RU2336836C1 - Method for surgical treatment of orbital rhinosinusitis complications - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention essence is to determine prevalence of pyoinflammatory process in orbital cavity using computer and magnetic resonance tomography of paranasal sinuses as well as opening of the affected paranasal sinuses and orbital cavities with endonasal ethmoidotomy under endotracheal anesthesia. According to the results of computer and magnetic resonance tomography localization of the suppurative focusis detected in the ethmoidal labyrinth and orbital cavity. Perforation place of the cigarette lamina is selected in the following order: if the anterior part of the ethmoidal labyrinth is involved in the pyoinflammatory process and the apostasis is located up to the middle concha lamina level, the middle part of the lesser pancreas is ablated partially and the anterior cells of the ethmoidal labyrinth are resected. If the suppurative focusis is localized in the cribriform bone and orbital cavity more dorsad in relation to the middle concha lamina, the anterior and posterior parts of the ethmoidal labyrinth are opened. Then the cigarette lamina with orbital cavity periosteal coverage are perforated with a cut from he top downwards. Then drain in the form of narrow strip of latex rubber is inserted in the orbital cavity through the cut. Then arch-curved and individually matched silicon stent is inserted in the nasal cavity. The stent shall have a round window located at the level of the patient's middle nasal passage. A drain is taken through the window to the vestibule of nose.

EFFECT: preventing risk of orbital cavity matter prolapse into nasal cavity and provision of opportunity of breathing through nose on first day after surgery.

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Description

The invention relates to medicine, otorhinolaryngology, and in particular to methods of surgical treatment of orbital rhinosinusogenic complications, and can be used to increase the effectiveness of treatment of purulent-inflammatory processes in orbit.

A known method of surgical treatment of orbital rhinosinusogenic complications, including determining the prevalence of purulent-inflammatory process in the orbit using computed and magnetic resonance imaging of the paranasal sinuses, as well as opening the affected paranasal sinuses and orbit with mandatory endonasal ethmoidotomy under endotracheal anesthesia (see. surgical interventions for retrobulbar abscesses. "Russian rhinology, 1995, N2, p. 54-55).

However, the known method in its use has the following disadvantages:

- does not provide high treatment efficiency for such a complex and threatening state of the organ of vision of pathology as orbital rhinosinusogenic complications,

- has a high morbidity with respect to intranasal structures and orbit,

- does not exclude the possibility of prolapse of the contents of the orbit into the nasal cavity through a superimposed round window in the medial wall of the orbit,

- does not provide nasal breathing in the first day of the postoperative period.

The objective of the invention is to provide a method for the surgical treatment of orbital rhinosinusogenic complications.

The technical result is to ensure high efficiency of treatment of orbital rhinosinusogenic complications while reducing trauma in relation to the orbit, there is no risk of prolapse of the contents of the orbit into the nasal cavity, and also ensuring the possibility of breathing through the nose on the first day after surgery.

The technical result is achieved by the fact that the proposed method of surgical treatment of orbital rhinosinusogenic complications, including determining the prevalence of purulent-inflammatory process in the orbit using computed and magnetic resonance imaging of the paranasal sinuses, as well as opening the affected paranasal sinuses and orbit with endonasal ethmoidotomy under endotracheal narcotic this according to the results of computed and magnetic resonance imaging determine the localization of the purulent focus in the ethmoid the labyrinth and orbit, choose the place of perforation of the tissue plate as follows: when the anterior part of the ethmoid labyrinth is involved in the purulent-inflammatory process and when the abscess is located to the level of the terminal lamina of the middle nasal conch, the middle part of the hooked process is partially removed, the anterior cells of the ethmoid labyrinth are resected, and in the case of localization of the purulent focus in the ethmoid bone and orbit, the anterior and posterior openings are more dorsal with respect to the plate of the middle nasal concha sections of the ethmoidal labyrinth, then perforate the tissue plate with the periosteum of the orbit with a cut in the direction from top to bottom, then drainage is introduced into the cavity of the orbit through the cut in the form of a narrow strip of latex rubber, a curved arch in the form of an arch and a silicone stent adapted individually for the patient are installed, at the same time, a round window is cut in the stent, which will be located at the level of the average nasal passage of the patient, drainage is opened through the window in front of the nose.

The method is as follows.

Using computer and magnetic resonance imaging, the patient determines the position of the medial wall of the orbit in axial and coronary projections and determines the depth of the process. At the same time, during computed and magnetic resonance imaging, the location of the perforation of the tissue plate is additionally selected and the opening volume of the trellis labyrinth is determined. Carry out endotracheal anesthesia. Perform endonasal ethmoidotomy. A more ventral location of the focus of inflammation (upper lateral, anterior lateral subperiosteal abscesses) determines the place of perforation of the tissue plate to the level of the terminal plate of the middle nasal concha, opening of the anterior part of the ethmoid labyrinth. Involvement in the purulent-inflammatory process of the posterior sections of the ethmoid labyrinth and the location of subperiosteal or retrobulbar abscesses more dorsally determines the opening of the anterior and posterior ethmoid labyrinth, and the perforation of the medial wall of the orbit is dorsal with respect to the terminal plate.

Then perform perforation of the medial wall of the orbit. Under endoscopic control, the middle nasal concha is displaced by the mediator with a raspator, the partial middle part of the hook-shaped process, the ethmoid bulla, is removed sequentially by an aggressive microdebrider cutter. In this case, in the case of localization of the focus of inflammation behind the terminal plate of the middle turbinate, the posterior cells of the ethmoid labyrinth are additionally opened to the sphenoid sinus.

Under endoscopic control, a tissue plate is perforated with a sickle knife in the direction from top to bottom, front and back as medially as possible with respect to the medial wall of the orbit. At the same time, the knife blade penetrates into the orbit cavity by no more than 2-3 mm, the cut length is 1-1.5 cm, and the periosteum of the orbit is opened simultaneously with the bone part of the medial wall. A strip of latex rubber 5 mm wide, 20 mm long is introduced into the cavity of the orbit through the wound. Then, silicone stents, curved in the form of an arch, adapted individually for the patient, with a round window of 1.5 cm diameter, which is cut in silicone at the level of the middle nasal passage, are introduced into both halves of the nasal cavity, the glove drainage is brought out through the window on the threshold of the nose, then the stent is fixed through the nasal septum with a single interrupted suture. Stents are removed 3 days after surgery.

Among the essential features characterizing the method of surgical treatment of orbital rhinosinusogenic complications, the following are distinguishing:

- determination based on the results of computer and magnetic resonance imaging of the localization of the purulent focus in the trellis labyrinth and orbit,

- the choice of the location of the perforation of the tissue plate as follows: when the anterior part of the ethmoid labyrinth is involved in the purulent-inflammatory process and when the abscess is located up to the level of the terminal lamina of the middle nasal conch, the middle part of the hook-shaped process is subsequently removed, the anterior cells of the ethmoid labyrinth are resected, and the foci in the ethmoid bone and orbit more dorsally with respect to the plate of the middle turbinate open the anterior and posterior sections of the ethmoid wow maze

- perforation of the tissue plate with the periosteum of the orbit with a cut in the direction from top to bottom,

- the introduction into the cavity of the orbit through the drainage section in the form of a narrow strip of latex rubber,

- the installation in the nasal cavity of a bent in the form of an arch and individually adapted for the patient silicone stent,

- execution in the stent of a round window, which will be located at the level of the average nasal passage of the patient,

- excretion through the drainage window in front of the nose.

Experimental and clinical studies of the proposed method for surgical treatment of orbital rhinosinusogenic complications have shown its high efficiency.

The method when using provides

- significantly less trauma in relation to intranasal and orbital structures,

- reducing the length of the patient’s stay in bed from 22.9 ± 2.1 to 16.9 ± 1.9 bed days,

- an increase in the number of patients who recovered to 61 (91.1%), the number of patients with clinical improvement to 6 (8.9%), compared with the traditional method (32 (68.1%) and 12 (25.5%, respectively) ,

- reduction in the number of relapses during the year to 3 (8.1%) in comparison with traditional methods (9 (32.1%).

The implementation of the proposed method for the surgical treatment of orbital rhinosinusogenic complications is illustrated by the following clinical examples.

Example 1. Patient E., medical history No. 1376, 41 years old, was admitted to the ENT department on 03/23/98 due to exacerbation of left-sided chronic purulent ethmoidogymorofrontitis, complicated by a subperiostal abscess of the left orbit with complaints of headache, pain in the forehead on the left, sensation pressure in the left eye, decreased visual acuity of the left eye, swelling of the eyelids of the left eye, difficulty in nasal breathing, nasal congestion. The computed tomogram in axial and coronary projections revealed homogeneous dimming of the left maxillary sinus, anterior part of the left ethmoid labyrinth with an upper lateral subperiosteal abscess located in the area of the medial wall of the orbit in front of the terminal plate of the middle nasal concha.

According to emergency indications, endonasal left-sided ethmoidotomy, frontotomy and sinusotomy were performed under endotracheal anesthesia. Under endoscopic control, the middle nasal concha was displaced medially with a raspator, the partial middle part of the hooked process, the ethmoid bulla, and also the anterior cells of the ethmoid labyrinth to the terminal plate of the middle nasal conch were successively removed with an aggressive microderider cutter. Then, the crescent-shaped knife was punched with a sickle-shaped knife in the top-down and front-back directions as medially as possible with respect to the medial wall of the orbit. At the same time, the knife blade penetrated into the orbit cavity by no more than 2-3 mm with a cut length of 1.5 cm. At the same time, the periosteum of the orbit was dissected and the contents of the abscess were evacuated. A strip of latex rubber 5 mm wide, 20 mm long was introduced into the patient’s orbit through the resulting incision. Then, flat silicone stents with a round window 1.5 cm in diameter at the level of the middle nasal passage, previously fitted in them in the form of an arch, were introduced into both halves of the patient’s nasal cavity. The glove drainage was removed through the window of the silicone stent and the stent was fixed through the nasal septum with a single interrupted suture. Stents and drainage were removed 3 days after surgery.

On day 3, a significant decrease in exophthalmos was noted, hyperemia and edema of the eyelids significantly decreased on day 5. On the 7th day, relief of congestion in the fundus was noted. Discharged from the department on the 10th day in satisfactory condition. Visual acuity at discharge VIS OS 1.0.

Example 2. Clinical observation.

Patient G., medical history No. 5604, 46 years old, was admitted to the ENT department on January 25, 2003 about a right-sided acute purulent sinusitis and right retrobulbar abscess with complaints of pain and pressure in the right cheek, in the left eye, decreased visual acuity of the left eyes, swelling of the eyelids of the left eye, purulent discharge from the right half of the nasal cavity, nasal congestion, weakness, malaise. On examination, pain during percussion of the projection zone of the right maxillary sinus, edema and hyperemia of the mucous membrane were determined rhinoscopically, the presence of profuse mucopurulent discharge, purulent exudate from the middle nasal passage was observed endoscopically after aspiration.

Computed tomography of the paranasal sinuses in axial and coronary projections was performed, which revealed the involvement of the entire right ethmoid labyrinth in the purulent-inflammatory process, the location of the retrobulbar abscess is dorsal with respect to the terminal plate of the middle nasal concha.

According to emergency indications, endonasal left-sided ethmoidotomy, frontotomy and sinusotomy were performed under endotracheal anesthesia. Under endoscopic control, the middle nasal concha was displaced medially with a raspator, the middle part of the hook process, then the ethmoid bull, and also the anterior and posterior cells of the ethmoid labyrinth to the anterior wall of the sphenoid sinus were sequentially removed. Then, the crescent-shaped knife was punched with a crescent blade more dorsally with respect to the terminal plate of the middle nasal concha in the top-down, front-back maximally medial with respect to the medial wall of the orbit. At the same time, the knife blade penetrated into the orbit cavity by no more than 2-3 mm with a cut length of 1.5 cm. At the same time, the periosteum of the orbit was dissected and the contents of the abscess were evacuated. A strip of latex rubber 5 mm wide, 20 mm long was introduced into the patient’s orbit through the resulting incision. Then, flat silicone stents with individually round arch 1.5 mm in diameter round window at the level of the middle nasal passage were previously introduced into both halves of the patient’s nasal cavity. The glove drainage was removed through the window of the silicone stent and the stent was fixed through the nasal septum with a single interrupted suture. Stents and drainage were removed 3 days after surgery.

On day 5, there was a significant decrease in exophthalmos and ptosis, conjunctival hyperemia and chemosis. Discharged from the department on the 15th day in satisfactory condition. Visual acuity at discharge VIS OS 0.8.

Claims (1)

A method of surgical treatment of orbital rhinosinusogenic complications, including determining the prevalence of purulent-inflammatory process in orbit using computed and magnetic resonance imaging of the paranasal sinuses, as well as opening the affected paranasal sinuses and orbit with endonasal ethmoidotomy under endotracheal anesthesia, characterized in that magnetic resonance imaging determine the localization of the purulent focus in the trellis labyrinth and orbit, select the location of the perforation and a tissue plate as follows: when the anterior part of the ethmoid labyrinth is involved in the purulent-inflammatory process and when the abscess is positioned to the level of the lamina of the middle nasal conch, the middle part of the hooked process is sequentially removed, the anterior cells of the ethmoid labyrinth are resected, if the purulent lesion is localized in the ethmoid bone the orbit is more dorsal with respect to the plate of the middle nasal concha; the anterior and posterior sections of the ethmoid labyrinth are opened, then the papas are perforated iris plate with the periosteum of the orbit with a cut in the direction from top to bottom, then drainage is introduced into the cavity of the orbit through the cut in the form of a narrow strip of latex rubber, a curved arch in the form of an arch and individually adapted for the patient fit into the nasal cavity, while a round window is cut into the stent , which will be located at the level of the average nasal passage of the patient, drainage is opened through the window on the threshold of the nose.