RU2365347C1 - Method of small pancreas remodeling - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: invention can be used at the congenital or acquired anatomo-functional small pancreas incompetence, and also as a stage of an endonasal surgical intervention assuming full or partial small pancreas resection. The channel in a mucosa of a lateral wall of a nose before a zone of ostiomeatal complex is formed. After that a cartilaginous implant is implanted in the formed channel, taken from anterior nasal septum departments.

EFFECT: prevention of flow of an inhaled air stream immediately in a zone of paranasal sinus anastomosises, and back, possibility to direct an exhaled air stream in a zone of ostiomeatal complex.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used for congenital or acquired anatomical and functional anatomical insolvency of the hook process, and also as a stage of endonasal surgery involving a complete or partial resection of the hook process.

Today, it is indisputable that one of the leading factors in the occurrence and course of recurrent inflammatory diseases of the paranasal sinuses is a violation of the architectonics of the nasal cavity, due to congenital and acquired abnormalities of the structure of the intranasal structures (including the hook process), which have a detrimental effect on the ventilation and drainage function sinuses [Kryukov A.I., Shubin M.N. Indications and efficacy of traditional extranasal and endonasal endoscopic surgical interventions in patients with chronic sinusitis. // Anniversary collection of scientific works of the symposium dedicated to the 10th anniversary of the Association of Phoniatrists and Phonopaedists / Vladimir - 2001; p. 210-212; Piskunov S.Z., Piskunov G.Z. Morphological and functional features of the nasal mucosa and paranasal sinuses. The principles of gentle endonasal surgery. // M. - 1991; 48 c.]. The fact is that the structural elements of the osteomeatal complex, regularly located relative to each other, perform the function of the so-called sinus valve [Piskunov GZ, Piskunov SZ Clinical rhinology. M., 2002 - 390 p.]. A large number of such anomalies are described, here are some of them: a perforated hook-shaped process, a pressed hook-shaped process, a pneumatized hook-shaped process, and hook-shaped hypoplasia. It should be noted that anomalies in the structure of the hooked process are not pathologies per se, they must be evaluated in relation to each specific case.

In the anatomical and functional inconsistency of the hook-shaped process, a stream of cold, moist air, in a large amount containing dust particles and microorganisms, enters directly into the paranasal sinuses. As far back as 1941, in experimental studies it was shown that in each case of opening the maxillary sinus in a rabbit, a chronic inflammatory process develops by expanding the natural opening in the sinus [Hilding A.C., Banovetz J. / Occluding scars in the sinuses: relation to bone growth. // Laryngoscope - 1963, Vol.73, p.1201-1218]. Later A.W.Proetz, based on his own experimental studies, made the following conclusion: if the sinus is opened in such a way that at least part of the inhaled air enters its cavity, then the activity of the ciliated epithelium ceases after a few minutes [Proetz A.W. Applied physiology of the nose. - St. Louis: Zimmerman-Petty Co., 1953. - P.439]. It must be remembered that the surgical intervention itself can lead to a violation of the aerodynamics of the paranasal sinuses. Indeed, the key stage of endoscopic endonasal intervention is the complete or partial resection of the hook-shaped process, which is performed to visualize the natural anastomosis, which naturally violates the natural air exchange in the anterior paranasal sinuses. Therefore, today in rhinosurgery there is a need to develop a technique for remodeling the hook-shaped process with its iatrogenic damage, congenital or acquired anatomical and functional insolvency.

In this regard, we examined and treated 10 people suffering from recurrent bacterial sinusitis against the background of anatomical and functional inconsistency of the hook process. By anatomical and functional inconsistency of the hook process, we mean such a structure (including size) of the hook process when a situation arises in the osteomeatal complex region, as a result of which conditions are formed for the jet of inhaled air to enter the paranasal sinuses. An objectively similar situation is usually determined by the ability to visualize the natural anastomosis of the maxillary sinus during endoscopic examination with an endoscope and / or visualization of perforation in the hook process with registration of the passage of an air stream through it on the exhale.

Among the individuals examined by us, the anatomical and functional insufficiency of the hook-shaped process was observed against the background of its hypoplasia in 7 patients, after endonasal surgery, in 3 patients. Among patients with iatrogenic origin of the disease, there was a complete or almost complete absence of a hook-shaped process on both sides. Patients complained of periodically occurring purulent inflammation in the maxillary sinus, accompanied by a headache, a feeling of heaviness in the nose, a rise in body temperature to subfebrile numbers, purulent discharge from the nose, and a deterioration in overall health. The frequency of exacerbations ranged from 3 to 6 times a year (an average of 3.9 times a year).

Monitoring of patients began with the last relapse of bacterial inflammation in the paranasal sinuses. Episodes of bacterial sinusitis in a number of examined patients (6 people) were confirmed radiologically (presence of a liquid level in the maxillary sinus, decreased pneumatization of the ethmoid labyrinth cells) or according to computed tomography of the paranasal sinuses (4 people). During the period of exacerbation, all patients underwent puncture of the interested sinus with obligatory bacteriological examination of the discharge.

All 10 patients underwent surgical treatment - remodeling of the hook process according to the author's method: under anesthesia or local anesthesia, a channel is formed in the mucous membrane of the side wall of the nose in front of the osteomeatal complex zone. After that, a cartilage implant taken from the anterior sections of the nasal septum is implanted into the formed canal (see drawing). Cartilage is taken after separation of the mucous membrane of the nasal septum through the incision of the mucous membrane, made 0.5 cm from the edge of the quadrangular cartilage. The technique allows you to form a reliable obstacle to the inhaled air flow.

The proposed technique for remodeling the hook-shaped process does not pretend to fully restore all the functions of the hook-shaped process, however, it helps to prevent the jet of inhaled air directly into the anastomastoid sinus anastomosis and accordingly direct the exhaled air flow into the osteomeatal complex.

The postoperative period in all patients was uneventful. Within 7 days after the operation, a daily toilet of the nasal cavity was performed, including adrenalization of the mucous membrane of the lower and middle nasal concha, removal of hemorrhagic and fibrinous clots. Starting from the 3rd day of the postoperative period, Aqua Maris was prescribed 3-4 doses in each half of the nose 5 times a day for two weeks. Regular monitoring of postoperative inflammation with visits to the otorhinolaryngologist 2-3 times a week continued for another two weeks. During the period of observation of the occurrence of bacterial inflammation in the paranasal sinuses, not one was observed in any patient.

The period of remote monitoring of patients was 1.5 years. During the observation, 7 months after bilateral remodeling of the hook-shaped process, a patient with hook-shaped hypoplasia of the hook-shaped process developed unilateral sinusitis (pathogen S. pneumoniae). The inflammatory process is cured by daily sinus punctures with a solution of antiseptic (miramistin), systemic antibiotic therapy (amoxiclav 1000 mg × 2 work days - 7 days). Over the next 4 months, no relapse of bacterial inflammation was observed. The result of the plasticity of the hook process is also considered unsatisfactory. In the remaining patients, no recurrence of bacterial inflammation was noted.

Thus, the result of treatment in patients with recurrent bacterial sinusitis was satisfactory in 9 people and unsatisfactory in 1 patient. Therefore, the proposed method for the surgical treatment of patients with anatomical and functional insufficiency of the hook-shaped process has demonstrated sufficient effectiveness, and therefore can be recommended for practical use. We propose to use the hook-shaped process remodeling in case of congenital and acquired abnormalities of the osteomeatal complex, as well as as a stage of endonasal intervention, involving complete or partial resection of the hook-shaped process.

Claims (1)

A method for remodeling a hook-shaped process, which consists in the fact that a cartilage implant is previously implanted from the front sections of the nasal septum into the formed channel in the mucous membrane of the side wall of the nose in front of the osteomeatal complex in the area of the hook-shaped process.

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