RU2572552C2 - Method for osteoplastic ultrasonic surgery of paranasal sinuses - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: mucous membrane is incised in a projection of an operated sinus. An ultrasonic cutting instrument is used to cut out a U-shaped flap as a single fragment. A base of the cut out flap is cracked, and the sinus is exposed by bending the base. After the pathological content is removed, and the sinus is irrigated, the flap is placed back. The wound is closed. If using an extranasal approach, the flap is formed of bone, periosteum and soft tissues as a single fragment. The flap is bent upwards. If using an endonasal approach, the flap is formed of bone, periosteum, soft tissues and mucous membrane as a single fragment. The flap is bent upwards, downwards or backwards.

EFFECT: method enables reducing injuries, provides re-implant supply ensured by the U-shaped flap due to a narrowed base of the flap eliminates the need for additional fixation.

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Description

The invention relates to medicine, namely to otorhinolaryngology, can be used for osteoplastic ultrasound surgery of the paranasal sinuses.

All surgical interventions in the paranasal sinuses are performed by extranasal, endonasal approaches or a combination thereof.

For the maxillary sinus, the classic is the Calwell and Luke operation, which involves opening the front wall in the canine fossa, opening a hole in it by biting out a healthy bone, carefully scraping the mucous membrane and applying an anastomosis on the medial sinus wall into the nasal cavity at the level of the lower nasal passage [ Elantsev B.V. Operative otorhinolaryngology. Alma-Ata: Kazakh state. Publishing House, 1959. - S. 106-112].

Endonasal autopsy of the maxillary sinus can be performed through the lower, middle nasal passages, as well as through the crest of the pear-shaped aperture (Claue, Shturman, Galle operations). In this case, the front end of the lower or middle nasal concha and adjacent cells of the ethmoid labyrinth are removed, forming a persistent permanent fistula with the nasal cavity [Elantsev B.V. Operative otorhinolaryngology. Alma-Ata, 1959. - S. 105-106].

For the frontal sinus, the operations of G. Killian and N. V. Belogolov are considered generally accepted, in which the frontal sinus bone is exposed from the arched incision of the skin and periosteum along the eyebrow and lateral surface of the nose and either the bone bridge is removed, removing the remaining bone (according to Killian), or a bone in the form of a gap is removed only in the direction of the superciliary arch, maintaining the front and lower walls of the sinus, but sharply restricting the view [B. Elantsev Operative otorhinolaryngology. Alma-Ata, 1959. - S. 133-134].

With these surgical interventions, various complications can be observed: bleeding, infiltrates, suppuration in the upper jaw and forehead, inflammation of the middle ear, paresthesia. It is also possible to retract the facial region and the ingrowth of soft tissues of the cheek or forehead into a defect, impaired innervation, which causes persistent pain during traumatic neuralgia of the trigeminal nerve branches, intraocular complications [Mishenkin N.V., E.B. Fayman. Osteoplastic surgery of retention maxillary sinus cysts. Omsk, 1983. - 115 s; Patent RU No. 2365347, IPC АВВ 17/03, publ., August 27, 2009].

Endonasal access to the frontal, ethmoid and main sinuses can be carried out according to Halle by cutting a vertical flap of the mucous membrane from the front end of the middle conch to the back of the nose 1.5-2 cm wide, exposing and removing the bone between the base of the middle conch and the medial wall of the orbit. Further, after removal of the anterior ethmoid cells, access to the frontal sinus is opened, and after opening the posterior cells of the ethmoid sinus, an approach is created to the lower front wall of the main sinus, which is opened with a sharp spoon, Chisel of Voyachek, chisel or milling cutter [Elantsev B.V. Operative otorhinolaryngology. Alma-Ata, 1959. - S. 116-119, 124-126, 140-141].

T.N. Leontieva and B.A. Isserlis developed an ultrasound instrument in the form of a chisel and microlobes for gentle surgery of the sphenoid sinus with a polypous and purulent form of its inflammation. In this case, after the classical approach to the sinus was carried out according to Halle, a low-frequency ultrasonic instrument with a working part in the form of a micro-arm was bent at an angle of 20 ° to the axis, a polypous tissue was removed in the region of the lower and lateral edges of the hole, and then a low-frequency ultrasound instrument with the working part in the form of a micro-bit with the same bending angle was removed downward and laterally the anterior bone wall of the sinus [Patent RU No. 2033754, IPC АВВ 17/00, publ. 04/30/1995].

These accesses allow you to save the front walls of the maxillary, ethmoid and frontal sinuses, do not give cosmetic defects and trigeminal pain, but with them removing healthy bones changes the architectonics of the sinuses and their physiological relationships with the nasal cavity, which leads to impaired aerodynamics and protective function [RU patent No. 2365347, IPC АВВ 17/03, publ., August 27, 2009].

To prevent these complications, rhinosurgeons proposed options for osteoplastic surgery, which involves not biting the sinus wall, but sawing out a bone fragment in various ways, followed by fixing it in the area of the surgical defect. Various options have been proposed for extranasal osteoplastic surgery, the essence of which is that either a free flap or a flap on the leg with soft tissues is cut out from the bone tissue of the anterior maxillary sinus, which is reimplanted into the bone defect without fixation at the end of the operation [Pantyukhin V .P. A new modification of radical surgery in the maxillary sinus // Some questions of surgery and traumatology: Sat. tr - Novosibirsk, 1963. - S. 329-331] or fixing with sutures made through holes specially made by boron in the bone by fenestration [Yashan I.A., Masik A.F. Osteoplastic surgery for sinusotomy // Actual issues of otorhinolaryngology. - K .: Health, 1967, p. 146-147; Marchenko G.N. Autoplasty of the anterior bone wall of the maxillary sinus after a sinusotomy. / Problems of Surgical Dentistry, Issue 3. Kiev, 1968. - S. 100].

The disadvantage of these methods is that the bone fragment cut by a conventional tool always turns out to be smaller than the opening that arises, its installation presents significant difficulties, and after replantation without additional fixation it can fall into the sinus, becoming a foreign body and the cause of sinusitis relapse [Pantyukhin V.P. A new modification of radical surgery in the maxillary sinus // Some questions of surgery and traumatology: Sat. tr Novosibirsk, 1963; Mishenkin N.V., Fayman E.B. Osteoplastic surgery of retention maxillary sinus cysts. Omsk, 1983].

However, fixation was often impossible due to brittle bones when cutting a flap and especially when it was fenestrated. The flap was split and even while maintaining its position, it was often subsequently sequestered [Mishenkin N.V., Faiman EB. Osteoplastic surgery of retention maxillary sinus cysts. Omsk, 1983].

Closest to the claimed technical essence and the achieved technical result is a method of osteoplastic surgery in the paranasal sinuses, which make a horizontal incision of the mucous membrane, departing 1 cm from the frenulum of the upper lip, and also 1 cm higher than the alveolar bone and to the first large molar. In this case, soft tissues of the buccal region without periosteum are dissected with a scalpel. The dissected mucous membrane, together with the soft tissues, is extended by the raspator to the entire width of the anterior wall of the maxillary sinus and up to the exit site of the inferior ocular nerve. Within the boundaries of the anterior wall of the maxillary sinus, a lingual periosteum is dissected with a scalpel and it is separated to the sides with a width of 1-2 mm. Then, a tongue-like bone-periosteal flap is cut using an ultrasonic cutting tool in a previously done groove along the bone strip freed from the periosteum, bringing the bone shavings to the surface, open the sinus. Under the control of vision, all pathological (cysts, polyps, pus, foreign inclusions and inflammatory-altered mucous membranes) are removed from the sinus, expanding, if necessary, natural anastomoses with the nasal cavity, the wound is washed with an antiseptic solution, hemostasis is performed. Then the bone-periosteal flap is placed in place and osteoplastic fixation of the reimplant is performed using the bone-cyacrine composition, which hardens under the influence of high temperature created by an ultrasonic instrument (scapula). The wound is sutured behind the mucous membrane with interrupted sutures [Mishenkin N.V., Mishenkin V.E. Ultrasound surgery for multiple osteomas of the paranasal sinuses // Tomsk State University Journal. otorinolar 1990; 1: 74-76; Mishenkin N.V. Osteoplastic surgery of retention cysts of the maxillary sinus // N.V. Mishenkin, E. B. Fayman / Omsk, 1983. - P. 72-77].

The disadvantages of this method are the high morbidity and complexity of cutting out an osteoplastic flap, insufficient nutrition of the reimplant due to the absence of mucous membrane and soft tissues rich in blood vessels in the flap, the need for additional fixation of the flap using a bone-cyacrine composition, which can cause a local allergic reaction, inflammation and as a consequence, rejection of the reimplant. In addition, this method does not allow the use of a magnifying or endoscopic technique, since an osteoplastic flap, deprived of fixation due to a soft tissue component during surgical intervention, is broken off when installing fiber optics, navigation equipment and manipulations with additional tools. The inability to use sophisticated techniques and modern techniques of functional endoscopic surgery significantly limits the scope of osteoplasty for operations on the paranasal sinuses despite all its advantages.

The technical result of the invention is the development of low-traumatic access during operations on the paranasal sinuses, combining the possibility of good visualization with obtaining a functional result, eliminating the need for fixation of reimplant, maintaining the architectonics and basic functions of the sinuses, providing the possibility of using a magnifying or endoscopic technique.

The specified technical result is achieved by the fact that in the method of osteoplastic surgery on the paranasal sinuses, according to which the mucous membrane is cut, in the projection of the operated sinus, the osteoplastic flap is cut using an ultrasonic cutting tool, opening the sinus, the operation is performed, removing the pathological contents of the sinus, the wound is washed, at the end of the operation, the flap is placed in place, after which the wound is sutured, according to the claimed invention, the osteoplastic flap is cut out un th complex fragment horseshoe shape, whereupon a cut nadlamyvayutsya base osteoplastic flap and autopsied sinus through its bending.

With the extranasal approach, the horseshoe-shaped osteoplastic flap is formed by a single complex fragment consisting of bone, periosteum and soft tissues, the cut of the osteoplastic flap is folded upward, and at the end of the operation and laying the flap in place, the wound is sutured by nodal sutures.

With the endonasal approach, the horseshoe-shaped osteoplastic flap is formed by a single complex fragment consisting of bone, periosteum, soft tissues and mucous membrane, the cut osteoplastic flap is folded up, down or back, and at the end of the operation, after putting the flap in place, the wound is sutured with nodal sutures or brackets.

The horseshoe-shaped form of the osteoplastic flap due to the narrowed base, along which the cut flap is bent, reduces trauma and eliminates the need for additional fixation of the flap using a bone-cyacrine composition, and the osteoplastic flap is made in the form of a single complex fragment, including not only the bone and periosteum, but also tissue rich in blood vessels provides adequate nutrition for reimplant.

The invention is illustrated by drawings, which illustrate:

Fig. 1 - formed a single complex osteoplastic flap horseshoe-shaped, with an extranasal approach to the maxillary sinus bent up;

Fig. 2 - a single complex osteoplastic flap horseshoe-shaped, with an endonasal approach to the maxillary sinus bent posteriorly.

The method is as follows.

Surgical osteoplastic interventions in the paranasal sinuses can be performed from extranasal or endonasal access. In any case, the operation is performed in the position of the patient lying on his back under endotracheal anesthesia or local anesthesia using an ultrasonic cutting tool attached to the acoustic unit of any type of generator with a frequency of 25-44 kHz.

For extra nasal access, for example, to the maxillary sinus, the patient is made a small incision in the mucous membrane along the transition fold under the upper lip at the level from the second to the fourth tooth. Then, the wound is slightly stretched by hooks upwards and to the sides and in the area of the dog’s fossa without separating the periosteum, the osteoplastic flap is cut out within the operated sinus with a single complex horseshoe-shaped fragment consisting of bone 1, periosteum 2 and soft tissues 3, after which the sinus is opened by the hole fragment and its bend up. Hemostasis at this stage of work is practically not carried out, because low-frequency ultrasound has a good coagulating effect. Then, an operation is performed directly on the sinus: the pathological contents of the sinus are removed, expanding, if necessary, the natural anastomoses with the nasal cavity. At the end of the operation, the osteoplastic flap is placed in place with a single fragment (like the cover of a chest), smoothing the periosteum, soft tissues with the mucous membrane and suturing the wound. Additional fixation is not required, because the bone gap is small and a single complex osteoplastic flap is well retained due to the bone base and soft tissues. Drainages are not used, the nasal cavity is not plugged. On the 2-3rd day there is an active cleansing of the sinus from hemorrhagic residues through natural anastomoses.

Similarly, an operation is performed on the frontal or frontal and ethmoid sinuses with external access. After performing a skin incision along the eyebrow with a transition, if necessary, in a vertical direction along m. Procerus skin is separated within the intended opening of the sinus, a single complex horseshoe-shaped osteoplastic flap is formed, consisting of bone, periosteum and soft tissues within the marked sinuses. The sinus is opened by breaking the base of the flap and bending it up. All pathological is removed, at the end of the operation, the osteoplastic flap is placed in place and the wound is sutured.

For endonasal access, the opening of the maxillary sinus can be performed through the lower, middle nasal passages. For this, a horseshoe-shaped complex osteoplastic flap consisting of bone 1, periosteum 2, soft tissues 3 and mucous membrane 4 is cut out as a single fragment with an ultrasonic cutting tool. The sinus is opened by breaking the base and bending the flap up or back. Through access, the sinus is operated on: all pathological contents are removed, expanding, if necessary, the natural anastomoses with the nasal cavity. At the end of the operation, the osteoplastic flap is placed in place, the wound is sutured.

From this access, the frontal, ethmoid and main sinus are also operated on (with the approach to the front-lower edge of the latter).

For endonasal access for transeptal opening of the main sinus, the operation begins with the usual submucosal resection of the nasal septum. Separate the mucous membrane on one side, cut the cartilage, separate the mucosa on the other hand, separate the leaves of the separated mucosa with an elongated nasal dilator, install a bone-cartilaginous skeleton of the septum between the branches, which are resected in the anterior and posterior sections. Then, the mucous membrane with rostrum sphenoidale is separated from the same pocket until the natural openings located in the anterior wall of both sphenoid sinuses appear in the field of view. With an ultrasound instrument, a complex horseshoe-shaped flap consisting of bone, periosteum and mucous membrane is cut out in the region of the anterior or anterior lower sinus wall. The sinus is opened by breaking the base of the flap and bending it more often downward. After the sanitation phase of the operation, the flap is placed in place.

An example of the method

Patient L., 32 years old, was admitted to the clinic in December 2009 about a right-sided chronic purulent odontogenic maxillary sinusitis, a foreign body of the right maxillary sinus (filling material). The patient underwent an ultrasound debridement operation on the right maxillary sinus with extranasal osteoplastic access using an operating microscope. Under endotracheal anesthesia in the supine position, a small incision of the mucous membrane along the transition fold under the upper lip at the level from the second to the fourth tooth was made using an ultrasonic scalpel attached to the acoustic node of the low-frequency ultrasound generator 26.5 kHz. In the area of the canine fossa, an integrated fragment of a horseshoe-shaped osteoplastic flap consisting of bone, periosteum and soft tissues was cut with a single fragment using an ultrasound instrument, after which the sinus was opened by breaking the base of the osteoplastic flap and bending it up. Bleeding was not noted due to the cutting out of the flap together with soft tissues. Under the control of an operating microscope, dense fragments of a foreign body (filling material) were removed from the sinus with forceps, granulation in the sinus fundus area was destroyed and removed with a bone spoon, the sinus was washed with furacilin solution to remove pus and mucus. Under magnification × 8, the natural sinus anastomosis was revised and small polyps removed from it. Patency of anastomosis restored. After that, the osteoplastic flap was put in place. The wound was sutured behind the mucous membrane with 3rd interrupted sutures. On the 5th day, a control puncture of the sinus was performed through the lower nasal passage using a Kulikovsky needle. Detachable - a small number of hemorrhagic clots, patency of the anastomosis with a nasal cavity of 1 degree. The postoperative course is favorable, swelling of the right cheek is insignificant, arose on the 3rd and completely stopped on the 7th day, after which the patient was discharged home.

According to the results of a radiographic computer examination after 6 months (06/26/13), no traumatic and inflammatory phenomena were detected on the control MSCT, the cut line was almost invisible, and the flap consolidation was complete.

The proposed technology for the formation of osteoplastic surgical access to the paranasal sinuses is quite simple, does not require special techniques for using waveguide instruments. The use of a horseshoe-shaped osteoplastic flap in the form of a single fragment allows not only easy and bloodless opening of the sinuses, but also does not require special methods of fixation using bone fenestration or using plastics and allografts.

This method allows you to provide a good overview during surgery, to preserve the architectonics of the sinuses, and, consequently, their aeration and the function of mucociliary clearance, allows you to use any endoscopic, enlarging and navigation technique with extra- and endonasal approaches and their combinations.

The rapid restoration of functional indicators in all variants of osteoplastic surgery by the present method improves the effectiveness of treatment, reduces the number of early and late postoperative complications and reduces postoperative hospital bed.

Claims (3)

1. The method of osteoplastic surgery on the paranasal sinuses, according to which the mucous membrane is cut, in the projection of the operated sinus, the osteoplastic flap is cut using an ultrasonic cutting tool, opening the sinus, the operation is performed, removing the pathological contents of the sinus, the wound is washed, the flaps are placed on the end of the operation place, after which the wound is sutured, characterized in that the osteoplastic flap is cut out with a single complex fragment of a horseshoe-shaped shape, after which yvayut base a cut osteoplastic flap and autopsied sinus through its bending. 2. The method according to p. 1, characterized in that in the extranasal approach, the osteoplastic flap of a horseshoe-shaped form is formed by a single complex fragment of bone, periosteum and soft tissues, the limb of the cut osteoplastic flap is carried up, and at the end of the operation and laying the flap in place, the wound is sutured by application on soft tissue nodal joints. 3. The method according to p. 1, characterized in that with the endonasal approach, the horseshoe-shaped osteoplastic flap is formed by a single fragment of bone, periosteum, soft tissues and mucous membrane, the cut osteoplastic flap is folded up, down or back, and at the end of the operation after the flap is laid the wound is sutured into the mucous membrane with interrupted sutures or brackets.

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