RU2271166C2 - Method for treating fractured anterior and inferior walls of frontal sinuses - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves exposing anterior and inferior walls and periosteum is cut to bone along fracture line. Periosteum is detached 1 cm far from the edge. Fractured bone fragments are set. Milling holes of 0.3 mm large diameter are done in each splitter and in intact bone at least 3.0 mm far from fracture line. The bone fragments are rigidly attached to the intact bone body and to each other by means of circular interrupted sutures with surgical suture material like titanium nickelide thread TH-20 having diameter of 0.12 mm.

EFFECT: retained frontal sinuses functions; prevented bone resorption.

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Description

The invention relates to medicine, namely to otorhinolaryngology.

Injuries of the upper and middle zones of the facial skull are found in 3-22% of victims. Of all the paranasal sinuses, frontal injuries are most likely to be injured by direct exposure. In the vast majority of cases, fractures are of a compression nature. Violation of the integrity of bone structures is accompanied by hemorrhage in the sinus and the formation of hemosinus, which is a favorable nutrient medium for an ascending infection. In a significant percentage of cases, neighboring structures are involved in the traumatic process, most often - orbit. The consequences of injuries of the frontal sinuses are manifested not only in disfiguring the face, but also in the frequent development of complications such as post-traumatic frontal sinusitis, frontal bone osteomyelitis, inflammatory processes in the orbit (N. A. Rabukhina, N. M. Chuprynina. X-ray diagnosis of diseases of the maxillofacial region. M .: Medicine, 1991, - 368 p.).

As you know, the only method of treating patients with trauma to the front and lower walls of the frontal sinuses with displacement of fragments is surgical. Most authors recommend an early reposition of fragments, since only timely redress reduces treatment time and prevents the development of severe complications (MP Nikolayev. On the tactics of treating facial skeleton injuries // Bulletin of Otorhinolaryngology. - 1999. - No. 1. - P.28 -thirty).

A known method of treating injuries of the frontal sinuses according to the method of A.I. Kameneva. The method consists in the fact that repaired bone fragments associated with the periosteum are fixed using a chrome catgut. In this case, the operation is completed with a tight tamponade of the sinus lumen with iodoform powder to fix the fragments in the postoperative period. The wound is conducted in an open way. After 3-4 weeks, the lumen of the sinus is closed by suturing the wound with a secondary suture (A.I. Kameneva. Treatment of injuries of the frontal sinuses and ethmoid labyrinth // Bulletin of Otorhinolaryngology. 1972. - No. 3. - P.67-72).

The disadvantages of this method:

- Violation of the nutrition of the sinus mucosa due to a violation of its aeration under pressure with a tampon with the possible development of post-traumatic frontal sinusitis.

- An increase in the volume of a cosmetic defect due to secondary sutures.

- A long period of treatment in a hospital setting.

- Lack of "rigid" fixation of fragments to undestructed bone.

There is a method of fixing fragments of facial bone bones using bone steel plates according to the method of B.L. Pavlov, in recent years, implemented by the production of sets of mini-plates of titanium by Lorenz-Martin, Leibinger, Luhr and others (Yu.I. Bernadsky. Traumatology and reconstructive surgery of the cranial-maxillofacial region. - M .: Medical literature, 1999, - 456 p.).

The disadvantages of this method:

- The inability to fix the mini-plate with mini-screws, since the thickness of the front and lower walls of the frontal sinus is less than 1 mm.

- Post-traumatic facial deformity: the plate is visible through the thin skin of the forehead.

The known method, selected as a prototype, fixing fragments of the front and lower walls of the frontal sinuses. An incision is made along the eyebrow, slightly exceeding the size of the deformation in width. By layer-by-layer dissection of the skin, subcutaneous tissue, the front and partially lower walls of the frontal sinus are exposed. The periosteum is dissected to the bone along the fracture line and exfoliates with a rasp 1 cm from the edge. An elevator is introduced into the sinus along the fracture line, with the help of which the fragments are raised and set in the correct position. Using a drill, milling holes with a diameter of 1 mm are superimposed in each fragment and in an undestroyed bone. When applying holes, the total length of the bracket (from 3.0 to 6.0 mm) and the diameter of the wire 0.6-0.8 mm are taken into account. Brackets of titanium nickelide with a "memory" of the TN-10 alloy shape. The number of milling holes depends on the number of fragments (with 2 fragments - 4 holes, with 3 fragments - 6, etc.). Using the Politzer balloon, the operation of the fronto-nasal canal is checked. Brackets are introduced into the drilled holes, the legs of which are previously straightened in liquid nitrogen. When heated, the brackets take their primary form, fixing the fragments. Drainage is introduced into the sinus - a tube made of silicone with a diameter of 1.0 mm, for the treatment of the sinus mucosa in the postoperative period and the elimination of postoperative hemosinus. The wound is sutured in layers with a cosmetic suture on the skin of the eyebrow (V.E. Gunter, V.V. Kotenko, M.Z. Mirgazizov and other alloys with shape memory in medicine. - Tomsk, 1986, - 206 pp.).

The disadvantages of this method:

- When applying milling holes, it is practically impossible to accurately measure the distance between two holes, because a fragment of the sinus wall is movable (when the brackets “act”, there is a lack of fixation or displacement of the fragment to the edge of an unbroken bone)

- Bone overpressure results in bone resorption with possible “migration” of the brace into the frontal sinus.

- Feeling braces under the skin of the forehead, which causes discontent of patients.

Object of the invention: the elimination of post-traumatic deformity of the front and lower walls of the frontal sinuses while maintaining the function of the frontal sinuses.

The task is achieved in that after exposure of the anterior and partially lower walls of the frontal sinus, the periosteum is dissected to the bone along the fracture line and peeled off with a rasp 1 cm from the edge. An elevator is introduced into the sinus along the fracture line, with the help of which the fragments are lifted and installed in the correct position, followed by the formation of milling holes in each fragment and in an unbroken bone. Holes are formed with a diameter of 0.3 mm without accurately measuring the distance between them arbitrarily, deviating from the fracture line by a distance of at least 3.0 mm, and are “rigidly” fixed with a conventional circular interrupted suture with a surgical suture material in the form of a thread of an alloy based on titanium nickelide grade TH-20, with a diameter of 0.12 mm. Fragments are fixed to the unbroken bone and among themselves.

The novelty of the method:

1. Milling holes are small - 0.3 mm, which reduces additional surgical trauma.

2. Accurate measurement of the distance between the two holes is not required.

3. Suture material is used - a thread made of an alloy based on titanium nickelide, with a diameter of 0.12 mm, grade TN-20.

The method is explained by the drawings. Figure 1, Figure 2.

Figure 1. The position of fragments of the anterior wall of the frontal sinus after their reposition is shown (in the example there are two of them).

Figure 2. The fixation of fragments by a titanium thread is shown.

The essence of the method is as follows.

In the presence of post-traumatic deformation of the front and lower walls of the frontal sinuses, the following type of operation is used.

An incision is made along the eyebrow, slightly exceeding the size of the deformation in width. By layer-by-layer dissection of the skin, subcutaneous tissue, the front and partially lower walls of the frontal sinus are exposed. The periosteum is dissected to the bone along the fracture line and exfoliates with a rasp 1 cm from the edge. Along the fracture line, an elevator is introduced into the sinus, with which fragments 1 and 2 are raised and installed in the correct position - Fig. 1.

Using a drill, milling holes are formed in a diameter of 0.3 mm without accurately measuring the distance between them 4 on fragments 1, 2 and in an undestroyed bone 3, departing from the fracture line by a distance of at least 3.0 mm. The number of milling holes depends on the number of fragments (with 2 fragments - 4 holes, with 3 fragments - 6, etc.), there may be more. Fragments 1, 2 are fixed through the holes to the unbroken bone 3 and between each other with the usual circular interrupted sutures with surgical suture material 5 - a thread made of an alloy based on titanium nickelide grade ТN-20, with a diameter of 0.12 mm - Fig.2. This technique allowed to “rigidly” fix the fragments, as the degree of fixation is determined by the surgeon when tightening the knot, and in the prototype the bracket with the “memory” of the TN-10 alloy shape first fixes with excessive pressure on the edge of the bone, then freely “hangs” in the holes. In addition, this method uses a thread with a diameter of 0.12 mm, which is not further felt under the skin of the forehead. Using the Politzer balloon, the operation of the fronto-nasal canal is checked. Drainage is introduced into the sinus - a tube made of silicone with a diameter of 1.0 mm for the treatment of the sinus mucosa in the postoperative period and the elimination of postoperative hemosinus. The wound is sutured in layers with a cosmetic suture on the skin of the eyebrow.

Thus, the application of this technique allows you to eliminate post-traumatic deformation of the front and lower walls of the frontal sinuses while maintaining the function of the frontal sinuses.

Clinical example: patient T., 21 years old, a student, was admitted to the ENT clinic on 02/02/2003 with a diagnosis of Post-traumatic deformity of the front and lower walls of the left frontal sinus, diplopia. Closed head injury: concussion. Injury in life, 01/31/2003 hit in the face with an unknown object. I went to the hospital in Osinniki (at the place of residence), from where I was sent to the ENT clinic in Novokuznetsk.

February 4, 2003 - operation - Frontotomy on the left with reposition of fragments.

An incision was made along the eyebrow about 3.0 cm. The skin, subcutaneous tissue with exposure of the anterior and partially lower walls of the left frontal sinus were dissected in layers. The periosteum is dissected to the bone along the line of fractures and peeled off with a rasp 1 cm from the edges. A depressed fracture contains two fragments of the anterior wall of the frontal sinus of 1.5 cm each and a depressed fragment of the lower wall of about 2.0 cm. An elevator was introduced into the sinus along the fracture line, by means of which the fragments were raised up and installed in the correct position. Using a drill, 6 milling holes with a diameter of 0.3 mm were made without accurately measuring the distance between them, deviating from the fracture line of at least 3.0 mm, one hole in each fragment and three holes in the unbroken bone. Fragments to the unbroken bone with circular interrupted sutures and surgical suture material — a thread made of an alloy based on titanium nickelide of the TN-20 grade, with a diameter of 0.12 mm, are “rigidly” fixed through the holes. Fragments are also bonded to each other. This technique allowed to “rigidly” fix the fragments, as the degree of fixation is determined by the surgeon when tightening the node. Using a Politzer balloon, the frontal-nasal canal was checked: patency is free. A drainage is introduced into the sinus - a tube made of silicone with a diameter of 1.0 mm, along the fracture line and is fixed to the skin with a suture. The wound is sutured in layers with a cosmetic suture on the skin of the eyebrow. For 6 days, the sinus was washed with physiological saline with the addition of hydrocortisone emulsion (1.0 ml per wash). Discharged from the department on the 8th day after the operation with a good cosmetic and functional result. Examined a year later, a control computed tomography of the frontal sinuses was carried out: there was no deformation of the forehead, sinus pneumatization was normal.

Using this method of treating fractures of the front and lower walls of the frontal sinuses simplifies the technique of performing the operation, since there is no need to accurately maintain the distance between the milling holes. There is comfort in patients - there is no sensation of the presence of foreign objects under the skin of the forehead.

This method is used in clinical practice. 8 patients were operated on. There is no secondary deformation, pneumatization of the frontal sinuses is normal. Significantly reduced treatment time in the hospital.

Claims (1)

A method for the treatment of fractures of the front and lower walls of the frontal sinuses, including exposure of the front and lower walls with dissection of the periosteum to the bone along the line of fractures and its detachment by 1 cm from the edges, reposition of fragments in the correct position, followed by the formation of milling holes in each fragment and in an unbroken bone characterized in that they form holes with a diameter of 0.3 mm at a distance of not less than 3.0 mm from the fracture line and rigidly fix the fragments to the unbroken bone and between them with circular interrupted sutures with a surgical suture erialom into a thread of an alloy based on NiTi brand TN-20 0.12 mm diameter.

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