RU2539372C1 - Method for surgical treatment of frontal sinusites - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: frontal sinus is approached in a typical location and sanitated. After the sanitation procedure, a bone defect is covered with high-structure hydrogel matrix of sodium alginate, wherein dioxidin 0.03g and ε-aminocapronic acid 0.15g are pre-administered. The sinus is obliterated with MK-9M osteoplastic composition. The approach point is covered with the same matrix, on the top of which the wound is closed completely and coated with Coletex-ADL hydrogel tissue.

EFFECT: method provides preventing early and late suppurative complications, promotes preventing intracranial complications, reduces the recovery time by the protective antiseptic, homeostatic, antitoxic properties of the used matrix, which prevents the composition prolapse into the intracranial cavity as a brace.

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Description

The invention relates to medicine, namely to otorhinolaryngology and can be used mainly in the treatment of frontal sinusitis with concomitant destruction of the walls of the frontal sinuses.

A known method of obliteration of the frontal sinuses, consisting in trepanation of the sinus, removal of the mucous membrane, processing of the walls of the sinus. For coagulation and sterilization of the walls of the frontal sinus, air-plasma flows were used with an outlet temperature of 3000-3500 ° C, after which they were further obliterated with a biocompatible implant material with a high osteoconductive and osteoinductive property of hydroxyapoles and kalapol (RF Patent 2476171/24 IPC A61B publ. 2013).

The disadvantage of this method is that it does not take into account the destruction of the posterior and orbital walls of the frontal sinus, as a result of which the meninges are exposed, infection can penetrate into the cranial cavity. In addition, the use of a plasma stream for sterilization and coagulation of a cavity with an outlet temperature of 3000-3500 ° C in the projection of this localization can be a strong damaging factor for intracranial structures, exposed pathological processes and tightly adjacent to the posterior and orbital bony walls of the frontal sinus.

A known method for the surgical treatment of frontal sinuses, which consists in opening the frontal sinus and anterior cells of the ethmoid labyrinth, followed by plastic surgery of the fronto-nasal anastomosis with a flap of the nasal mucosa, while the plastic is performed with a flap of the upper lateral wall of the nasal cavity having a front base (Patent 2118512, IPC A61B 17 / 24, publ. 1998).

The disadvantage of this method is that there is a compression of the legs of the mucous flap with a hardening osteoplastic composite, which is accompanied by trophic disorders and the death of the flap. In the future, the necrotic area of the mucous flap will be an inflammatory-toxic source that communicates with the cranial cavity and its structures.

The closest is a method of treating frontal sinuses by obliteration of the frontal sinuses with the MK-9M osteoplastic composition during surgical interventions for destructive chronic, post-traumatic frontal sinuses, with giant frontal sinus osteomas with destruction of the walls of the frontal sinuses and the process penetrating the cranial cavity. To increase the effectiveness of surgical treatment, with these pathologies, the MK-9M adhesive osteoplastic composition is used for obliteration, which is filled in the sinus. Hardening of the composite material occurs in 10-15 minutes, while the frontal and orbital sinus surfaces are modeled in the area of defects and the message with the cranial cavity or orbit is eliminated (“Possibilities and prospects of surgical obliteration of the frontal sinuses with the MK-9M adhesive osteoplastic composition”: Dissertation of Kharkov N. A. for the degree of candidate of medical sciences. Moscow, 2006, p.57-58).

The disadvantage of this method is the possibility of toxic effects on intracranial anatomical structures adjacent to the defect in the region of the posterior sinus wall. In addition, when the osteoplastic composition hardens, the latter expands somewhat in volume and is able to prolapse into the cranial cavity, exerting a chemical and compressing effect on intracranial structures.

The objective of the invention is to eliminate these drawbacks, increase the effectiveness of treatment due to the antiseptic, hemostatic properties of the matrix, which, as a corset, prevents the composition from prolapse into the cranial cavity, and also has a protective antitoxic and antiseptic effect, which helps to prevent intracranial complications, shorten recovery time, improve quality life of the patient.

To do this, in the method of surgical treatment of frontal sinuses, access to the frontal sinus in a typical place, sinus sanitation, obliteration of its cavity with MK-9M osteoplastic material, wound closure. What is new is that after the debridement, the area of the bone defect is lined with a “Highly structured hydrogel matrix based on sodium alginate”, into which dioxidine is preliminarily added in an amount of 0.03 g and ε-aminocaproic acid in an amount of 0.15 g, and after obliteration of the sinus with osteoplastic glue MK-9M compositions are lined with the same Matrix on top of which the wound is sutured tightly and closed with a Coletex-ADL hydrogel napkin.

Figure 1 shows x-ray computed tomograms of the frontal sinuses, in axial projection, with post-traumatic destruction of the front (1) and posterior (2) walls of the sinuses, with pronounced reactive inflammatory changes in the surrounding soft tissues (3) that look thickened, their differentiation is reduced.

Figure 2 presents a diagram of the violation of the integrity of the anterior (1) and posterior (2) walls of the frontal sinuses in case of damage to their walls as a result of fractures, destructive changes due to inflammatory or neoplastic processes, as well as after surgical interventions performed for this pathology.

Figure 3 presents a diagram of trepanation and subsequent obliteration of the frontal sinus with an osteoplastic composite (3), with a lining of bone defects of the anterior (1) and posterior (2) walls of the frontal sinuses with the Coletex matrix. The skin wound is sutured (4).

Figure 4 presents a photo of a patient K.Z., 67 years old, when admitted to the hospital for chronic post-traumatic frontal sinusitis, exacerbation - deformation of the frontal region (1) due to pronounced infiltrative changes in soft tissues is noted.

The method is as follows.

Under operating conditions, under general anesthesia, a soft tissue incision is made through all layers above the interested frontal sinus in a typical place. After processing the surgical field with an antiseptic solution, destructively changed fragments of the anterior wall of the frontal sinus are removed, tissues of the fistulous passages are excised, revision, removal of pathological granulations and sinus sanitation are performed. In the presence of destruction of the posterior wall of the frontal sinus, its sequestered fragments are removed until the dura mater is exposed. The sinus wall defect is lined with a Coletex hydrogel matrix, into which 0.03 g dioxidine and 0.15 g ε-aminocaproic acid are preliminarily added. MK-9M adhesive osteoplastic composition is used to fill the frontal sinus cavity. The hardening of the composite material occurs in 10-15 minutes, while modeling the frontal and orbital surfaces of the sinus in the area of defects, and eliminate the message from the cranial cavity. After sinus obliteration with osteoplastic material, the access site is lined with the same Coletex Hydrogel Matrix, over which the wound is sutured tightly and closed with a Coletex-ADL Napkin with a local anesthetic lidocaine.

In the postoperative period, the patient is given intravenous antibiotic therapy, desensitizing, dehydration therapy.

Before discharge, in order to objectify the results of treatment, the nature of healing of the postoperative wound of the frontal region is assessed, the patient is given recommendations for prolonging treatment on an outpatient basis: taking antibiotic tablets (for 5-7 days), magnetotherapy for the postoperative wound of the frontal region (No. 5), postoperative treatment wounds with a hydrogel napkin “Coletex-ADL”.

Example 1

Patient Z., 67 years old. Received in the ENT department on an emergency basis. With complaints of severe headaches, swelling in the forehead, fever up to 37.4 ° C, which was noted during the week. From the anamnesis: the patient received an injury to the frontal region in an accident 5 months ago. She independently applied to the admission department of otorhinolaryngology. Consulted by maxillofacial surgeons, neurosurgeons, otorhinolaryngologists, diagnosed with chronic post-traumatic frontal sinusitis, exacerbation. Hospitalized. Objectively, upon examination there is an infiltrate in the projection of the frontal sinus on the right, palpation is soft to the touch, painless, the skin over the latter is not changed.

A CT study of the paranasal sinuses was carried out, total filling of the frontal sinuses with fluid and soft tissue contents was established, there is a destruction of the front and rear walls of the frontal sinuses, with the penetration of the process into the cranial cavity. MRI was performed - there were signs of lepto- and pachymengial inflammatory changes. The patient was consulted by a therapist, neurologist, optometrist. An ECG, laboratory tests of blood and urine were performed. The patient is shown surgical treatment. Patient consent is obtained.

Under operating conditions, under general anesthesia, an incision was made in a typical place. A skin-muscle flap was removed, a soft-tissue formation was exposed in the projection of the anterior wall of the right frontal sinus, the latter was carefully and bluntly removed and removed. When it was opened on the operating table, a cavity with pus was obtained, the material was sent for histological examination. After removal of the aforementioned suppurative, suppressed formation (possibly an infected organized hematoma), the posterior destroyed wall of this frontal sinus with lysed fragments opened. Reconstructed sinus. Then, the sinus posterior wall defect is lined with the Coletex Hydrogel Matrix, into which dioxidine and ε-aminocaproic acid were previously introduced in the above amounts. Next, the adhesive osteoplastic composition MK-9M was used, which filled the cavity of the frontal sinus. Hardening of the composite material occurred after 15 minutes, while the frontal and orbital surfaces of the sinus in the region of defects were modeled, and communication with the cranial cavity was eliminated. After sinus obliteration with osteoplastic material, the access site was lined with the same Coletex Hydrogel Matrix, over which the wound was sutured tightly.

In the postoperative period, the patient was given intravenous antibiotic therapy, desensitizing, dehydration therapy.

Dressings were performed after 2 days. The postoperative period was uneventful, the postoperative wound healed by primary intention. After repeated examinations of a therapist, neurologist, oculist, repeated laboratory tests, CT and MRI examinations, obtaining the results of a histological examination, the patient was discharged on the 7th day for outpatient aftercare in the community in a satisfactory condition.

Result: in comparison with the prototype, the patient was discharged from the hospital earlier, there was no risk of secondary meningitis, intracranial abscesses. Conducting physiotherapy from the first day after surgery in combination with the Coletex hydrogel matrix, into which dioxidine and ε-aminocaproic acid were previously introduced, made it possible to enhance the hemostatic effect, stimulate reparative processes due to anti-inflammatory, decongestant, antiseptic effects. The complex of properties given to the Coletex Hydrogel Matrix allows to reduce inflammation in the postoperative period, strengthen healing processes, speed up the healing time, and improve the patient’s quality of life.

Example 2

Patient K., 48 years old, was admitted to the ENT department with complaints of headache, purulent discharge from the fistula. Sick for 4 years. A history of 2 operations on this frontal sinus regarding recurrent purulent-inflammatory processes. The latter exacerbation with the formation of a fistula does not connect with anything. The patient was examined. CT of the sinuses was made, consultations of a neurologist, therapist, laboratory tests of blood, urine, ECG were conducted. According to the results of the examination, a diagnosis was made: recurrent left-sided chronic frontal sinusitis (exacerbation), fistula of the anterior wall of the left frontal sinus. Diabetes. Surgical treatment is shown to the patient; consent is obtained.

Under operating conditions, under general anesthesia, an incision was made in a typical place, after the surgical field was treated with an antiseptic solution, fistulous tissues were excised, sinus revision and debridement were performed, there was a bone defect on the posterior wall of the frontal sinus covered by polyposis-granulation tissue, which was neatly removed before exposure of the dura mater. The defect of the back wall of the sinus in the area of the bone defect was lined with the Coletex Hydrogel Matrix, into which dioxidine and ε-aminocaproic acid were previously introduced. Next, the adhesive osteoplastic composition MK-9M was used, which filled the cavity of the frontal sinus. The hardening of the composite material occurred after 10 minutes, while the frontal and orbital surfaces of the sinus in the region of defects were modeled, and communication with the cranial cavity was eliminated. After sinus obliteration with osteoplastic material, the access site was lined with the same Coletex Hydrogel Matrix, over which the wound was sutured tightly and closed with a Coletex-ADL Napkin with a local anesthetic lidocaine.

In the postoperative period, the patient was given intravenous antibiotic therapy, desensitizing, dehydration therapy. Dressings were performed after 2 days.

The postoperative period was uneventful, the patient was discharged on the 7th day, the postoperative wound healed by first intention, after repeated examinations by the therapist, neurologist, oculist, repeated laboratory tests, CT and MRI examinations, obtaining the results of a histological examination, the patient was discharged for outpatient follow-up at the place of residence.

Result: in comparison with the prototype, where obliteration of the frontal sinuses with a biocompatible implant material with high osteoconductive and osteoinductive properties of hydroxyapoles (HAP) and kalapol was carried out after trepanation and removal of destructively altered wall fragments, excision of pathological granulations and mucous membrane of the plasma membrane, flow, with an outlet temperature of 3000-3500 ° C, when using the method proposed by us, local application of the air-plasma flow, which e can be a powerful damaging factor for intracranial structures. Increasing the effectiveness of surgery on the frontal sinuses, during which the sinus walls and defects in them are lined with the Coletex Hydrogel Matrix.

The presence of dioxidine antiseptic in the hydrogel matrix allows the antimicrobial preparation to be brought directly to the inflammatory focus, which is a preventive measure against the development of purulent-inflammatory complications, the presence of which leads to repeated surgical intervention. Sodium alginate, which is the hydrogel base of the matrix, provides a protective, stimulating and anti-inflammatory effect. Comprehensive local treatment for trepanation of the frontal sinuses, carried out for frontal sinuses with concomitant destruction of the walls of the frontal sinuses, implying intraoperative use of the Hydrogel Matrix, in which dioxidine and ε-aminocaproic acid were previously introduced, and magnetotherapy contributes to the postoperative 6 hours after surgery healing of postoperative wounds of the frontal region in optimal terms, reducing the stay of patients in the hospital by 7-10 days, avoided the development of early and late purulent complications, improve the quality of life of patients.

Claims (1)

A method of surgical treatment of frontal sinuses, including access to the frontal sinus in a typical place, sinus sanitation, obliteration of its cavity with osteoplastic material of composition MK-9M, suturing of the wound, characterized in that after the sanitation, the area of the bone defect is lined with a “Highly structured sodium alginate hydrogel matrix” in which dioxidine is preliminarily introduced in an amount of 0.03 g and ε-aminocaproic acid in an amount of 0.15 g, and after sinus obliteration with an adhesive osteoplastic composition MK-9M places access line the same matrix, over which wound is sutured closed tightly and napkins hydrogel "Koleteks-ADL."

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