RU2308245C1 - Method for treating closed depressed fractures of frontal sinuses face walls - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out supra-orbital frontotomy and reducing fracture zone. Frontonasal canal is revised prior to the supra-orbital frontotomy, Hemosisnus is removed and flexible catheter coiled in spiral is introduced into frontal sinus lumen through fracture line. Antibacterial therapy means is supplied via the catheter in postoperative period during 5-6 days and then, the catheter is to be removed.

EFFECT: enhanced effectiveness of treatment; improved cosmetic results.

3 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology, and specifically to methods for treating closed, depressed fractures of the front wall of the frontal sinus.

A known method of treating depressed fractures of the front wall of the frontal sinus [1], in which the operation is performed supraorbital frontotomy. If it is not possible to preserve bone fragments of the front wall of the frontal sinus, the latter are replaced by a plate of high polymer polyethylene.

The disadvantages of this method is that the fracture of the front wall is replaced by an implant, and this in the postoperative period can manifest itself by rejection of the latter. The rejection of the implant subsequently leads to a pronounced cosmetic defect. The method is traumatic, which prolongs the time of postoperative healing and does not guarantee secondary displacement of the implant. The need to have an implant made of high molecular weight polyethylene limits the possibilities of ENT surgeons in treating a fracture of the frontal sinus, and the inability to introduce antiseptic solutions into the frontal sinus can lead to late postoperative complications (frontal osteomyelitis, etc.).

Also known is a method of treating depressed frontal sinus fractures, in which, during an operation of supraorbital frontotomy, when a frontal sinus fracture is pressed, bone fragments are fixed between the last milling holes by nickelide with titanium threads, fishing line, nickelide with titanium brackets [2].

The disadvantages of this method is the need to have additional medical equipment in the form of a boron machine and nickelide titanium materials for fixing fragments. The method is traumatic and due to the lack of intra-axillary immobilization, secondary deformation of bone fragments of the front wall of the frontal sinuses is not ruled out. The application of milling holes in bone fragments in the future can manifest itself as osteomyelitis and the development of frontal sinusitis. Despite the fact that this method involves caring for the frontal sinus in the form of washing the latter with antiseptic solutions through the frontal-nasal canal, this care cannot be called full-fledged, and the creation of a stronger positive pressure in the frontal sinus when washing it can lead to secondary fracture deformation and as a result, to a cosmetic defect of the upper zone of the face.

Closest to the claimed is a method of treating closed depressed fractures, including performing an incision in the frontal region, skeletonizing a portion of the frontal bone, reposition of fragments of its front wall, and the incision in the frontal region is performed from a point located on the line of projection of the fracture edge onto the skin in the superciliary region, and for skeletonization, select the site adjacent to the fracture zone at the incision site, after which from the incision through the soft tissues of the frontal region above the fragments, near the periosteum, parallel to the tangent, to the upper edges of the orbits, a Kirschner needle is bent along an arc corresponding to the bend of the frontal bone at the fracture site, the length of which is 2-3 cm longer than the length of the depressed area [3].

The disadvantages of this method is the impossibility in the postoperative period of local care in the form of washing the frontal sinus with antiseptic solutions. The method does not involve revision of the fronto-nasal canal to clarify its normal functioning, which subsequently can lead to late postoperative complications in the form of empyema of the frontal sinus.

A new technical task is to increase the effectiveness of treatment by reducing complications, creating the conditions for obtaining a good long-term cosmetic result, reducing treatment time and preventing late complications.

To solve the problem, in the method of treating closed impressions of the front wall of the frontal sinuses, which consists in revising the fronto-nasal canal followed by supraorbital frontotomy, reponiting the fracture site, the hemosinus is removed, after which elastic coiled in the form of a spiral is introduced into the frontal sinus lumen through the fracture line a catheter through which local antimicrobial therapy is performed for 5-6 days in the postoperative period, after which the catheter is removed

The method is as follows.

At the first stage of the method, it is necessary to verify the normal patency of the fronto-nasal canal from the side of the fracture of the front wall of the frontal sinus and, if necessary, expand it. This is carried out by an opto-endoscopic revision of the fronto-nasal canal, for example, with the help of Karl Storz endoscopes with subsequent probing of the frontal sinus. After making sure of a good patency of the fronto-nasal canal, proceed to the second stage of the method.

The second stage of the method is carried out under general anesthesia: conduct supraorbital frontotomy with exposure of the fracture of the front wall of the frontal sinus (figure 1). An elevator is introduced into the frontal sinus along the fracture line, closer to its lateral part, with which the fracture is repaired to the level of the contralateral side, the hemosinus is removed. A bayonet-shaped tweezers (Figure 2) are inserted through the location of the fracture of the frontal sinus front wall fracture, on which a polyvinyl chloride hollow elastic catheter with a diameter of up to 4 mm over the entire length is wound with a spiral (for example, from a medical system for intravenous injection). By rotational movements, the catheter is removed from the tweezers and left in the frontal sinus. The elastic properties of the catheter allow the latter to take the shape of the frontal sinus and immobilize bone fragments from the inside. The outer free part of the catheter through the suture line is displayed in the lateral angle of the wound (Fig.3).

At the third stage of the method, against the background of general antibiotic therapy, sanitation of the frontal sinus is carried out, introducing through the same hollow catheter solutions of antiseptics or antibiotics that are freely evacuated from the frontal sinus through the fronto-nasal canal. Five days later, an elastic catheter for the free edge is removed from the frontal sinus and the patient is transferred to outpatient treatment.

The following clinical examples demonstrate the effectiveness of the method.

Example 1. Patient A., 27 years old, was hospitalized in the ENT department of MK LPMU "City Clinical Hospital No. 3 of Tomsk" in a planned manner. From the anamnesis: three days before hospitalization he was beaten, after which there was a deformation in the area of the front wall of the right frontal sinus. The diagnosis was confirmed by a clinical examination, photographing the patient in front and profile, as well as radiography of the paranasal sinuses in the front and side projection, computed tomography of the paranasal sinuses.

Upon admission, he complained of a cosmetic defect in the upper zone of the face on the right, as well as hemorrhagic discharge from the right half of the nose with a violation of its respiratory and olfactory functions. After examining a neurologist and an ophthalmologist who excluded a head injury, the patient was diagnosed with a closed, depressed fracture of the right frontal sinus. Hemosinus.

The patient was treated using the proposed method. During the first stage, good patency of the fronto-nasal canal was established and hemosine was partially evacuated. A day later, the second stage of the method was carried out with the placement of an immobilizing hollow elastic catheter in the right frontal sinus and removal of hemosinus residues.

During the third stage of the method, against the background of general antibiotic therapy, antihistamine treatment and vasoconstrictor drops in the nose, rinsing through the hollow frontal sinus catheter with a solution of 1% dioxidine twice a day was performed.

The third day. The patient noted the cessation of hemorrhagic discharge from the right half of the nasal cavity, improving the sense of smell. When examining the site of surgery, a small postoperative hematoma of the supraorbital region. On palpation, the position of the fragments of the front wall of the right frontal sinus is correct. Through the catheter, the sinus is flushed with a 1% dioxin solution. The fronto-nasal canal functions well.

Fourth day. The patient does not show complaints, nasal breathing is free, the sense of smell, subjectively, has recovered. When examining the site of surgery, a decrease in the hematoma of the right supraorbital region was noted, the position of the fragments of the front wall of the frontal sinus was correct. Postoperative suture heals by first intention. The sinus through the catheter is flushed with a 1% dioxin solution.

Within 5-6 days, the hematoma of the right supraorbital region was stopped almost completely. There is no cosmetic defect in the upper zone of the face, the fronto-nasal canal is functioning normally, the immobilizing catheter from the frontal sinus has been removed. On the 6th day I was discharged for outpatient treatment.

When viewed after one month, the postoperative suture is healed by first intention to achieve complete symmetry of the front wall of the right frontal sinus with the contralateral side. Violation of the respiratory and olfactory function of the nose are absent.

Example 2. Patient S., 30 years old, was hospitalized in the ENT department of MK LPMU "City Clinical Hospital No. 3 of Tomsk" in a planned manner. On admission, he complained of deformation of the facial skeleton in the projection of the left frontal sinus, recurrent left-side frontal sinusitis up to 2-3 times a year. From the anamnesis it was found that the deformation of the left supraorbital region appeared about 2 years ago after hitting a blunt object in the face. On examination, a consolidated impressed fracture of the front wall of the left frontal sinus was diagnosed. The diagnosis was confirmed by radiography of the paranasal sinuses in the direct and lateral projections, computed tomography, photographing the site of deformation of the upper zone of the face.

The treatment according to the proposed method. At the first stage of the method, an optical endoscopic revision of the left frontal-nasal canal was carried out and its patency was established due to deformation of the frontal process of the upper jaw prolapse into the lumen of the latter. Patency of the fronto-nasal canal is restored.

At the second stage of the method, under anesthesia, a supraorbital frontotomy was performed on the left with a reposition of the consolidated fracture by the elevator and chisels. A hollow elastic catheter was inserted into the frontal sinus lumen, which allows for immobilization of bone fragments of the front wall of the left frontal sinus from the inside. The free end of the catheter is brought to the lateral angle of the skin incision.

At the third stage of the method, the left frontal sinus was washed through a catheter with a solution of 1% dioxidine (2 times a day) against the background of general antibiotic therapy, antihistamine treatment, and vasoconstrictive drops in the nose.

On the third day after surgery - moderate hematoma of the soft tissues of the left supraorbital region. The standing of the fragments of the front wall of the left frontal sinus is correct; when washing through the catheter with a 1% solution of dioxidine, the fronto-nasal canal functions well.

On the 4th, 5th, 6th days after surgery, the patient has no complaints. The soft tissue hematoma of the left supraorbital region almost stopped. The configuration of the front wall of the left frontal sinus corresponds to the contralateral side. On the 6th day from the moment of hospitalization, an elastic immobilizing catheter was removed from the frontal sinus. The patient was discharged for outpatient treatment.

When viewed after a month, no complaints. The upper area of the face on the right and left are symmetrical, there is no cosmetic defect, the healing of the postoperative suture by primary intention.

The proposed method of treatment was tested on the basis of the ENT department of the MK LMPU "City Clinical Hospital No. 3 of Tomsk" in the treatment of 12 patients with closed impressions of the front walls of the frontal sinuses both in the early stages of the disease (1-5 days) - 8 people, and with consolidated fractures in the later stages (6 months - 2 years) - 4 people.

The application of the proposed method allowed to achieve in all cases a good cosmetic result, reducing treatment time by 4-5 days, as well as eliminating the development of possible late complications of an impressed fracture of the frontal sinuses (frontal bone osteomyelitis, chronic frontal sinusitis, etc.).

Thus, the proposed method allows for the effective treatment of depressed early and consolidated fractures of the front wall of the frontal sinuses due to the good immobilization of the latter in the postoperative period by placing an elastic hollow catheter in the frontal sinus lumen. The proposed method for the treatment of fractures of the front wall of the frontal sinuses allows at the first stage to conduct an audit of the fronto-nasal canal and, if necessary, restore its full patency. The placement in the frontal sinus of an elastic hollow catheter implies good fracture immobilization in the second stage of the method. Local sanitation of the frontal sinus, achieved by the introduction of the last antiseptic solutions and antibiotics through the hollow catheter, promotes effective reparative processes in the wound with the achievement of a good cosmetic result, shortening the treatment time and preventing delayed complications with pressed fractures of the front wall of the frontal sinuses.

The advantages of the proposed method are as follows: the method is simple, safe, has a good cosmetic effect in the treatment of depressed fractures of the front wall of the frontal sinuses both in the early period of the onset of pathology and in consolidated fractures. When using the method, along with good cosmetic results, the treatment time for patients is reduced and the development of early and late complications of this type of ENT pathology is prevented.

Information sources

1. Nikolaev M.P. On the tactics of treating facial skeleton injuries // Bulletin of Otorhinolaryngology. - 1999, No. 1. S.28-30.

2. A method for the treatment of fractures of the front and lower walls of the frontal sinuses (Abstracts of Russian patent documents for 1994-2006) // No. 2004114374, 10.27.2005

3. The method of fixing fragments with dented fractures of the anterior wall of the frontal sinus, RF patent No. 2231322, 06/27/2004 (prototype).

4. Pavlov V.V. The use of endoscopic technology in the surgical treatment of closed fractures of the frontal sinus walls // Materials of the All-Russian Scientific and Practical Conference with international participation dedicated to the 70th anniversary of the State Medical Academy and the Department of Otorhinolaryngology: "Actual problems of modern otorhinolaryngology". - Novosibirsk, 20-21.10.2005. - C.114-116.

Claims (1)

A method for treating closed depressed frontal sinus front wall fractures, including supraorbital frontotomy and fracture site reponition, characterized in that the frontal nasal canal is revised before supraorbital frontotomy, hemosinus is removed, and then a spiral-shaped, elastic-coiled elastic is introduced into the frontal sinus lumen through the fracture line a catheter through which antibacterial therapy is carried out for 5-6 days in the postoperative period, after which the catheter is removed.

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