Methods for the study of the nose, paranasal sinuses and the organ of smell. Symptoms of chronic inflammation of the maxillary sinus (chronic sinusitis) Probing of the main sinus

Probing allows you to penetrate into the cavity of the sinuses without opening them through natural fistulas, which explains the great interest in this research method in the diagnosis of lesions. paranasal sinuses nose. For the first time, the French dentist J. Jourdain (1761) introduced the probe to the touch through the natural fistula into the maxillary sinus. Subsequently, he successfully performed systematic sinus lavage in patients with purulent sinusitis. In 1883, V. Hartmarm reported the cure of 3 patients with purulent sinusitis after repeated washings of the sinus through a natural fistula. Later, L. I. Sverzhevsky (1927) found that in 65% of cases there is a narrow semilunar fissure, which prevents catheterization of the natural sinus fistula.

Gradually flushing maxillary sinus through the natural fistula, it began to be forced out by sinus puncture through the middle and lower nasal passages. Currently, probing of the maxillary sinus is rarely used, mainly in pediatric practice [Shadyev X. D., 1973; Rutten E., 1969, etc.]. This is due to the fact that the puncture method for diagnosing and treating diseases of the maxillary sinuses is very effective, quite simple and applicable to almost any patient.

The method of probing the frontal sinuses through the natural fistula, developed by E. A. Lansberg (1966), with visual control of the position of the probe-cannula in the nasal cavity and frontal sinus using an image intensifier tube, is reliable and quite effective. Successful probing of the frontal sinus, according to E. A. Lansberg (1966), A. G. Maltsev (1974), L. B. Dainyak and A. G. Maltsev (1974), E. I. Kosyakova (1980), is possible in 94-95% of cases. Difficulty probing is more often due to the curvature of the nasal septum, hypertrophy of the middle turbinate, polyps. After elimination of this intranasal pathology, probing of the frontal sinus is successfully carried out.

The Lansberg cannula probe is made of soft, easy-to-bend stainless steel with a blunt end and holes on the sides of the end of the cannula. This form makes it possible to use the same probe-cannula for various positions of the fronto-nasal fistula. The outer diameter of the cannula is 3 mm. In our practice, we use the Lansberg method, but often we probe without using an image intensifier tube. When sounding, the following landmarks are used. The probe is inserted between the anterior end of the middle turbinate and the side wall of the nasal cavity, directing it upwards, anteriorly and slightly outwards. The basic rule must be observed - the probe must be inserted without violence. With the correct introduction of the probe into the anastomosis, it moves freely, and its lower end lies on the lower lip. If the probe encounters an obstruction, it must be removed and a new attempt made, moving the end of the probe closer or further away from the typical location of the fronto-nasal opening in the middle nasal passage, which is located at the most anterior end of the semilunar fissure.

Probing is performed after local application anesthesia with a 5% solution of cocaine with adrenaline, which are introduced on the turunda into the middle nasal passage or using a threaded probe with cotton wool wrapped around it. The position of the patient can be lying on his back or sitting with his head thrown back. In doubtful cases, to control the position of the probe-cannula, an X-ray examination can be performed under the screen in frontal and lateral projections. After the position of the probe-cannula in the sinus is reliably established, suction and washing of the frontal sinus is performed. Thus, probing is a diagnostic and therapeutic measure. AG Maltsev (1974) with a therapeutic purpose for patients with acute and chronic sinusitis introduced into the sinus through the fronto-nasal fistula a drainage tube made of fluoroplastic for repeated washings. The tube is inserted using a cannula-shaped guide rod and left for the entire treatment period.

Probing is also an important method in the diagnosis and treatment of the sphenoid sinus. However, this Method has not yet received wide distribution, since its implementation is unsafe due to significant difficulties due to the deep location of the sphenoid sinus in the skull, close relationships with vital formations of the cranial cavity, as well as the complexity of controlling the manipulation. With favorable anatomical relationships in the nasal cavity, probing of the sphenoid sinus can be performed through the natural opening of the sinus visible during anterior rhinoscopy. However, this possibility, especially in the presence of pathological processes in the nasal cavity, is rare. Therefore, when probing, one has to be guided by the Zuckerkandl line, defined by two points: the anterior nasal spine and the middle of the free edge of the middle nasal concha. If the first point is more or less definite, then it is very difficult to be guided by the second point, since the middle turbinate can have a different size and position, and sometimes as a result of the transferred surgical intervention and "is completely absent. Therefore, the Zuckerkandl line serves only as an approximate guide when probing the sphenoid sinus and should be supplemented by searching for a natural fistula by touch. With a certain skill, probing does not present great difficulties and should serve as the main method of penetrating the sinus cavity without opening it. Probing the sphenoid sinus is somewhat facilitated by X-ray control with electron-optical conversion.

Before proceeding to washing cavities, fistulas, paranasal sinuses through their natural orifices, etc., it is necessary to palpate the existing holes. This is done with the help of bellied probes, which are carefully inserted into the corresponding holes and feel their edges, thereby determining the condition of the surrounding tissues.

If a probing of the middle ear in the presence of perforation, it is quite simple, but it is much more difficult to do this in relation to the frontal and main sinuses. After thorough anesthesia of the middle nasal passage, an S-shaped bellied probe is inserted under the anterior end of the middle nasal concha. When palpating, the tip of the probe must be directed to the nasal septum, and not laterally. When the probe enters the mouth of the frontal sinus, there is a feeling of falling into the cavity.

Probing of the main sinus performed with a bellied probe, the tip of which is bent at a right angle at a distance of 2 cm. After anesthesia of the olfactory fissure, the probe is inserted between the middle turbinate and the nasal septum so that the end of the probe crosses the middle turbinate along its middle, and the lower end rests against the lower edge of the nostril. When advancing to a depth of 6-7 cm, the probe rests against the anterior wall of the main sinus.

By feeling in different directions they find hole. When the probe enters the mouth, it feels like falling into the cavity. If after that you continue to advance the probe forward, then after 1.5-2 cm it will rest against the back wall of the sinus.
Probing the natural mouths of the maxillary sinuses, as a rule, is not performed, since the drainage technique maxillary sinus using a puncture through the lower nasal passage is much easier than through the middle one.

sounding may be a pre-stage of sinus drainage. Drainage and punctures of the paranasal sinuses are covered in the section of outpatient operations.
Often punctures of the paranasal sinuses culminate in a prolonged washing procedure, which is performed using a dropper, usually used for blood transfusion. With the help of a fork, the procedure can be performed immediately for two sinuses. Number of drops medicinal solution maybe 20 to 40 per minutes. The duration of the procedure, and consequently, the contact of the mucous membrane of the sinuses with the drug, stretches up to 30-40 minutes. The dropper is used for washing the sinuses and after operations on them.

Probing is also an important method in the diagnosis and treatment of the sphenoid sinus. However, this method has not yet become widespread, since its implementation is unsafe due to significant difficulties due to the deep location of the sphenoid sinus in the skull, close relationships with vital formations of the cranial cavity, as well as the complexity of controlling the manipulation. Probing is done with the patient's head tilted back. With favorable anatomical relationships in the nasal cavity, probing of the sphenoid sinus can be performed through the natural opening of the sinus visible during anterior rhinoscopy. However, this possibility, especially in the presence of pathological processes in the nasal cavity, is rare. Therefore, when probing, one has to be guided by the Zuckerkandl line, defined by two points: the anterior nasal spine and the middle of the free edge of the middle nasal concha. If the first point is more or less definite, then it is very difficult to be guided by the second point, since the average turbinate may have a different size and position, and sometimes as a result of a surgical intervention, it is completely absent. Therefore, the Zuckerkandl line serves only as an approximate guide when probing the sphenoid sinus and should be supplemented by the search for a natural fistula to the touch. With a certain skill, probing does not present great difficulties and should serve as the main method of penetrating the sinus cavity without opening it. Probing of the sphenoid sinus is somewhat facilitated by X-ray control with electro-optical conversion. (one)

Rice. 16. Probing of the main sinus. 1 - opening of the Eustachian tube; 2 - main sinus; 3 - sieve plate; a - the correct position of the probe; b and c are incorrect positions.

With a very wide olfactory fissure, as happens, for example, with an atrophic process in the nose, it is possible to see the natural opening of the main sinus with anterior rhinoscopy and probe it directly under the control of the eye. However, in most cases this gap is too narrow, and the opening is hidden in the recessus sphenoethoidalis; then, even after careful anemization with cocaine-adrenaline, the sinus opening cannot be seen. In some cases, the sinus opening becomes available for probing after the forced expansion of the olfactory fissure with an elongated nasal dilator. In most cases, however, it is necessary to probe the sinus by touch. The probe is inserted along the Zuckerkandl line, which, on the eve, passes at the lower edge of the nostril in the nasal cavity along the middle of the free edge of the middle shell, resting against the anterior wall of the main sinus, and sometimes into its opening. Having reached the front wall of the sinus, it is carefully felt with a probe until it enters the sinus. If the probing is done correctly, it feels like the probe has entered the space in which it is fixed. To determine the position of the probe, a posterior rhinoscopy is performed. (7) Since the opening of the sinus is located almost at the very roof of the nose, the probe should be slightly bent down at the end. The distance from the posterior edge of the nasal opening (i.e. from the spina nasalis anterior) to the anterior wall of the main sinus in adults is 6-7 cm. Therefore, in order to be sure that the probe is actually inserted into the sinus, it is necessary that the length of the part inserted into the nose the probe was at least 7.5-8 cm (from the vestibule of the nose to the anterior wall of the main sinus in men 8 cm, in women 7.5 cm). With large sinuses and the correct position of the bend of the probe, it can penetrate deep into the sinus to its posterior wall by another 2-3 cm. If the probe is raised higher, i.e., kept closer to the front edge of the middle shell, then the end of the probe will rest against the sieve plate; when lowering the probe below, it will fall into the throat (Fig. 16). Having reached the front wall of the sinus, we carefully feel this wall with a probe, raising and lowering it, and also turning it outward (in the recessus sphenoethoidalis) until we get the feeling that it has passed through the hole into the sinus. After that, it is possible to produce sinus lavage through the appropriate cannula. With significant hypertrophy of the middle shell, deformation of the nasal septum and polyposis, probing the sphenoid sinus without appropriate preliminary surgical measures is impossible.

Technically, probing of the maxillary sinus is carried out more simply. For the first time, the introduction of a probe into the maxillary sinus was described by J. Jourdain (1761), later the method became widespread, and only the introduction of puncture into the practice of rhinology relegated it to the background. Probing of the maxillary sinus is carried out through the middle nasal passage in the region of the semilunar fissure on the border of the middle and posterior third of the middle nasal concha.

Manipulation is performed with a bellied nasal probe, the end of which is bent at a right angle at a distance of 5–7 mm. With a curved part, facing laterally and upward, they slide along the mucous membrane of the specified area, and when favorable conditions the probe penetrates through the fistula into the sinus. The method of probing the maxillary sinus has diagnostic value only when a positive result- runoff separated from the sinus past the probe. Recently, indications for its use have been significantly limited due to insufficient information content.

However, the method is sufficiently simple and atraumatic, therefore it is common in pediatric otorhinolaryngology [Shadyev X. D., 1973].

Probing the frontal sinus requires a doctor with high qualifications and extensive experience.

Manipulation due to the inconsistency of the anatomical and topographic relationships in the nasal cavity and the variety of options for the structure of the frontonasal canal is not always safe, and sometimes technically impossible. However, under favorable conditions, according to A. G. Maltsev (1974), L. B. Dainyak and A. G. Maltsev, E. I. Kosyakova (1980), probing of the frontal sinus is successfully carried out in 94 - 95% of patients.

In pediatric rhinology, the method of probing the frontal sinuses is largely limited by the age-related structural features of the paranasal sinuses. This manipulation becomes possible with sufficient development of the frontal sinus, which is observed no earlier than 7 years of age.

A number of probes and cannulas have been proposed for probing and often simultaneously flushing the frontal sinuses. However, most of the modifications differed in length, curvature or curvature of the cannula and probe.

Probing of the frontal sinus is performed under the anterior end of the middle turbinate.

In this case, the probe is directed between the anterior end of the middle turbinate and the lateral wall of the nose, keeping the direction of the probe tip up, anteriorly and slightly outward.

1 - sounding of the sphenoid sinus;
2 - probing of the maxillary sinus;
3 - probing the frontal sinus.

Some experts recommend that in order to facilitate the probing of the sinus, dislocate the middle shell, shifting its front end towards the nasal septum. Successful probing of the frontal sinus provides an opportunity for topical diagnosis of an isolated lesion of one frontal sinus without resorting to more traumatic methods.

Probing of the sinuses of the ethmoid bone

Sinus probing is not widely used. Numerous methods of probing both anterior and posterior sinuses have been described. Anatomotopographically, the outlet of the anterior ethmoid sinuses is located almost in the middle between the natural openings of the frontal and maxillary sinuses.

Probing of the posterior ethmoid sinuses is carried out through the upper nasal passage. However, in most patients, it is possible to penetrate the probe into the outlet of the anterior sinuses only after the displacement of the middle turbinate to the nasal septum or preliminary resection of a part of the middle turbinate, which is not always justified.

Given the complexity of the manipulation and the insufficient differential diagnostic value of the method, in last years probing of the ethmoid sinuses is quite rare, and most rhinologists prefer the suction method.

The technique of probing the sphenoid sinus has been proposed for a long time, but has not received proper distribution due to its relative complexity. The deep location of the sphenoid sinus, the narrowness of the nasal passages and, as a result, insufficient visual control during manipulation create difficulties in its implementation; there is a danger of damage to the vital formations of the cranial cavity.

Probing of the sphenoid sinus is carried out after a preliminary radiographic study showing the size and shape of the sinus. A thin bellied nasal probe is inserted along the line connecting the anterior nasal spine with the middle of the lower edge of the middle nasal concha (Zuckerkandl line). As a rule, the entrance to the sinus after passing the probe to the anterior wall of the sphenoid sinus is detected by touch.

Due to the fact that the formation of the sphenoid sinus occurs from the age of 7 - 8, and full development - not earlier than at 18 - 20 years, this probing is used very rarely in the practice of pediatric rhinologists.

"Inflammation of the paranasal sinuses in children",
M.Ya. Kozlov

51434 0

The study of the nose and paranasal sinuses is carried out after studying the anamnesis and begins with an external examination and palpation. On examination, attention is paid to the condition of the skin and soft tissues of the face and external nose, the absence or presence of defects, the symmetry of both halves of the face, and the shape of the external nose. Palpation should be done carefully. With soft movements of the hand, the presence or absence of pain in the nose and the projection of the paranasal sinuses is established. If a fracture of the bones of the nose is suspected, the pathological mobility of bone fragments and the presence of crepitus are determined.

Endoscopy of the nasal cavity

Inspection of the nasal cavity (rhinoscopy) is carried out using a light source, which should be located to the right of the subject, at the level of his ear at a distance of 15-20 cm, somewhat behind, so that direct light from it does not fall on the area being examined. The focused light reflected from the frontal reflector is directed to the examined area.

Further examination is carried out using a special dilator (Fig. 1), held in the left hand, which is inserted into the vestibule of the nose. With the right hand, the doctor fixes the patient's head, which allows changing its position during examination. In other cases in right hand the doctor holds tools for manipulation in the nasal cavity.

Rice. one. Instruments for rhinoscopy:

1 - mirror for anterior rhinoscopy; 2 - mirror for posterior rhinoscopy

Endoscopy of the nasal cavity is divided into anterior(direct) and back(indirect). Anterior rhinoscopy is performed in two positions: with the head upright and with the head tilted back. In the first position, the vestibule of the nose, the anteroinferior half of the nasal septum, the anterior end of the inferior concha, the entrance to the inferior nasal passage, and the lower and middle sections of the common nasal passage are visible (Fig. 2).

Rice. 2.

a: 1 - lower shell; 2 - middle nasal passage; 3 - olfactory gap; 4 - middle shell; 5 - base of the nasal septum; b- posterior (indirect) rhinoscopy: 1 - uvula of the soft palate; in- view during posterior rhinoscopy: 1 - lower shell; 2 - upper shell; 3 - pharyngeal tonsil; 4 - coulter; 5 - middle shell; 6 - pharyngeal opening of the auditory tube; 7 - soft palate; G- fixation of the soft palate: 1 - rubber catheters; 2 - soft palate

In the second position, you can examine the upper and deeper sections of the nasal cavity. It is possible to see the upper part of the nasal septum, the middle nasal passage, the anterior third of the middle nasal concha and the olfactory fissure. By turning the subject's head, one can examine in detail the listed structures of the nasal cavity.

Anterior rhinoscopy pays attention to various signs, reflecting both the normal state of endonasal structures, and their certain pathological conditions. The following signs are evaluated:

a) the color of the mucous membrane and its moisture content;

b) the shape of the nasal septum and pay attention to the vascular network in its anterior sections, the caliber of the vessels;

c) the state of the turbinates (shape, color, volume, relation to the nasal septum), palpate them with a bellied probe to determine elasticity and compliance;

d) the size and contents of the nasal passages, especially the middle one and in the region of the olfactory fissure. In the presence of polyps, papillomas or other pathological tissues, they are evaluated appearance and, if necessary, take tissue for biopsy.

Posterior rhinoscopy allows you to examine the posterior parts of the nasal cavity, the vault of the nasopharynx, its lateral surfaces and the nasopharyngeal openings of the auditory tubes.

Posterior rhinoscopy is performed as follows (see Fig. 2, b): with a spatula held in the left hand, the front two-thirds of the tongue is pressed down and slightly forward. The nasopharyngeal mirror, preheated (to avoid fogging of its surface), is inserted into the nasopharynx behind the soft palate, without touching the root of the tongue and the posterior pharyngeal wall. Interferences are a pronounced gag reflex, a thick and "recalcitrant" tongue, a hypertrophied lingual tonsil, a narrow throat, a long tongue, protruding vertebral bodies with severe lordosis cervical spine, inflammatory diseases pharynx, swelling or scarring of the soft palate. If conventional posterior rhinoscopy fails due to the presence of objective interference, appropriate topical anesthesia is used to suppress the gag reflex, as well as retraction of the soft palate using one or two thin rubber catheters (see Fig. 2, G).

After application anesthesia of the nasal mucosa, pharynx and root of the tongue, a catheter is inserted into each half of the nose and its end is removed from the pharynx with a forceps. Both ends of each catheter are tied together with slight tension, making sure that the soft palate and uvula do not wrap towards the nasopharynx. Thus, immobilization of the soft palate is achieved and free access to the nasopharynx is opened.

In the nasopharyngeal mirror (diameter 8-15 mm), only certain parts of the examined area are visible. Therefore, to view all formations of the nasopharynx, slight turns of the mirror are made, sequentially examining the entire cavity and its formations, focusing on the posterior edge of the nasal septum and the vomer (see Fig. 2, in).

In some cases, there is a need digital examination of the nasopharynx, especially in children, since indirect posterior rhinoscopy is rarely possible in them. During a digital examination of the nasopharynx, its overall size and shape are assessed, the presence or absence of its partial or complete obliteration, senechia, adenoids, choanal obstruction, hypertrophied posterior ends of the inferior turbinates, choanal polyps, tumor tissue, etc. are determined.

A more detailed picture of the nasal cavity can be obtained using modern optical endoscopes (Fig. 3) and television endoscopy techniques.

Rice. 3. Direct posterior rhinoscopy using a rigid optical endoscope: 1 - eyepiece; 2 - tube; 3 - lens; 4 - viewing angle

Diaphanoscopy

In 1889 Th. Heryng was the first to demonstrate a method of light transillumination of the maxillary sinus by inserting a luminous light bulb into the oral cavity (Fig. 4, a, 2).

Rice. four.

a- devices for diaphanoscopy: 7 - switching device for connecting an electric light bulb; 2 - glass bulb (bulb) for transillumination of the maxillary sinuses; 3 — the flask darkened on a lateral surface for transillumination of frontal bosoms; b- image of the "Hering spectra": 1 - frontal light spot; 2 - infraorbital spot; 3 - maxillary spot

Currently, there are much more advanced diaphanoscopes that use bright halogen lamps and fiber optics, which allows you to create a powerful stream of focused "cold" light.

The procedure of diaphanoscopy is carried out in a dark cabin with a weak illumination of dark green light, which increases the sensitivity of vision to red light. To translucent the maxillary sinus, a diaphanoscope is inserted into the oral cavity and a beam of light is directed to the hard palate, while the subject tightly fixes the tube of the diaphanoscope with his lips. Normally, a number of symmetrically located reddish light spots appear on the front surface of the face: two spots in the area of ​​the canine fossae (between the zygomatic bone, the wing of the nose and upper lip), which indicate good airiness of the maxillary sinuses. Additional light spots appear in the region of the lower edge of the orbit in the form of a crescent concave upwards (evidence of a normal state top wall maxillary sinus).

For transillumination of the frontal sinus, a special optical nozzle is provided that focuses the light into a narrow beam, which is applied to the superomedial angle of the orbit so that the light is directed through its superomedial wall towards the center of the forehead. In the normal state of the frontal sinuses, dull dark red spots appear in the region of the superciliary arches.

Ultrasound procedure

Ultrasound examination is performed in relation to the maxillary and frontal sinuses; using this method, it is possible to establish the presence of air in the sinus (normal), liquid, thickening of the mucous membrane or dense formation (tumors, polyps, cysts, etc.). The device used for ultrasound examination of the paranasal sinuses was called "Sinusscan". The principle of operation is based on the irradiation of the sinus with ultrasound (300 kHz) and the registration of the beam reflected from the formation located in the sinus. The result of the study is displayed on a special display in the form of spatially separated bands, the number of which corresponds to the number of echogenic layers. Their distance from the "zero" band corresponding to the surface skin, reflects the depth of each layer, which forms either the level of fluid in the sinus, or a volumetric formation.

X-ray examination

X-ray diagnostics is aimed at identifying the degree of airiness of the nasal cavity and paranasal sinuses, the presence of pathological formations in them, and determining the state of their bone walls and soft tissues. facial area, presence or absence foreign bodies, detection of anomalies in the development of the facial skeleton, etc. For more effective detection of space-occupying formations of the maxillary sinus, radiopaque substances are used, for example, yodipol, introducing them into the sinus cavity. Anatomical and topographic features of the paranasal sinuses to obtain sufficient information about their condition require special arrangements in relation to the X-ray beam and the surface of the X-ray sensitive film, on which images of certain structures of the study area are visualized.

Examination of the anterior paranasal sinuses

(Fig. 5) allows you to visualize the anterior paranasal sinuses, especially clearly - the maxillary:

• L sinuses (1) separated by a bony septum. Their image is limited by the bone border.
• Orbits (2) darker than all other sinuses.
• Labyrinth cells (3) projected between the eyes.
• Maxillary sinuses (4) located in the center of the facial array. Sometimes inside the sinuses there are bony partitions that divide them into two or more parts. Great importance in the diagnosis of diseases of the maxillary sinus has X-ray visualization of its bays (see Fig. 6) - alveolar, lower palatine, molar and orbital-ethmoid, each of which can play a certain role in the occurrence of diseases of the paranasal sinuses.
• Infraorbital fissure through which exit zygomatic and infraorbital nerves, is projected under the lower edge of the orbit. It is important when performing local-regional anesthesia. With its narrowing, there is "neuralgia of the corresponding nerve trunks.
• Round hole (6) is projected in the medial part of the planar image of the maxillary sinus (on the radiograph, it is defined as a rounded black dot surrounded by dense bone walls).

Rice. 5.

a- laying scheme: 1 - X-ray sensitive film; 6, in- radiograph and diagram for it: 1 - frontal sinus; 2 - eye socket; 3 - cells of the lattice labyrinth; 4 - maxillary sinus; 5 - nasal septum; 6 - round hole

Nasofrontal styling(Fig. 6) allows you to get a detailed image of the frontal sinuses, eye sockets and cells of the ethmoid labyrinth. In this projection, the cells of the ethmoidal labyrinth are visualized more clearly, but the dimensions and lower sections of the maxillary sinus cannot be fully visible due to the fact that the pyramids of the temporal bones are projected onto them.

Rice. 6.

a- laying scheme; b- X-ray; in- scheme of visualized objects: 1 - frontal sinus; 2 - cells of the lattice labyrinth; 3 - eye socket; 4 - the lateral part of the sphenoid bone; 5 - medial part of the sphenoid bone; 6 - wedge-shaped gap

Side laying(Fig. 7) is intended mainly to determine its relation to the anterior cranial fossa.

Rice. 7.

a- laying scheme; b- X-ray; in- scheme of visualized objects: 1 - frontal sinus; 2 - nasal bone; 3 - cells of the lattice labyrinth; 4 - eye socket; 5 - maxillary sinus; 6 - sphenoid sinus; 7 - front nasal bone; 8 - posterior wall of the maxillary sinus (projection of the maxillary tubercle); 9 - molar; 10 - frontal process of the zygomatic bone; 11 - lattice plate; 12 - styloid process; 13 - Turkish saddle

It allows you to visualize those elements that are marked on the X-ray diagram. The lateral projection is important when it is necessary to assess the shape and size of the frontal sinus in the anteroposterior direction (for example, if it is necessary to trepanopuncture it), determine its relationship to the orbit, the shape and size of the sphenoid and maxillary sinuses, as well as many other anatomical formations of the facial skeleton and anterior parts of the skull base .

Examination of the posterior (craniobasilar) paranasal sinuses

The posterior paranasal sinuses include the sphenoid (main) sinuses; some authors also include the posterior cells of the ethmoid bone in these sinuses.

(Fig. 8) reveals many formations of the base of the skull, is used if necessary to visualize the main sinuses, the rocky part temporal bone, openings of the base of the skull and other elements. This projection is used in the diagnosis of skull base fractures.

Rice. eight.

a- X-ray; b- scheme of visualized elements: 1 - frontal sinuses; 2 - maxillary sinuses; 3 - lateral wall of the maxillary sinus; 4 - lateral wall of the orbit; 5 - sphenoid sinuses; b - oval hole; 7 - round hole; 8 - pyramid of the temporal bone; 9, 10 - anterior and posterior torn holes; 11 - apophysis of the base of the occipital bone; 12 - the first cervical vertebra; 13 - apophysis of the odontoid process of the II cervical vertebra; fourteen - lower jaw; 15 - cells of the ethmoid bone; 16 (arrow) - the top of the pyramid of the temporal bone

sphenoid sinuses ( 5 ) are distinguished by a significant variety of structure; even in the same person, they can be different in volume and asymmetric in location. They can spread into the surrounding parts of the sphenoid bone (large wings, pterygoid and basilar apophyses).

In addition to the listed standard projections used in the X-ray examination of the paranasal sinuses, there are a number of other stackings used if it is necessary to enlarge and more clearly highlight any one anatomical and topographic zone.

Tomography

The principle of tomography was formulated in 1921 by the French physician A. Bocage and implemented in practical work Italian radiologist Vallebona (A. Vallebona). This principle has become an integral part of orthopantomography and computed tomography. On fig. 9 shows an example of a tomogram of the anterior paranasal sinuses. In some cases, when an odontogenic disease of the maxillary sinus is suspected, an orthopantomographic study is performed, which displays a detailed picture of the dentition (Fig. 10).

Rice. 9. Tomogram of the anterior paranasal sinuses in direct projection: a — radiograph; b — diagram of visualized elements: 1 — maxillary sinus; 2 - orbit; 3 - cells of the lattice labyrinth; 4 - frontal sinus; 5 - middle shell; 6 - lower sink

Rice. ten. Orthopantomogram of the facial skeleton:

1 - alveolar process of the facial skeleton in expanded form; 2 - nasal septum; 3 - the cavity of the maxillary sinus in expanded form; 4 - posterior wall of the maxillary sinus; 5 - the roots of the teeth embedded in the lower wall of the maxillary sinus

CT scan(CT) (synonyms; axial CT scan, computed x-ray tomography) is a method based on the circular transillumination of the human body by a scanning x-ray emitter moving around the axial axis at a selected level and with a certain step.

In otorhinolaryngology, CT is used to diagnose inflammatory, oncological, and traumatic lesions of the ENT organs (Fig. 11).

Rice. eleven.

1 - maxillary sinus; 2 - common nasal passage and nasal septum, curved to the right; 3 - lower nasal concha; 4 - nasopharynx; 5 - the upper part of the sphenoid sinus; 6 - cells of the mastoid process and the pyramid of the temporal bone; 7 - the body of the main bone; 8 - posterior cranial fossa; 9 - the main sinus, posteriorly - the Turkish saddle; 10 - language; 11 - ethmoid bone; 12 - oral cavity; 13 - cavity of the laryngopharynx

Probing of the paranasal sinuses

Probing of the paranasal sinuses (Fig. 12) is used to examine them with the help of special endoscopes and introduce them into them medicines. In the latter case, special catheters are used.

Rice. 12. Scheme of probing the paranasal sinuses:

a- probing of the maxillary sinus: 1 - uncinate process; 2 - semilunar cavity; 3 - maxillary sinus; b- sounding of the frontal sinus: 1 - uncinate process; 2 - funnel; 3 - frontal sinus; 4 - crescent cavity; 5 - the main sinus; in- sounding of the main sinus: 1,2,3 - consecutive positions of the catheter (4); S - trajectory of the catheter end

Probing of the paranasal sinuses is performed under local application anesthesia. The place of “search” for the outlet openings of the maxillary and frontal sinuses is the semilunar cavity, located under the inferior nasal concha: the opening of the frontal sinus is determined in front, and the opening of the maxillary sinus is posteriorly. The scheme of probing the main sinus is shown in fig. 12, in.

Study respiratory function nose

The simplest and fairly objective method widely used in clinical practice, is a test with a fluff of V.I. Voyachek. It allows you to judge the state of the respiratory function of each individual half of the nose, to which, during breathing through the nose, a cotton fluff is brought to each nostril. The quality of nasal breathing is judged by the movement of the fluff. The method of "respiratory spots" proposed by Zwaardemaker also belongs to simple methods for studying the respiratory function of the nose. When breathing, on a polished metal plate brought to the nostrils of the nose with semicircular lines applied to its surface (R. Glatzel's mirror), misted surfaces appear, by the size of which the degree of air permeability of the nasal passages is estimated.

Rhinomanometry. To date, a number of devices have been proposed for conducting objective rhinomanometry with the registration of various physical indicators of the air flow passing through the nasal passages. Thus, the method of computer rhinomanometry allows to obtain various numerical indicators of the state of nasal breathing. Modern rhinomanometers are complex electronic devices, the design of which uses special microsensors that convert intranasal pressure and airflow rate into digital information. The devices are equipped with special programs for mathematical analysis with the calculation of nasal breathing indices, means of graphical reflection of the studied parameters in the form of monitors and printers (Fig. 13).

Rice. 13. Graphic display of airflow parameters in the nasal cavity during nasal breathing (according to Kiselev A.S., 2000):

1 - with difficulty in nasal breathing; 2 - with normal nasal breathing

The presented graphs show that during normal nasal breathing, the same amount of air (y-axis) passes through the nasal passages for more than a short time at half, three times less air jet pressure (abscissa axis).

Acoustic rhinometry. This study uses the method of sound scanning of the nasal cavity in order to determine its volume and total surface.

The device consists of a measuring tube and a special nasal adapter attached to its end. An electronic sound transducer at the end of the tube sends out a continuous broadband sound signal or a series of intermittent sound signals and registers the sound reflected from the endonasal tissues as it returns to the tube. The measuring tube is connected to an electronic computer system for processing the reflected signal. Graphical display of the parameters of sound rhinometry is carried out continuously. The display shows both single curves of each nasal cavity and a series of curves reflecting the dynamics of changing parameters over time. The value of this method lies in the fact that it can precise definition quantitative spatial parameters of the nasal cavity, their documentation and research in dynamics. In addition, the installation provides ample opportunities for carrying out functional tests, determining the effectiveness of applied medicines and their individual selection. A computer database, a color plotter, storage in memory of the received information with the passport data of the examined, as well as a number of other possibilities, make it possible to attribute this method very promising both in practical and research terms.

Study of the olfactory organ

Methods for studying the sense of smell are divided into subjective, conditionally objective and unconditionally objective.

In everyday clinical practice, they are mainly used subjective ways, based on the presentation of the testing odor to the subject and on his verbal report: “yes”, “no”, “yes, but I cannot determine”, while the subject names a specific smell.

Conditionally objective methods based on the registration of so-called olfactory-vegetative reactions arising in response to the activation of the projection systems of the subcortical olfactory centers, their connections with the stem structures and the hypothalamus. These reactions may include changes in heart rate, phase changes in the respiratory cycle, changes in respiratory rate, olfactopupillary reflexes, changes in galvanic skin response, etc.

Certainly objective methods based on the registration of evoked potentials under the influence of odor substances. All methods of researching the sense of smell are divided into qualitative and quantitative.

Subjective methods are used when presenting an odorous substance in close proximity to one and then to the other nostril; the patient is offered to actively sniff and answer if he smells, and if he does, then what kind of smell it is. To conduct this study, different authors have proposed sets of various odorous substances. The most widely used in clinical practice is the method of V. I. Voyachek (Table 1), proposed by him back in 1925. This method is based on the use of several odorous substances well known to most people, the standard solutions of which are arranged in ascending order of odors.

Table 1. Odorimetric passport of V. I. Voyachek

The correct conduct of a qualitative study of the sense of smell provides for a certain standardization of experience: the exclusion of the possibility of ingress of vapors of an odorous substance into the unexamined half of the nose; carrying out an assessment of an odorous substance during inhalation with a breath hold in order to exclude its retrograde entry into the second half of the nose during exhalation. A piece of filter paper 0.5-1.0 cm in size, fixed in a crevice of a torch and moistened in a solution of an odorous substance, is brought to one nostril, closing the other, and the patient is asked to take a light breath through his nose, hold his breath for 3-4 seconds and determine what smell he feels. The results of the study are evaluated according to a five-degree system, depending on what odors the subject perceives:

• I degree - the subject identifies the weakest smell - No. 1;
• II degree - only smells under No. 2,3,4 are perceived;
• III degree - smells are perceived under No. 3, 4;
• IV degree - smells are perceived under No. 4.

It should be noted that ammonia at the same time causes irritation of the branches of the trigeminal nerve.

If none of the odors is perceived, the diagnosis is made. anosmia.

At hyposmia rule out a mechanical cause. To do this, carefully examine the upper parts of the nasal cavity and, if necessary, treat them with a single lubrication of the mucous membrane with a solution of adrenaline chloride 1: 1000 (but not with an anesthetic!) And after 5 minutes, a second examination is carried out. The appearance or improvement of the sense of smell after this procedure indicates the presence of "mechanical" hyposmia.

Quantitative study of olfactory function provides for the definition threshold of perception and recognition threshold. For this, substances of olfactory, trigeminal and mixed action are used. The principle of the technique is to dose the volume of air containing odorous substance in a constant concentration, or in a gradual increase in its concentration until a threshold of perception is obtained.

The method of quantitative study of smell is called olfactometry, and the devices with which this method is carried out are called olfactometers. The classic examples of such devices are the Zwaardemaker, Elsberg-Levi, Melnikova-Dainiak olfactometers (Fig. 14).

Rice. fourteen.

a — Tsiaardemaker; b - Elsberg; a - Melnikova - Dainyak

Otorhinolaryngology. IN AND. Babiak, M.I. Govorun, Ya.A. Nakatis, A.N. Pashchinin