RU2238682C1 - Method for treating exudative inflammation of frontal sinus in patients with retrobullar form of nasofrontal communication at availability of large latticed hooked bulla, bulla ethmoidalis uncinata - Google Patents

Abstract

FIELD: medicine, rhinology.

SUBSTANCE: in case of detecting the fusion of hooked process and latticed bulla one should endonasally removed the observed neoplasm at its whole distance. One should further perform sanitation of affected frontal sinus due to endonasal probing.

EFFECT: higher efficiency of therapy.

1 ex

Description

The invention relates to medicine, namely to otorhinolaryngology.

Treatment of patients with inflammatory diseases of the frontal sinuses continues to be one of the most difficult and relevant tasks in otorhinolaryngology.

The anatomical variability of the structure of the frontal sinus and its communication with the nasal cavity play a leading role in solving this problem (Piskunov S.Z., Zavyalova F.N., Guryev I.S., Piskunov BC Features of the pathological process in the paranasal sinuses depending on the location and sizes of anastomosis. / Russian rhinology. - 1999. - No. 2. - S.16-19).

Despite the successes achieved in the study of the etiopathogenesis of inflammatory diseases of the paranasal sinuses and the use of modern endoscopic and X-ray diagnostic techniques for the diagnosis and treatment, the question of choosing a method for treating frontal sinusitis is still standard and generalizing (Jarrar Schäger. Evaluation of the effectiveness of some methods of treatment of chronic frontal sinusitis / West Otorhinolaryngology. - 1990. - No. 3. - P.25-26).

Conservative anti-inflammatory and physiotherapeutic treatment, widely used in everyday otorhinolaryngological practice, is not only ineffective, but also due to its inadequacy leads to a chronic process and the development of complications (Blagoveshchenskaya N.S. Combined lesion of the frontal sinuses and brain. - M .: Medicine, 1972).

The most common treatment for frontal sinusitis in our country and abroad is the extranasal opening of the affected frontal sinus with the imposition of an artificial anastomosis. But despite the radicalism of this method, the percentage of frontitis recurrence universally exceeds 60%, which many attribute to obliteration of the newly formed frontal-nasal anastomosis (Gyusan A.O., Gyusan S.A., Uzdenova R.Kh. On the issue of recurrent frontal sinuses. / Otorhinolaryngology at the turn of the millennium.Materials of the XVI Congress of Otorhinolaryngologists of the Russian Federation. Sochi, March 21-24, 2001 - St. Petersburg: RIA-AMI. - 2001. - P.553-554).

However, even with patency of the fronto-nasal anastomosis, the inflammatory process in the frontal sinuses recurs in a large number of cases, orbital and intracranial complications often occur, which entails multiple extranasal surgical interventions up to obliteration of the frontal sinuses, which lead to the formation of persistent cosmetic facial defects ( Bogdanov V.V., Balabaitsev A.G., Bogatov P.P. Surgical treatment of recurrent frontal sinusitis and frontal osteomyelitis. / Russian rhinology. - 2001. - No. 2. - S.114-115).

In this regard, a number of researchers prefer sparing minimally invasive methods of treatment of frontal sinusitis. The most common method in our country and abroad was the method of trepanopuncture of the frontal sinus, which was first reported by A. Muhlen in 1911 at a meeting of the Doctors Society in Leipzig (Muhlen A. Zur Diagnosenstellung der Stimhohleneiterung. Verhandl.d. Gesellsch.deutsch. / / Naturf.u. Aerzte, Leipzig. - 1911. - Bd. 82. - S. 338-342).

The best indicators of the use of trepanopuncture were noted in the treatment of acute and subacute exudative frontal sinuses while maintaining the drainage and ventilation function of the natural outlet of the frontal sinus (Gyusan A.O., Gyusan S.A., Uzdenova R.Kh. Retrospective analysis of the results of the treatment of acute and chronic frontal sinusitis by the method trepanopunktsii./ Current issues of audiology and rhinology. Abstract of the report of the scientific and practical conference. Kursk June 7-8, 2000 - M., 2000. - S.109-110).

With anatomical obstruction of the fronto-nasal communication, the use of this technique not only lengthens the length of hospital stay, casts doubt on the effectiveness of the treatment, but also contributes to the transition of the acute process to the chronic one (Gnoy AR, Gannon PG, Ganjian E. et al. A potential role for nasal obstruction in development of acute sinusitis: an infection study in rabbits. // Am. J. Rhinol. - 1998. - Vol.12, No. 6. - P.399-404).

Endonasal sounding of the frontal sinuses for rinsing and administering drugs was first proposed by A. Jurasz in 1883, and a scientific publication appeared in 1887 (Jurasz A. Uber die Sondirung der Stirnhohle. / Berlin, klin. Wschr. - 1887. - No. 3. - S.34-36).

The complexity of performing endonasal sounding of the frontal sinuses due to the anatomical variability of the fronto-nasal communication did not allow her to find as many supporters as trepanopuncture (Volkov A.G. Frontal sinuses. Rostov-on-Don: Phoenix, 2000).

The cause of the narrowing of the fronto-nasal communication is the excessive pneumatization of the structures of the ethmoid bone forming this message. Excessive pneumatization of the hook-shaped process and the ethmoid bull narrow the drainage and ventilation passage to the frontal sinus with infundibular, or indirect, and retrobular forms of the fronto-nasal communication, make it difficult or impossible to endonasally probe the frontal sinuses (Landsberg E.A. Importance of diagnosing endonasal and for diseases of the frontal sinuses. / Bulletin of Otorhinolaryngology. - 1966. - No. 2. - P.54-57; Mashkova TA. Topographic and anatomical risk factors for the development and chronicity of inflammatory diseases of the lung bosnnyh sinuses. Author's abstract of thesis ... doctor of medical sciences. - M., 2002. - 30 p.).

In the scientific literature there is no information about the possibility of carrying out endonasal diagnostic and therapeutic measures in patients with exudative frontal sinusitis with a retrobullary form of fronto-nasal communication. If endonasal sounding of the frontal sinus is not possible in such patients, preference is given to extranasal opening of the frontal sinus according to the generally accepted technique.

It is known that the frontal sinus aperture is located on its lower wall near the posterior wall bordering the anterior cranial fossa (Miloslavsky M.V. Frontal sinuses (topographic-anatomical and craniological examination): Thesis ... Doctors of medical sciences - M., 1903. - 192 p.). Therefore, the expansion of the fronto-nasal communication due to resection of its posterior portions is fraught with penetration into the cranial cavity and the development of severe intracranial complications. In the retrobular form of the fronto-nasal communication, which we observed in 6 preparations from 61 (9.8%) and in 3 of 229 (1.3%) patients with frontitis, endonasal sounding of the frontal sinuses without violating the integrity of the structures forming the fronto-nasal message was anatomically impossible. Endonasal sounding of the frontal sinus became possible after resection of the ethmoid bulla.

The obtained results explain the reasons for failures in carrying out endonasal diagnostic and therapeutic measures in patients with frontal sinusitis with a retrobular form of the fronto-nasal communication and indicate the need for surgical correction of the structure of the ethmoid bone, namely, resection of the ethmoid bulla to restore the ventilation and drainage function of the fronto-nasal message in such patients .

When the hook-shaped process, processus incinatus, and the large ethmoid vesicle, bulla ethmoidalis merge, the lunate cleft, hiatus semilunaris, is absent, and the possibility of the infundibular form of the fronto-nasal communication is excluded (Mashkova T.A. to the topographic and anatomical features of the lateral wall of the nasal cavity / T .A. Mashkova, A.V. Chernykh, A.V. Isaev, Russian rhinology. - 2002. - No. 4. - P.35-36; Isaev A.V. Large latticed hook-shaped vesicle - a rare formation of the ethmoid bone / A.V. Isaev, T. A. Mashkova, A. V. Chernykh. System analysis and management in biomedical x systems -. 2003 - Vol.2, №2 -. pp 19-20). In such cases, the frontal sinus can communicate with the nasal cavity either recessively or retrobully.

The presence of such a pneumatized formation (large ethmoid lattice vesicle, bulla ethmoidalis uncinata) disrupts the ventilation and drainage functions of the fronto-nasal communication in patients with frontitis, and prevents endonasal sounding of the affected frontal sinus during its retrobular communication.

The large latticed hook-shaped vesicle, bulla ethmoidalis uncinata, as an extreme variant of the atypical topographic and anatomical relationships of the structures of the ostiomeatal complex, we observed on autopsy of the corpse when studying the variant anatomy of the fronto-nasal communication on fixed preparations of the fronto-ethmoid block (Mashkova T.A. to topographic anatomical features of the lateral wall of the nasal cavity / T.A. Mashkova, A.V. Chernykh, A.V. Isaev Russian rhinology, - 2002. - No. 4. - P.35-36; Isaev A.V. Large latticed hook-shaped vesicle - rare about transform of the ethmoid bone / A.V.Isaev, T.A.Mashkova, A.V.Chernyh // System analysis and control in biomedical systems -. 2003 - Vol.2, №2 -. S.19-20). The variant of the structure of the anatomical formations of the lateral wall of the nasal cavity that we discovered and not previously described in the literature available to us prompted us to give a clinical assessment of the effect of the large ethmoid hook-shaped vesicle on the treatment results and the possibility of performing diagnostic and therapeutic procedures for inflammatory diseases of the frontal sinuses.

The above methods for the treatment of inflammatory diseases of the frontal sinuses do not imply the presence of a large ethmoid hook-shaped vesicle and a retrobular form of the fronto-nasal communication.

Closest to the claimed object is a method of endonasal endoscopic sinusotomy. However, the question of the volume of endonasal endosurgical and microsurgical treatment for inflammatory pathology of the frontal sinuses, in particular the removal of the hooked process, remains unresolved (Piskunov S.Z. Some Anatomical and Physiological Problems of Functional Rhinosinus Surgery // Russian Rhinology - 1998. - No. 2. - C .62; Mashkova TA Endonasal endoscopic sanitizing correction of the structure of the ethmoid bone in the treatment of inflammatory diseases of the frontal sinuses. / Ministry of Health of the Russian Federation. Voronezh State Medical Academy named after NN Burdenko. - Voronezh , 2002. - 8 pp. Manual depository at TsNMB MMA named after I.M.Sechenov No. D-27015 dated 05/20/2002; Draf W., Weber R., Keerl R., Constantinidis J. Current aspects of the frontal sinus surgery. I: Endonasal frontal sinus drainage in inflammatory diseases of the paranasal sinuses // UNO. - 1995. - Vol. 43, No. 6. - P.352-357).

The technical result is achieved in that in patients with exudative frontitis with a retrobular form of the fronto-nasal communication in the presence of a large ethmoidal vesicle, to ensure complete drainage of the affected frontal sinus and the possibility of its rehabilitation during endonasal probing, endonasal resection of the major ethmoid vesicle, bulla ethmoidalis all along it.

In clinical practice, we observed one patient with frontitis in whom a large ethmoid hook-shaped vesicle was found during endoscopy of the nasal cavity.

Example. Patient Z., medical history No. 6529-3-87, was admitted to the ENT department of the Regional Clinical Hospital of Voronezh on 05/20/03 with a diagnosis of right-sided acute purulent hemisinusitis. Sick for about 2 weeks. He was treated on an outpatient basis with anti-inflammatory drugs and punctures of the right maxillary sinus with temporary improvement. Upon receipt of a complaint of pain in the right frontal region. With anterior rhinoscopy, edema and hyperemia of the mucous membrane of the right half of the nasal cavity were determined. The middle nasal concha is paradoxically curved and pressed against the displaced medially lateral wall of the nasal cavity. Separated from the paranasal sinuses was not detected even after prolonged anemia. With posterior rhinoscopy in the right choana - traces of pus. On computed tomograms in the coronary and axial projections of 05/20/03, darkening of the right frontal and maxillary sinuses. With a puncture of the right maxillary sinus in the washing fluid, a small mucopurulent clot. An attempt to probe the right frontal sinus failed. Trepanopuncture of the right frontal sinus was performed under local anesthesia. Thick pus under pressure emerged from the trepanation hole. Washing of the sinus is painful, difficult. Nose discharge was not detected. When endorinoscopy using a serial endoroscope of the company Striker with zero and 30 ° optics, a fusion of the hook-shaped process and the large ethmoid vesicle - the large ethmoid vesicle-like vesicle, bulla ethmoidalis uncinata, was found. This formation extended below the free edge of the middle turbinate. The lunar slit did not differentiate. The frontal sinus aperture was not found in the anterior middle nasal passage.

After maximal abduction of the middle turbinate, pus was found medially behind the upper part of the large ethmoid hook-shaped vesicle. Probing of the frontal sinus is anatomically impossible. Under local anesthesia, a resection of a large ethmoid hook-shaped vesicle was performed along its entire length. At autopsy, it was found that this formation consists of several cavities filled with pus. After removal of the large ethmoid hook-shaped vesicle from the frontal sinus, about 10.0 ml of creamy pus was released. The frontal sinus aperture about 3 mm in size was located behind a large ethmoid hook-shaped vesicle. Probing and rinsing the frontal sinus are free. On examination, 05/21/03 in the right middle nasal passage, abundant mucous discharge with an admixture of blood. With endonasal washing of the right frontal sinus, a large amount of mucus with an admixture of pus was obtained. Antibiotics are introduced into the sinus. On the fifth day after the operation, exudation from the sinus ceased. Physiotherapeutic treatment is prescribed. The patient was discharged on the seventh day after surgery for outpatient treatment. When viewed after 1 month, no complaints. There are no inflammatory changes in the nose. The right frontal sinus is freely probed. On the roentgenogram violations of pneumatization of the right frontal and maxillary sinuses were not found.

Using the proposed method contributed to the restoration and stable functioning of the fronto-nasal communication of the affected frontal sinus, ensured the effectiveness and stability of the results of its rehabilitation by endonasal sounding.

Claims (1)

A method of treating exudative frontitis in patients with a retrobular form of the fronto-nasal communication, characterized in that when the fusion of the hooked process and the large ethmoid vesicle is detected, the endonasally detected lesion is removed along its entire length and subsequently, the affected frontal sinus is rehabilitated by endonasal sounding.