RU2331374C1 - Method of treatment of odontogenous maxillary sinusitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to otolaryngology and can be used for treatment of odontogenous maxillary sinusitis. Puncture of affected sinus through inferior nasal meatus with its washing with physiological solution is performed. Forced aeration of sinus is carried out. Microirrigator is inserted and washing with perftoran in the volume of 20 ml is fulfilled. Micro maxillary sinusotomy is performed by cutting of tunica micosa in vestibule of mouth from 4 to 5 tooth of upper jaw on the side of affection. Mucoperiostal flap is detached from canine fossa 15x15 mm long. Cutter opening with diameter of 5-8 mm is imposed in the anterior wall of sinus. Endoscope is inserted into the opening and foreign body is removed.

EFFECT: reduced intrusion traumacity, facilitated removal of foreign body when treating odontogenous maxillary sinusitis.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used to treat inflammatory lesions of the paranasal sinuses caused by foreign bodies.

There is a method of preoperative preparation of the maxillary sinus for surgical treatment for perforated odontogenic sinusitis (application for invention No. 96123695, IPC АВВ 17/00, А61K 33/08, А61К 33/44, publ. 09/10/1998, Method for preoperative preparation of the maxillary sinus in osteoarthritis perforated odontogenic sinusitis), which consists in the fact that through the microirrigator, through the perforation or fistula in the projection of the socket of the extracted tooth, a sorbent (SUMS-1) is introduced into the cavity of the maxillary sinus in a hypertonic solution of chlorine sodium, daily for 4-5 days control the degree of detoxification of the mucous membrane.

The disadvantage of this method is the restriction of use for non-perforated sinusitis, taking into account the danger of blockade of the natural anastomosis of the maxillary sinus with a sorbent and the difficulty in visualizing pathological elements of the sinus during endoscopic manipulations. If the sorbent is not completely removed from the sinus, there is a danger of developing granulation inflammation around its particles with irreversible changes in the sinus mucosa.

The closest in essence is the method of treatment of odontogenic maxillary sinusitis, proposed by S.Z. Piskunov (S.Z. Piskunov, A.I. Lazarev, T.G. Bykanova. Conservative and surgical treatment of odontogenic maxillary sinusitis. / Kursk, 2004. - p. 48-49, 59-60), which consists in puncture of the affected sinus in a typical place under the lower nasal concha with a Kulikovsky needle under application anesthesia. Then, through the needle of the Kulikovo sinus, it is washed with saline, the contents of the sinus are taken into a sterile tube for bacteriological examination. A conductor line is inserted through the puncture needle. After the puncture needle is removed, and through the hole formed during the puncture, a catheter is inserted through the conductor, after which the conductor is also removed. The end of the catheter is fixed with a band-aid to the cheek. After drainage of the maxillary sinus twice a day with an interval of 12 hours, the sinus is washed with a solution of chlorhexidine, boric acid to clean water. After that, sinus aeration is performed, which helps to remove the washing solution from its lumen. Then an antibiotic is injected into the sinus. All patients undergo forced sinus oxygenation. After examining the patient and the disappearance of the purulent discharge, an endoscopic extranasal opening of the maxillary sinus is performed with mini access through the front wall of the maxillary sinus according to the Kozlov B.C. method. (1997): the lip is pulled by the hook of Farabef, the trocar with the funnel mounted on it is installed on the front wall of the maxillary sinus, retreating 5-10 mm laterally from the center of the canine fossa. By rotational movements of the trocar, the wall is punctured, and then a funnel is inserted through the trocar into the sinus, and the trocar is removed. Through the funnel, the sinus is examined by an endoscope and under its control the hyperplastic mucous membrane, foreign bodies are removed. To examine the sinus, the position of the funnel can be changed.

The disadvantages of the prototype are the restriction of the review of the sinus coils and simultaneous manipulations in these departments through the funnel, insufficient and fixed diameter of the wound canal up to 5 mm, which does not allow to remove large foreign bodies with this access, and also significantly complicates the removal of massive caseous and fungal masses that obstruct the canal , while examining the sinus is very difficult, the duration and complexity of the surgical intervention is significantly increased. The treatment methods used in preoperative preparation (administration of aqueous chlorhexedine, antibiotics, forced sinus aeration) do not have sorption and membrane-stabilizing properties.

The objective of the invention is to increase the efficiency and reduce the invasiveness of surgical treatment of odontogenic maxillary sinusitis caused by foreign bodies, reducing the rehabilitation time of operated patients.

This object is achieved in that the treatment of odontogenic maxillary sinusitis is carried out in a manner that includes puncture of the affected sinus through the lower nasal passage with washing with physiological saline, forced sinus aeration. The introduction of a microirrigator and washing with drugs until the purulent discharge disappears. Performing a microhydrotomy and removal of a foreign body. Re-puncture of the sinus on the third day after micro-gyrotomy. Perftoran in a volume of 20 ml is used as a medicine. Washing is carried out once a day. Micro-gyrotomy is performed by cutting a mucous membrane in front of the mouth from 4 to 5 teeth of the upper jaw on the affected side. The mucoperiostal flap is peeled off from the canine fossa for 15 × 15 mm, a milling hole is applied with a diameter of 5-8 mm in the front wall of the sinus, into which the endoscope is inserted.

The novelty of the invention.

- Perftoran in a volume of 20 ml is used as a medicine. Washing is carried out once a day.

- Micro-gyrotomy is performed by cutting a mucous membrane in front of the mouth from 4 to 5 teeth of the upper jaw on the affected side. The mucoperiostal flap is peeled off from the canine fossa for 15 × 15 mm, a milling hole is applied with a diameter of 5-8 mm in the front wall of the sinus, into which the endoscope is inserted.

Perftoran has gas transport, membrane stabilizing and sorption properties, is chemically inert and is not metabolized in the body. Recommended for topical use in case of lung lavage, washing of purulent wounds, abdominal cavity. (Instructions for medical use, approved by the Department of State Control of Medicines and Medical Equipment of the Ministry of Health of Russia on 12.24.02 P.001962 / 01-2002). This allows you to stop the acute inflammatory process in the sinus, which facilitates the search for a foreign body when using a minimally invasive endoscopic method of its removal. The use of this preoperative preparation limits the inflammatory process of the sinus mucosa to its sections that are irreversibly changed, and makes it possible to preserve more sinus mucosa, which normalizes after conservative therapy. This allows you to reduce trauma and the volume of the removed mucous membrane. The next day, the sinus is washed with saline, the catheter is removed.

After this, a micro-gyrotomy is performed. Access to the maxillary sinus through a milling hole in its front wall of 5-7 mm is minimally invasive and sufficient for free manipulation in all sections of the sinus using an endoscope. This simplifies the removal of large foreign bodies, massive caseous and fungal masses. This reduces the duration and complexity of the surgical intervention and its invasiveness. Puncture of the sinus for the evacuation of the wound is carried out for 3 days.

In the postoperative period, etiotropic treatment is carried out, aimed at eradicating the pathogen in the form of antibiotic therapy, taking into account the results of microbiological and mycological studies conducted earlier.

The method is as follows.

In patients with maxillary sinusitis caused by the ingress of foreign bodies into the sinus, the following treatment is performed.

After collecting the anamnesis and examining the patient for diagnostic purposes, an x-ray of the paranasal sinuses in the nasal-chin projection is performed. The localization of a foreign body and the degree of sinus damage are determined. Under local application anesthesia of the mucous membrane of the lower nasal passage (3% dicain or 10% lidocaine), the affected maxillary sinus is punctured using the Kulikovsky needle through the lower nasal passage. Through the needle of the Kulikovo sinus, it is washed with a 0.9% sodium chloride solution in the volume necessary until the discharge is completely stopped (100-150 ml), the washings are taken for microbiological and mycological studies. At the same time, the nature of the discharge, patency of the anastomosis with the nasal cavity, and sinus volume are assessed. Then 20 ml of air is introduced into the sinus, which is achieved by sinus aeration and flushing water evacuation. Through the Kulikovsky needle, a fishing line is inserted into the puncture hole as a conductor, along which a micro-irrigator is installed. Then, perftoran in the amount of 20 ml is introduced through a microirrigator. The next day, the sinus is washed with saline and, if no pathological discharge is obtained, the microirrigator is removed from the sinus. Then, the patient under general anesthesia or infiltration anesthesia with 1% novocaine 5-7 ml performs an incision of the mucous membrane to the periosteum in front of the mouth at the level of 4 and 5 teeth of the upper jaw on the affected side. The mucous membrane moves away from the periosteum by a septal raspator, 3 mm above the cut of the mucous membrane, and the periosteum is dissected. This achieves additional tortuosity of the wound channel, which contributes to more reliable adhesion of its walls and prevents the formation of fistula. Next, a mucoperiostal flap is peeled off with a septic raspator, exposing the bone wall of the canine fossa for 15 × 15 mm, is retracted and held by the Farabef hook. A milling cutter through a canine fossa is 5 mm in size, through which a Karl Storz rhinoscope of 5 mm diameter with end and side optics with an angle of 30 and 70 degrees is inserted. If the manipulation is carried out without general anesthesia, 1 ml of anesthetic (3% dicain or 10% lidocaine) is instilled into the sinus. A foreign body, the presence of caseous masses, polyps, granulations, and for how long the mucous membrane is affected, are revealed. If necessary (hard-to-reach zone, large foreign body), the milling hole expands with a milling cutter up to 8 mm. The foreign body is removed with the help of Blackley forceps and an electric suction pump. The sinus is washed with isotonic saline using a large volume injection syringe (20 ml) with a cannula attached to it to wash the attic. Caseous masses are removed, which are aspirated together with rinsing water by an electric suction pump, and the curette is separated from the sinus mucosa. Further, at an endoscopic examination, the affected sinus mucosa is evaluated in more detail. Blackley forceps or a curette remove polyps and granulations. The sinus is again washed with saline. Farabef's hook is removed from the wound. The patient is closed his mouth and pressed on the cheek in the projection of the wound for 10 seconds to achieve adhesion of the wound channel. Given the data of microbiological and mycological studies of the discharge obtained during the first sinus puncture, systemic antibacterial or antifungal therapy is prescribed. On the third day, the operated maxillary sinus is punctured through the lower nasal passage under local application anesthesia (3% dicain, 10% lidocaine) with a Kulikovsky needle, the sinus is washed with an isotonic sodium chloride solution, the patency of the anastomosis with the nasal cavity is assessed, and the secretion from the sinus is removed. On the 6-7th day after the operation, the patient is discharged.

Example: Patient S., 29 years old, was admitted to the ward with complaints of heaviness in the cheek area on the right, periodic headache in the right half of the head, unmotivated weakness. From the anamnesis it was possible to find out that he had been treated 14 teeth 6 years ago with filling the channel with radiopaque filling material. The above complaints worry the patient for 4 years periodically, worse with a cold. X-ray analysis determines the total decrease in pneumatization of the right maxillary sinus, the presence of an x-ray contrast elongated foreign body of 2 × 4 mm in the anteroposterior sinus. Upon admission to the patient under local application anesthesia, the right maxillary sinus was punctured using the Kulikovsky needle through the lower nasal passage. When washing the sinus with a physiological solution of sodium chloride 0.9%, a decrease in its volume to 5 ml was revealed, 4 ml of pus and caseous masses were washed. Wash water taken for microbiological and mycological studies. 20 ml of air was introduced into the sinus. A microirrigator is introduced through the puncture hole. A single injection of perftoran in an amount of 20 ml was carried out through a microirrigator. The next day, the sinus is washed with saline, no discharge was obtained, the microirrigator from the sinus was removed. An incision was made to the patient under general anesthesia in front of the mouth at the level of 14 and 15 teeth. The mucous membrane is exfoliated 3 mm upwards and the periosteum is dissected at this level. A mucoperiostal flap was peeled off with a raspator, and the bony wall of the canine fossa 15 × 15 mm was exposed. A milling cut through a canine fossa 5 mm in size. An endoscope was introduced, the sinus was examined by end and lateral optics with an angle of 30 degrees, a foreign body was found shrouded in black caseous masses in the region of the anterior part of the alveolar bay. Blackley's forceps removed a foreign body, caseous masses and the adjacent polypous changed mucous membrane over 6x8 mm. The sinus is washed with isotonic saline, while the remains of caseous masses are aspirated. A good patency of the natural anastomosis with the nasal cavity was revealed. Farabef hook removed, wound channel pressed through the cheek for 10 seconds. On the third day, a puncture of the right maxillary sinus was performed through the lower nasal passage with a Kulikovsky needle, the sinus was rinsed with isotonic sodium chloride solution, the anastomosis with the nasal cavity is freely passable, the mucous clot with a volume of about 0.5 ml is washed out. On the 7th day after the operation, the patient was discharged with recovery.

According to this technique, we treated 13 patients. In these cases, the postoperative period was reduced from 10-13 to 6-7 days.

Thus, the method makes it possible to remove a foreign body of the maxillary sinus while minimizing the removal of the affected mucous membrane and makes the complex treatment of the maxillary sinusitis caused by it minimally invasive and less traumatic. This reduces the time of treatment and rehabilitation of patients with this pathology.

Claims (1)

A method of treating odontogenic maxillary sinusitis, including puncture of the affected sinus through the lower nasal passage with washing with physiological saline, forced sinus aeration, microirrigator administration and drug washing until the purulent discharge disappears, microgeymorotomy is performed and foreign body removal is performed, second sinus puncture is performed for the third sinus sinusitis on the third day characterized in that as a medicine use perftoran in a volume of 20 ml, washing the wire t once a day, micro-gyrotomy is performed by cutting a mucous membrane in front of the mouth from 4 to 5 teeth of the upper jaw on the affected side, the mucoperiostal flap is peeled from the canine fossa for 15 × 15 mm, a milling hole with a diameter of 5-8 mm in the front wall is applied sinuses into which the endoscope is inserted.