12 months. after it (average after 7.6 months). The study of the integumentary epithelium was carried out with a scanning electron microscope and an image analyzer, which was enhanced in the area of the integumentary epithelium, where the surface of the mucous membrane was covered with ciliated (integumentary) epithelium. In 20 cases of chronic maxillary sinusitis (16 patients), functional endoscopic operations. The saturation of the right and left sides with ciliated epithelium before surgery was 60.7+28.8% and 39.9+21.5%, respectively, in the area of the supralateral wall of the maxillary sinus and in the area of the opening. The saturation of the ciliated epithelium of the supralateral wall was significantly higher than in the region of the opening of the maxillary sinus (p<0,01). После операции основная насыщенность эпителиального покрова составила 74,3+22,6% в области супралатеральной стенки и 51,3+16,1% в области отверстия верхнечелюстной пазухи, т.е. значительно превышала предоперационную (р<0,01). Исследование показало, что слизистая оболочка верхнечелюстной пазухи при хронических синуситах способна регенерировать, а разрушенный реснитчатый эпителий может восстановиться до нормы с улучшением условий вентиляции и дренирования верхнечелюстной пазухи после эндоскопического хирургического вмешательства.

The lack of timely and adequate treatment of inflammatory processes in the nasal cavity and its paranasal sinuses is often the cause of the development of polyposis of these structures. The effectiveness of endoscopic technologies is obvious here.

R. Jankowski et al. conducted a comparative study of the functional results of ethmoidectomy and nasalization (the imposition of a wide fistula to restore the passage of air masses) in patients with diffuse polyposis. By “nasalization” the authors mean radical ethmoidectomy with the systematic removal of all bone cells and the mucous membrane of the ethmoid labyrinth with extended antrostomy, sphenoidectomy, frontotomy and removal of the middle turbinate (R. Jankowski operated on 39 patients between March and September 1991) . Ethmoidectomy was used less systematically, but was adequate to the prevalence of the pathological process (the second author, D. Pigret, performed 37 operations between October and November 1994). In May 1994, the third author, F. Decroocq, sent a questionnaire by mail to patients participating in the study: 34 out of 39 “nasalization” groups (age 28-71 years, including 20 “asthmatics”, follow-up period 32-36 months. ) and 29 out of 37 “ethmoidectomy” groups (age 26-55 years, including 9 “asthmatics”, follow-up period 18-31 months). The total number of cases of improved breathing was 8.8+0.2 after nasalization and 5.9+0.6 after ethmoidectomy. The improvement in sense of smell was similar in the groups after 6 months. after surgery and remained at the same level for 36 months. after nasalization (6.9+0.7 patients), while after ethmoidectomy, the sense of smell worsened to 4.2+1 after 24 months.

The improvement in the condition of patients with asthma was significantly more pronounced in the nasalization group, the need for steroid hormones was lower in them. The results of this study show that in the treatment of polyposis of the nasal cavity and paranasal sinuses, the more radical the surgical intervention, the better the functional results.

The study of J. Klossek et al. is also devoted to the treatment of polyposis of the nasal cavity and its paranasal sinuses. The authors note that, despite the progress made in recent years in endonasal surgery, diffuse polyposis of the nose and its paranasal sinuses remains an urgent problem. The aim of this work was to evaluate the results of treatment of diffuse polyposis by radical complete sphenoethmoidectomy with pre- and postoperative irrigation of the frontal sinus. The authors examined 50 patients with diffuse polyposis manifested by nasal obstruction, anosmia, and other symptoms of chronic sinusitis. All patients underwent endoscopic sphenoethmoidectomy, which included total opening and sanitation of the cells of the cribriform labyrinth and its pathologically altered mucosa. Preoperative and postoperative irrigation of the frontal sinus was performed. No complications were noted. In 39 out of 50 patients, a satisfactory sense of smell was achieved. Partial nasal obstruction was in 4 patients. By endoscopic examination, recurrence of polyposis was noted in 3% of cases in the posterior, in 23% in the anterior cells of the ethmoid labyrinth and in 50% in the region of the frontal sinus. The authors conclude that with widespread polyposis of the nasal cavity and its paranasal sinuses, total sphenoethmoidectomy with perioperative (before and after the intervention), as well as with subsequent postoperative therapy with the most effective steroid hormones, is indicated, which improves the general condition and local status or ensures a stable recovery.

R. Bolt et al. (1995) reported on the results of endoscopic surgical treatment of polyps in the nasal cavity and paranasal sinuses in children. Endoscopically operated 21 children with nasal polyps, who underwent 34 total operations and 65 unilateral. The symptoms of the preoperative period, examination data, as well as the results of functional endoscopic treatment of the nasal cavity and its paranasal sinuses were analyzed. The diagnosis was established on the basis of data from anterior rhinoscopy and computed tomography scanning. In 24% of cases, an allergic component was identified. Half of the children (52%) had previously been operated on for nasal polyps. They had a higher recurrence rate and poorer treatment outcomes compared to children in whom endoscopic surgery was primary. Subjective results of treatment were good in 77% of patients with a follow-up period of more than 2 years. However, there was a weak correlation between subjective and objective results. Minor complications were observed in 9.2% of 65 patients operated on one side. The advantages of endoscopic operations in children are noted.

The work of J. Triglia and R. Nicollas is devoted to the same topic. The authors state that polyposis of the nasal cavity and its paranasal sinuses in children is still little known and its etiology is not clear enough. Based on the data of an 11-year study, the authors highlight the etiological factors and evaluate the effectiveness of endoscopic surgery of the nasal cavity and paranasal sinuses in 46 children. No surgical complications were noted. Most patients reported improved quality of life, reduced nasal congestion (83%) and nasal discharge (61%). Small asymptomatic relapses (several micropolyps) were noted in 24% of cases, large relapses with the same symptoms as before surgery - in 12%. However, the number of recurrences was higher in the group of patients with fibrous cyst formation. At the same time, small relapses without any clinical manifestations were observed in 32% of these cases, and large relapses (with obvious clinical symptoms) in 16%. The problems of endoscopic sinus surgery should be decided jointly with the pediatrician and pulmonologist, and the solutions should be carefully worked out. The long-term results of treatment of these patients with a follow-up period of 3.7 years are encouraging.

Endoscopic operations in the treatment of benign tumors and oncology

A number of works are devoted to endoscopic transnasal surgical treatment of benign tumor processes, in particular angiofibromas.

M. Mitskavich et al. removed by intranasal endoscopic way juvenile angiofibroma in a 13-year-old girl. Within 24 months There were no signs of recurrence after the operation. According to the authors, endoscopic surgical technique has been used to treat some benign nasal tumors, such as inverted papilloma, while endoscopic removal of verified juvenile angiofibroma has not previously been reported. This technique is acceptable for tumors that are limited by the size of the nasal cavity and its paranasal sinuses with minimal spread into the pterygopalatine fossa.

R. Kamel back in 1996 reported a case of angiofibroma of the posterior parts of the nasal cavity on the right, nasopharynx and pterygopalatine fossa, which was completely removed without complications by transnasal access under endoscopic control. Within 2 years, endoscopic examinations and computed tomography (CT) with contrast showed no signs of continued growth or recurrence of the tumor. The author noted the advantages, limitations, and possible complications of this approach. It has been stated that size-limited angiofibromas available for the transnasal endoscopic approach can be removed by an experienced surgeon.

J. Klossek et al. published data on the removal of 109 mycetomas of the paranasal sinuses using functional endoscopic surgery. These tumors are most often diagnosed with extensive use of nasal endoscopy and CT. Tumors of all localizations were visible, 7 of them were located in several places (multicentric growth). Several clinical localizations were noted involving all paranasal sinuses. Heterogeneous inclusions with microcalcification, detected by CT, allow the diagnosis to be made with sufficient confidence, while homogeneous inclusions can even be regarded as bone lesions. For a wide opening and review of the affected paranasal sinuses, functional endonasal endoscopic sinus surgery was used in all cases, which allows accurate and thorough removal of tumor-affected areas. In the postoperative period, drug treatment was not prescribed. Long-term results were followed up for 29 months: only 4 recurrences were noted. This study, according to the authors, has increased interest in the use of endonasal endoscopic surgery for mycetomas of the paranasal sinuses.

Having characterized various aspects of the multilateral problem of using functional endoscopic surgery of the nasal cavity and its paranasal sinuses in the treatment of chronic inflammatory processes of a benign nature, one cannot ignore the issue of using the endoscopic method in other areas of medicine, in particular in oncology.

In the work of R. Kamel mentioned above, the study included 17 observations of inverted papilloma of the upper jaw and nasal cavity, which the author divided into two groups.

The first group included 8 cases with lesions of the maxillary sinus; these patients underwent endoscopic resection within healthy tissues.

The second group included 9 cases of damage to the maxillary sinus with or without spread into the nasal cavity; The patients were operated on in the volume of transnasal endoscopic medial maxillectomy.

Follow-up - an average of 43 months. in the first group and 28 months. in the second, with the exception of 5 cases with less than 2 years of study of long-term results, did not reveal relapses of the disease.

The author came to the conclusion that inverted papilloma can be divided into two groups from anatomical and behavioral points of view, and in accordance with this, it should be treated differently. For cases without maxillary sinus involvement, intranasal endoscopic resection is effective. In cases where the maxillary sinus is involved, transnasal maxillectomy is recommended and can be safely performed under endoscopic guidance.

M. Tutino expanded the range of endoscopic interventions, including, in addition to endoscopy, also minimal craniotomies that combine osteotomies and removal of bone tissue fragments to increase the accuracy of manipulations and reduce the number of complications in craniofacial surgery. When implanted into intracranial structures, the author opposes the widespread use of endoscopic techniques to reduce the incidence of complications and mortality during neurosurgical intracranial and plastic surgeries.

Functional transnasal endosurgery of the paranasal sinuses is rapidly being introduced into otorhinolaryngology and maxillofacial surgery, developing in many ways as its component. Naturally, there are differences in the description of the resulting complications, which vary in frequency and severity.

Complications of transnasal endosurgery

R. Gross et al. note that complications were significantly more serious when interventions were performed under general anesthesia compared to those performed under local anesthesia. Estimated blood loss was also significantly higher in operations performed under general anesthesia.

A broader and more detailed study of the problem of endoscopic sinus surgery was carried out by H. Rudert et al. An analysis of the clinical characteristics of patients was undertaken to identify and develop directions for safe surgical techniques. The data on 1172 patients (2010 surgeries) of the head and neck departments of the University of Cologne, who were operated on for chronic sinusitis from 1986 to 1990, were studied. The following postoperative complications were observed:

damage to the dura mater - in 0.8% of patients (0.5%, taking into account operations on the sides);

retrobulbar hematomas - in 0.25% (0.15%, taking into account operations on the sides);

bleeding requiring blood transfusion - in 0.8% of cases (0.5%, taking into account operations on the sides).

There were no cases of injury to the muscles of the orbit, the optic nerve, or the carotid artery. In 195 patients, dacryocystorhinostomy was performed (15% of them had previously been operated on in the area of the nose and its paranasal sinuses).

Proponents of the endonasal technique must recognize the variability of results, especially in cases where bone formations (thickened bone walls of the sinuses) become the subject of surgical activity and the doctor faces great technical difficulties.

The most formidable complication during and after the application of this method of endoscopic interventions is bleeding of various types, degrees, duration and volume.

Park et al. published a protocol for a complication of endoscopic transnasal sinus surgery: injury to the internal carotid artery. Cavernous sinus injury is a well-known terrible complication of endoscopic endonasal sinus surgery. However, information in the literature regarding the prevention and treatment of this complication is very scarce. The authors of the mentioned work discuss the issues of topographic anatomy, preventive measures, approaches to treatment.

Bleeding with less tragic consequences was analyzed by D. Barlow et al. They retrospectively analyzed 44 cases of nosebleeds that required hospitalization in the Newborn Care Center. The study set the following goals:

determine the indications for surgical treatment in such situations;

compare the effectiveness of different types of surgical interventions. In addition, the length of stay in the hospital, complications and the cost of services rendered were assessed.

In 18 patients, conservative methods of stopping nosebleeds were successful, in 26 patients had to resort to surgery. It was found that late nosebleeds (p<0,05) и величина гематокрита менее 38% (p<0,05) являются важными показателями для реализации необходимого хирургического лечения. Повторные кровотечения после первого хирургического вмешательства отмечены в 33% случаев после эмболизации, в 33% после эндоскопической гальванокаустики, в 20% после лигирования сосудов. В то время как эмболизация, перевязка и эндоскопическая гальванокаустика приблизительно схожи по проценту неудач, такие факторы анализа, как стоимость услуг, а также экспертиза в институте, могут оказаться решающими доводами в пользу хирургического метода лечения.

Conservative methods of stopping nasal bleeding are very diverse and consist in the use of hemostatic drugs up to numerous types of tamponade of the nasal cavities and nasopharynx. One of the latest proposed methods is the introduction of hemostatic sponges.

A. Shikani attempted to characterize the bacterial flora of the sinuses with chronic infection and evaluate the possibility of direct administration of antibiotics into spongy tissue in order to prevent the development of infection.

In the process of surgical intervention on the sinuses, the bacterial flora is sown in 89% of cases. The same flora is determined in 67% of cases with cultures from the nasal cavity and its paranasal sinuses after 1 week. after operation. By saturating the spongy structures of the “Merocel” type introduced into the sinuses with polymyxin, neomycin and hydrocortisone, this percentage can be reduced by 36. At the same time, pain is reduced when the sponge is removed from the sinuses during dressings. This confirms the feasibility of using antibiotics when using expanding sponges during endoscopic operations in the nasal cavity and paranasal sinuses.

Measures of prevention and elimination of complications of endoscopic surgery of this zone from the side of the orbit are distinguished by a certain originality. This is due to the high sensitivity of the anatomical formations of the orbit to any changes in their physiological status caused by surgical manipulations in the surrounding areas, both directly and indirectly. Not the last role is played by the topographic relationships of the anatomical structures of this part of the head, which are in close proximity to each other.

Despite the fact that ophthalmic complications during endoscopic operations in the nasal cavity and paranasal sinuses are well known, they are rare in clinical practice. Therefore, any reports on this topic are of undoubted interest to specialists.

So, I. Dunya et al. to study the frequency of complications from the orbit after intranasal interventions on the cribriform labyrinth, an analysis of 372 cases was carried out. In most of them, bilateral operations were performed. The authors found 5 ophthalmic complications. In their opinion, the following practical recommendations can help surgeons avoid complications:

if there is a suspicion of a violation of the integrity of the wall of the orbit (both according to CT and during surgery, especially with repeated surgical interventions), extreme care must be taken not to enter the periorbital tissues;

if the fatty tissue of the orbit falls into the operating field, it should not be injured (squeezed, twisted) when trying to remove it;

during the treatment of the patient, the surgeon and the anesthesiologist should work closely together;

good knowledge of anatomical variants avoids iatrogenic complications;

the surgeon is able to prevent a serious complication if he is able to recognize it at an early stage and take the necessary measures.

It is known how formidable inflammatory complications from the orbit can be (up to meningitis and thrombosis of the cavernous sinus through v. ophthalmica), if countermeasures are not taken in a timely manner. From this point of view, periorbital cellulites require serious attention, although they are often limited in localization to the preseptal region. In the absence of adequate therapeutic measures, they may be accompanied by post-septal inflammation and orbital subperiosteal abscesses (SPA). Surgical treatment of SPA consists in wide drainage - removal of cells of the ethmoid labyrinth by an external approach. Recently there has been a report on the use of endoscopic techniques for this purpose.

E. Page and B. Wiatrak studied the incidence and clinical presentation of post-septal cellulitis and orbital SPA in patients with periorbital cellulitis, as well as the effectiveness of endoscopic techniques in orbital SPA. In the period 1989-1994. observed 154 patients diagnosed with periorbital cellulitis. Postseptal inflammation was revealed in 19 of them. Surgical treatment was performed in 14 patients using an external approach, endoscopic intervention, or a combination of both. The authors managed to establish the following:

the role of paranasal sinus pathology as a cause of periorbital cellulitis;

the role of CT as a diagnostic test;

the effectiveness of aggressive active and timely drug therapy;

results of endoscopic drainage of orbital spas compared with those after external approach.

In this regard, it is impossible not to mention bleeding in this area as one of the causes of the development of inflammation, and also in view of their independent danger and the severity of the consequences, up to loss of vision, etc.

S. Saussez et al. met in their practice with 2 similar cases of orbital complications after intranasal endoscopic surgery. One complication arose in the immediate postoperative period - orbital hematoma, which required urgent decompression by lateral canthotomy. The second complication was acute bleeding in the orbit, which also required urgent lateral canthotomy. Both observations demonstrate the ability to quickly and safely surgically (lateral canthotomy) reduce intraorbital (intraocular) pressure.

Among the reasons for the increase in intraorbital pressure can be not only bleeding, but also swelling of the retrobulbar and periorbital tissue of various origins. All anatomical structures of the orbit, in particular the nervous tissue, can be subjected to compression. Its compression, leading to optic neuropathy, can also occur in patients with thyroid pathology - thyrotoxicosis, the so-called Graves' disease. In other words, this condition can be called "orbitopathy of thyroid origin."

To treat this dangerous complication, many surgical approaches have been proposed, thanks to which it is possible to achieve intraorbital decompression.

S. Graham and K. Carter described the technique of subciliary anterior orbitotomy - approach to the floor of the orbit with endoscopic resection of its medial wall. This allows you to remove the bone tissue of the bottom of the orbit medial and lateral to the infraorbital canal (inferoorbital nerve canal). The anterior orbital floor is left to support the eyeball.

This combined approach has a low complication rate. At the same time, it is possible to achieve an increase in the height (apex) of the medial wall of the orbit and decompression in the region of its bottom. The authors cite as an illustration 2 clinical observations where this approach was able to achieve a stable improvement in vision. Surgical interventions with such a combined approach have technical advantages over other operations for compression optic neuropathies of thyroid origin.

Complications up to blindness that have developed as a result of various causes, in particular trauma, can in some cases be eliminated surgically. Sometimes with traumatic blindness, the use of endoscopic techniques for decompression of the optic nerve gives an effect.

One of the most serious in surgery of the paranasal sinuses are complications after operations in areas close to the bone structures of the skull or to its contents - the brain. Surgical interventions in these areas with endoscopic assistance or performed completely endoscopically require both a thorough knowledge of anatomy and exceptional surgical technique. Due to the complexity and significance of this object of surgical intervention, even perfect knowledge and technique cannot guarantee against the occurrence of complications of different nature and consequences. One of the most formidable is damage to the meninges and the outflow of cerebrospinal fluid (CSF). The issue of technique to eliminate this complication is largely controversial. Most researchers prefer either an endoscopic or an external extracranial approach, depending on the preference, experience, and capabilities of the surgeon.

T. Kelley et al. proposed to the readers a work, the main task of which was to create an alternative technique for combating the outflow of CSF in the area of defects in the anterior cranial fossa. The study also aims to reflect the authors' own experience and present their techniques, most developed in practice. Case histories were analyzed. Eight patients needed to eliminate the areas of CSF leakage that occurred after the operation. Of these, 7 patients succeeded on the first attempt, 1 patient on the second. There were no complications during the follow-up period from 1.5 to 4 years. None of the patients had acute or delayed (late) meningitis. The authors make a conclusion about the safety and effectiveness of the technique of endoscopic closure of postoperative defects - fistulas in the region of the anterior cranial fossa, if it is performed by an experienced surgeon.

M. Wax et al. studied modern methods of treatment of spinal rhinorrhea since 1990. Out of 18 cases, in 7 cases, the complication arose during endoscopic surgery, in 3 cases - with lateral (lateral) rhinotomy with excision of a benign tumor of the nasal cavity, in 1 case - with secondary plastic surgery after intranasal ethmoidectomy, in 7 cases it developed spontaneously. In 11 patients, CSF leakage was detected during surgery. In 10 of them, defect plasty was performed immediately during the intervention, 1 patient required secondary plasty after unsuccessful conservative treatment. In 7 patients there was a rupture of the spinal membrane with spontaneous outflow of CSF. In 4 patients, the defect was detected by CT, in 2 - by cisternography. One patient underwent magnetic resonance cisternography. The presence of a defect identified by cisternography was confirmed during the operation in both cases. A pedunculated flap from the mucous membrane of the nasal septum was used for defect plasty in 4 patients, a free graft from the mucous membrane of the nasal septum was used in 7 patients, and the middle turbinate was used in 5 patients. In 2 patients, sinus obliteration was achieved using a muscular-fascial and fibrin sponge. 8 patients were operated on endoscopically, the rest used an external approach. In 17 patients (follow-up period of at least 1 year) there was no CSF leakage from the nasal cavity - rhinorrhea, one required repeated plastic surgery after 8 months. after operation.

Iatrogenic injury remains the most common cause of CSF rhinorrhea. Immediate diagnosis of this complication and the use of the most sparing approach are necessary. This ensures success in 95% of cases. The preference for an endoscopic or external approach is determined by the knowledge, experience and capabilities of the surgeon.

H. Valtonen et al. investigated ways to prevent CSF leakage during removal of suboccipital acoustic neuroma. The aim of the study was to determine the possibility of direct examination of the air cells of the temporal bone using endoscopic techniques. This, in turn, can create prerequisites for reducing the frequency of CSF leakage during operations for suboccipital acoustic neuroma, in which such a complication occurs most often. With the introduction of magnetic nuclear resonance into the clinic, which made it possible to improve the diagnosis of the smallest tumors - acoustic neuromas, the suboccipital approach is increasingly used. With its use, the average frequency of liquorrhea is 12%, sometimes reaching 27%, with the most common complication being rhinorrhea.

Ideally, this complication can be avoided by carefully closing all air cells exposed by this incision. Especially often they are opened in the region of the posterior wall of the internal auditory canal, as well as in the retrosigmoid region. Usually these cells are packed with various materials, more often indirectly, since their visualization through operating microscopes is impossible. The inability to recognize potentially dangerous cells may be an important reason for the development of liquorrhea after surgery. In this study, 38 cases of cerebrospinal rhinorrhea were studied during operations for suboccipital acoustic neuromas, during which a conventional (adapted to these conditions) technique was used. At the same time, tamponade of the temporal bone around the internal auditory canal was performed. For comparison, 24 corresponding operations were analyzed using an endoscope for direct and immediate visualization of all exposed cells. After assessing the location of all potentially dangerous cells using an endoscope, they were filled with bone wax. Then, grafts from fat taken from the edges of the wound were used to fill the remaining defect. Postoperative cerebrospinal rhinorrhea was observed in 7 (18.4%) of 38 cases in which endoscopic technique was not used. Of the 28 operations using an endoscope, there was not a single case of CSF leakage. The authors conclude that the use of endoscopes to visualize the air cells of the temporal bone, which are not directly visible by other methods, can reduce the incidence of postoperative CSF leakage during operations for acoustic neuromas performed by suboccipital access.

Despite the achieved standardization of intervention methods, this type of operation is associated with a certain risk. In most reports of complications, their minimality is noted. However, serious complications require immediate complex medical and surgical treatment in order to reduce the dangerous consequences. A complete preoperative examination and an accurate assessment of its results, good patient preparation, “soft”, adapted technique and experience gained by regular practice in this field of surgery play a large role in reducing the risk of complications.

ENT surgeons at SM-Clinic perform all types of operations, but in most cases they prefer microsurgical maxillary sinusotomy as the safest and most effective method.

Microsurgical maxillary sinusectomy

Microsurgical technique

General anesthesia

Operation time - 30-60 min

The cost of the operation: from 40,000 rubles *

Microsurgical microgeniotomy. The surgeon makes a small - 4 mm - hole in the anterior wall of the maxillary sinus. Access to it is carried out under the lip, from the vestibule of the oral cavity, above 4–5 teeth. Under the control of a microscope with different viewing angles and with the help of microinstruments, the doctor conducts an audit of the sinus cavity and performs the necessary manipulations: removes pus, cysts, polyps or a foreign body, rinses the cavity with a medicinal solution. After the maxillary sinusectomy, the access hole is sutured. Within a few days, there may be a slight swelling of the cheek tissues on the access side.

Microsurgical endonasal maxillary sinusectomy. In this case, access to the maxillary sinus is carried out without punctures. The doctor expands the natural or forms an artificial anastomosis in the region of the middle or lower nasal passage and introduces a microscope and microinstruments into it. Further manipulations are similar to those performed during microsurgical micromaxillary sinusectomy.

If there are contraindications to microsurgical intervention, the Center's ENT surgeons perform a classic operation.

Radical maxillary sinusectomy according to Caldwell-Luke.

General anesthesia

Operation time - 10-15 minutes

Time of stay in the hospital - 1 day

The cost of the operation: from 20,000 rubles. *

(excluding the cost of anesthesia and hospital stay)

Radical maxillary sinusectomy according to Caldwell-Luke. With the classical method, the surgeon makes a 5-6 cm incision in the mucosa under the upper lip to the bone and pushes the tissue to the side. Then, using a drill or chisel, a hole is made in the anterior bone wall of the sinus for the introduction of instruments. After that, the doctor installs drainage through the fistula into the middle nasal passage, removes purulent contents from the sinus, and rinses the cavity. The operation is completed by suturing the mucosal incision.

As a rule, all types of maxillary sinusectomy in the Center are performed under general anesthesia (endotracheal anesthesia). If there are contraindications to this type of anesthesia, the patient's desire or small volumes of surgery, we use local anesthesia.

Our specialists are high-level professionals with impressive experience in surgical interventions and are fluent in classical and modern methods of performing operations.

* the indicated prices are preliminary and may change if additional services are required, the price also does not include a preoperative examination.

The experience of otorhinolaryngologists of the world convincingly suggests that functional intranasal endoscopic operations on the paranasal sinuses to the greatest extent meet the requirements for the improvement of the diseased organ (mucosa) and the restoration of the patient's health.

Operations on the paranasal sinuses using endoscopes have almost a century of history, but in the modern version they are about 25 years old. Modern functional endoscopic rhinosurgery began in the seventies in Austria, and then spread throughout Europe, came to America and other continents. In Russia, endoscopic rhinosurgery has been developed since the early nineties.

Diseases of the nose and paranasal sinuses have long been widespread among the population. The famous surgeon, our compatriot N.I. Pirogov performed nasal polypotomy without knowing all the functions of the nose, but he sought to restore nasal breathing, which is the main function of the nose, and for this he inserted a finger into the nasopharynx, pushed polyps and hypertrophied shells forward and removed them with forceps. What happened at that time in the nose can be imagined. Then it became possible to use a forehead reflector and remove polyps to some extent under visual control. The era of so-called radical surgery has come. The concept of this surgery was based on the fact that if the entire mucous membrane was removed, then sinusitis would also be cured. Unfortunately, this has not been confirmed in practice. Work on the study of the physiology of the nose and paranasal sinuses, the assessment of the mucous membrane as a multifunctional organ, and the development of new types of endoscopes opened the era of modern functional endoscopic surgery.

Currently, functional endoscopic surgery of the nasal cavity and paranasal sinuses is the most consistent with our understanding of the importance of the mucous membrane in human life. Some time will pass and it is not excluded the emergence of new theories and a new solution to the treatment of inflammatory diseases of the nose and paranasal sinuses. The most likely path for the development of treatment issues seems to be in the development of drug therapy. Surgical treatment will be used to a greater extent as a corrective one, aimed at eliminating the causes predisposing to the development of inflammation - congenital and acquired deformities of the intranasal structures, failure of the drainage and clearance of the sinuses, and other shortcomings. Surgical treatment will take a more preventive focus.

The classical position of N.I. Pirogov that the surgeon must know anatomy perfectly remains always relevant. For surgical operations performed in cavities using additional devices, which, in particular, are endoscopes, knowledge of anatomy is an absolute prerequisite. Personal practical experience, and numerous works by various authors, suggest that in addition to knowledge of anatomy, it is necessary to keep in mind the fact that the individual structure of the nose and paranasal sinuses varies quite widely. Therefore, it is necessary to have a clear idea of what the surgeon expects during the operation.

The surgeon performing endoscopic operations must be familiar with the details of the anatomical structure and the main identifying anatomical points and structures.

Endoscopic examination of the nasal cavity is carried out in the operating room before the operation, observing the following sequence. First, the vestibule of the nose is examined. The nasal valve is evaluated. The nasal valve is the narrowest place in the nasal cavity, formed medially by the nasal septum, inferiorly by the floor of the nasal cavity, laterally by the anterior end of the inferior turbinate, and laterally superiorly by the caudal end of the superior lateral cartilage.

When examining the nasal valve with a conventional nasal mirror, we will not receive objective information, since we move the nasal wing aside and the nasal valve expands. Inspection without instruments does not give a complete picture of the state of the nasal valve angle, the magnitude of which largely determines the ability of the nasal valve to pass the air stream. The normal angle of the nasal valve is about 15 degrees, if the angle is less, then there may be a suction effect of the wing of the nose and narrowing of the nasal valve during inspiration until it closes. Difficulty in nasal breathing with a narrow nasal valve is especially noticeable during sleep, when a person inhales deeply, the wing of the nose sticks to the septum, and snoring occurs.

The endoscope makes it possible to examine the nasal valve without changing its shape and to evaluate the significance of each structure that makes up the valve.

Next, the endoscope moves along the nasal concha along the common nasal passage, examines the condition of the mucous membrane, the spines and ridges of the nasal septum, the posterior end of the inferior concha, the choana. The surgeon receives full information and determines the amount of necessary intervention on these anatomical structures. Then, during the reverse movement, the lower edge of the middle turbinate is examined, starting from its posterior end. At the last stage, the endoscope is directed to the upper nasal passage, the superior nasal concha, fistulas of the posterior ethmoid sinuses, fistula with the sphenoid sinus are examined.

Believe me: endoscopic operations are much safer than those done before for the treatment of similar problems. It is not so traumatic, blood loss is minimal, recovery is 2-3 days. Perhaps your case is not as neglected as mine, and then you should not worry all the more.

If you want everything to go as smoothly as possible:

1. Do not spare time for a complete examination - CT and MRI

2. Consult with different doctors (run away from those who, without looking at the picture, immediately draw conclusions)

3. If you are very worried - do not spare money for a good full anesthesia (But! Only high-quality - more at the end of the review)

4. Ask to be inserted into the nose after surgery hemostatic sponges and not tampons or worse, a bandage!

"Nerves are to blame"

I have never had any special problems with immunity, rarely got sick. But for the past three years, I've stopped recognizing myself. Eternal temperature 37 and red throat. I went around the doctors of all paid clinics in Moscow. They just didn’t say something, including that you see, the nerves are to blame))). Meanwhile, I started having a protracted sinusitis ...

Punctures are not a panacea

Many are prescribed punctures and some even help. BUT, remember! X-rays are not enough to send a person for this procedure. Do an MRI to identify the real cause of sinusitis. The puncture then did not lead to anything, water poured from the nose and that's it. However, the doctor did not guess that complaints about pressure and the absence of mucus are not just signs of sinusitis. Without properly understanding and not taking the appropriate pictures, he sent me for an operation. I refused.

Thank God, I managed to find an adequate doctor when I came to Anapa for treatment. He immediately said that he needed an MRI. The same evening, a large cyst was found in the right sinus. At first there was a shock - the operation is inevitable. But, I learned about endoscopic operations on the Internet and became a little calmer.

A bit of mysticism

I went to Krasnodar for a consultation. All the way I prayed that the doctor would make the right decision. And this must happen. It was on this day that the anesthesia machine broke down, and the doctor called everyone to reschedule the operation for a month.

Barely looking at the pictures, he replied that the reason was the partition. "But please," I replied. She never bothered me before. I had sinusitis six months ago, before that there were no problems. "Yes, and the summary for the MRI clearly states: the curvature is not large. But the doctor said that only septoplasty would help.

Surprise

I was not ready to wait another two months. I was tormented by a headache (more precisely, pressure) and a lack of oxygen. I went to Moscow. At the Institute of Neurosurgery, Burdenko was immediately told that MRI was not enough. CT scan (computed tomography) revealed the filling material in the other sinus. A few years ago, the therapist filled the canals and did not keep track (the therapist, in principle, should not do this), they did not provide me with any pictures then. And then the filling began to overgrow with fungi and bacteria, and eventually turned into a large dense fungus.

About the operation

Let me tell you straight away: I am a terrible coward. She exhausted both herself and her family with excitement. Tenoten helped to restrain her emotions. But my surgeon Marina Vladislavovna helped me finally forget about fear. Not a drop of indifference, only a desire to help and set up for a speedy recovery.

The surgeon explained that even if it is not possible to get a cyst and a filling endoscopically (they are too large), they will make a micro-incision above the lip, which is also not very scary (the tiny scar heals quickly).

They suffered with me for three hours, but EXPERIENCE and ENDOSCOPY won! Managed to get everything.

About anesthesia

Already on the eve of the operation in the evening it is better not to eat so that the next day the stomach is empty. This subsequently helped to avoid nausea from anesthesia. I was anesthetized with propofol. (After reading the ENT forums, I insisted on sevoran) and for three hours in a dream I was engaged in choosing New Year's gifts for relatives))) I woke up from the fact that the nurse called by name and said "breathe". Anesthesia did not give any clouding of consciousness, I clearly understood everything and woke up very quickly, as if from a normal dream. Why general anesthesia is preferable for ENT operations was convincingly expressed by mig17 on the loronline forum.

What to take to the hospital?

The first night was not painful, it was just unpleasant. A friend who went through a similar experience a year ago said that the torments are hellish, but this is not so. You can survive the night with sponges in your nose, although it is unpleasant. For another day I had blood clots coming out of my throat and nose. My throat was swollen and a little sore. This is normal after anesthesia. Ask for painkillers or suck on lidocaine lozenges. A teaspoon of peach oil will also help relieve pain. Edema helped me to remove Telfast from allergies a little.

Hemostatic sponges

The next day, one hemostatic plug was pulled out, and part of the other came out only after weeks of regular rinsing with Dolphin. The hemostatic sponge does not injure the sinuses, unlike conventional tampons. Comes out easy. And even if a particle got stuck in the nose and they could not get it, there is no need to panic - it will come out or resolve (they write that in 3-6 weeks).

Possible Complications

I read reviews, many have numbness of the lips or teeth. I had numbness in my two front teeth. But! it was before, but not as strong. They say it was because the cyst was pressing on a nerve. The numbness decreased after half a month, now I almost don’t feel it - everything is in order.

Almost a month after the operation, I can say that the improvement has certainly come. The constant fever and headaches are gone. Although the nose sometimes gets clogged (not all the pus has come out yet), but not for long - I forgot about the vasoconstrictor drops.

Good luck to everyone, and God bless!

Sinusitis is a purulent process in the maxillary sinus. Among all diseases of the ENT organs, this pathology comes out on top. Unfortunately, there are no characteristic symptoms for this disease, however, you should immediately consult a doctor if you feel:

headache, especially in the face;
nasal congestion;
purulent discharge from the nose;
swelling of the eyelids, cheeks;
soreness in the cheekbones, cheeks;
temperature rise;
weakness;
dizziness.

The development of the disease can be the result of many pathogenic factors. Most often, it occurs as a complication of acute respiratory viral infections, with "children's" infections, in the presence of an odontogenic infection. The causative agents can be bacteria, viruses, and other, less likely pathogens.

The main provoking factors:

Treatment methods for acute sinusitis

It should be noted right away that isolated sinusitis is very rare, most often they are diagnosed with rhino-sinusitis, that is, there is inflammation of the nasal mucosa. Often joins inflammation and other sinuses.

Treatment of acute sinusitis begins with minimally invasive treatment methods. Be sure to prescribe the washing of the maxillary sinuses. Assign a course of antibiotic therapy, antihistamines, vasoconstrictors, vitamins.

All treatment is aimed at restoring normal outflow from the maxillary sinus. Therefore, basically therapy is symptomatic and pathogenetic. Washing of the maxillary sinuses is also prescribed to improve the outflow of purulent contents.

In the case of a severe course of acute sinusitis, the treatment is prescribed more serious - puncture. In this situation, the pus became dense, its outflow is difficult, the anastomosis with the nasal cavity is not passable. Thanks to the puncture, it is possible to pump out pus, rinse the sinus cavity, and carry out local treatment.

Endoscopic sinus surgery

The maxillary sinus puncture is indeed a classic treatment. However, this procedure has its contraindications and complications. Modern microsurgery does not stand still, and endoscopic sinus surgery is now available.

This intervention is called endoscopic maxillary sinusectomy - a gentle, painless, effective procedure. Endoscopic surgery on the maxillary sinus is prescribed in cases where conservative therapy is ineffective, there are foreign bodies, or other reasons that impede the outflow of purulent secretions from the sinus.

Advantages of endoscopic treatment of acute sinusitis:

The operation is carried out under the control of a high-precision video monitor;
The operation is gentle, low-traumatic, painless.
There is minimal damage - the natural sinus fistula expands to normal anatomical sizes.
If necessary, a biopsy is taken.
You can perform general or local anesthesia.
The number of complications is kept to a minimum.
Does not require a long postoperative period.

There are several basic approaches for endoscopic treatment. The choice of access will depend on the nature of the process, its localization, the state of the nasal mucosa, and nasal passages. During one operation, it is possible to combine several types of access to provide the specialist with maximum visibility of the maxillary sinus.

Currently, endoscopic sinus otomy has become not only the treatment of choice, but also an ideal diagnostic method when it is necessary to determine the presence of cysts or tumors of the sinuses associated with acute sinusitis.

Currently, the treatment of acute sinusitis does not require punctures. Modern endoscopic techniques for the treatment of this disease are gentle, effective and less traumatic.

Diagnostics

In the Open Clinic network, specialists will conduct an examination, listen to complaints, and prescribe an examination. The main standard of examination for suspected sinusitis are:

Palpation of the sinuses
RG - maxillary sinuses
Rhinoscopy
Diaphanoscopy

Biopsy
CT, MRI
Blood tests
Fibroendoscopy.

In European countries, there is a standard examination for this disease. The main diagnostic method is radiography, but the methodology for conducting this study has changed in recent years. It has been established that isolated acute sinusitis is quite rare, so it is necessary to examine both the nasal cavity itself and the rest of the nasal sinuses. Radiography is carried out in three projections to exclude generalized inflammation.

Computer research methods - CT and MRI - are more modern methods of examination. Thanks to these techniques, it is possible to carry out differential diagnostics between sinusitis and tumors, cysts of the maxillary sinuses.

Cost of endoscopic maxillary sinus surgery

The “Open Clinic” network prefers the most effective, sparing, modern method of examination. This is an endoscopic operation.

Indeed, such procedures are carried out abroad all the time, they give good results and have no complications. However, their implementation requires high-quality equipment, highly qualified specialists, and the ability to interpret the result.

From these points, the concept of the price of endoscopic surgery on the maxillary sinus is formed. On average, prices in Moscow vary from 20,000 to 40,000 rubles. In the Open Clinic network, we provide you with various treatment programs depending on the type of intervention, degree of complexity, type of anesthesia. All our specialists are proficient in modern methods of treating acute sinusitis and achieve high and stable results!

Why should you come to us?

In the Open Clinic network:

A comprehensive examination of the ENT organs is carried out.
Operating rooms are equipped with modern, high-precision equipment.
Our specialists constantly improve their skills at the state and international level.
We practice an individual approach to the preparation of an individual treatment regimen for each patient.