RU2705404C1 - Method for paranasal sinus drainage in patients with consciousness disorders - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology, and can be used for drainage of paranasal sinuses in patients with consciousness disorders. That is ensured by drainage from the sinus cavity by means of a drain element using positive and negative pressure during drainage. Drainage element used is a flow-flushing drainage element consisting of two tubes of elastic material with rounded ends. One of the tubes is intended for aspiration and has an end having perforation in the form of side holes. Other tube is used as an irrigator tube. After the endonasal endoscopic operation, an endoscopic inspection is followed by installing a drainage tube for aspiration into the involved paranasal sinus or sinuses. Pipe for aspiration is installed so that its perforated end does not extend beyond sinus. Vacuum aspirator operated in a constant low vacuum mode is connected to the perforated end of the aspiration tube, namely, less than 20 kPa. Drop introduction system for medicinal preparations is connected to an irrigation tube. Further, by means of said flow-washing drainage element, drainage from sinuses with continuous aspiration of flushing liquid is performed for 4–6 days. At the same time aspiration is followed by administering a sterile aqueous solution of 0.05 % chlorhexidine from the drip introduction system at rate of 60 drops a minute.

EFFECT: method provides accelerating the sanation time of the infection center, reducing the number of complications in the postoperative period.

1 cl, 1 dwg, 1 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and can find application in the postoperative treatment of purulent diseases of the paranasal sinuses (hereinafter - SNP) in patients with intracranial complications (hereinafter - VChO), accompanied by severe forms of impaired consciousness.

The most common cause of impaired consciousness in patients with purulent ONP diseases is intracranial complications of acute and chronic rhinosinusitis. Infectious damage to the paranasal sinuses in patients with complicated purulent-inflammatory VChO course of the disease is widespread: polysinusitis - damage to two or more SNPs, pansinusitis - total damage to all sinuses. The average duration of treatment of patients in a multidisciplinary specialized hospital averages 24.2 ± 11.0 days, including 5.7 ± 3.5 days, patients are in the intensive care unit and intensive care.

Drainage of the maxillary, frontal, sphenoid sinuses is the main method of rehabilitation of the site of infection in the postoperative period. In patients with purulent-inflammatory VChO associated with SNP diseases, various types of impaired consciousness are diagnosed in 57.0% of cases. The forced horizontal position of a patient with impaired consciousness in the intensive care unit after surgical debridement of foci of SNP infection complicates the evacuation of pathological contents from the sinus lumen through natural or artificial anastomoses imposed during surgery. Stagnation and the absence of evacuation of the pathological contents of the sinus after surgical debridement inevitably leads to a relapse of the purulent process in the sinus, negative dynamics of the neurological status, and development of cerebral edema, which leads to hospital mortality of 15.2%.

Effective and prolonged drainage of SNPs in patients with impaired consciousness should be carried out as sparingly as possible, to ensure a minimum risk of complications, traumatic injuries of the sinus walls and anatomical structures bordering the sinus. It should also be possible to introduce drugs and antiseptics into the sinus cavity and prolonged exposure to the sinus mucosa, which, in aggregate, accelerates the debridement of the purulent focus, shortens the patient’s treatment time, rehabilitation time, and reduces the frequency of mortality and disability.

The invention relates to a flow-washing method for draining SNPs in patients with impaired consciousness and, therefore, for a long time forced to be in a horizontal position in the conditions of the intensive care unit and intensive care.

A known method of drainage of SNPs, including the installation of a catheter in the cavity of the maxillary sinus for a long time (see SZ Piskunov, AI Lazarev, TG Bykanova "Conservative and surgical treatment of odontogenic maxillary sinusitis", Kursk, 2004, pp. . 48-49).

When implementing this method, anesthesia of the nasal mucosa in the lower nasal passage is performed by application of a 10% lidocaine solution. Then, a needle is punctured at the upper point of the arch of the lower nasal passage at a distance of about 1.5-2.0 cm posterior to the anterior end of the lower turbinate. After installing the needle, using a syringe, the contents of the sinus is aspirated or washed out, and then an antiseptic or drug is administered. Through the puncture needle, a conductor line is inserted into the sinus cavity. After that, the needle is removed, and through the hole formed during puncture, a soft catheter is inserted through the conductor and the conductor is removed. The catheter is left in the sinus for repeated procedures for aspirating the contents of the sinus, rinsing, and portionwise administration of drugs to the sinus cavity.

The disadvantages of this method is that:

- drainage is possible only one maxillary sinus, the technical ability to drain the frontal, sphenoid sinuses in the implementation of this method is absent;

- sinus aspiration and irrigation is performed through one catheter; in patients with impaired consciousness, when washing, it is possible to aspirate the sinus contents and rinse water;

- the method may be accompanied by a number of complications, such as: penetration of the needle into the opposite, lateral wall of the maxillary sinus; bleeding; penetration of the end of the needle into the soft tissues of the cheek, orbit, or into the tissue of the pterygopalatine fossa; air embolism, etc.

There is also a known method for drainage of SNPs, including exposure to negative and positive pressure on the sinus cavities (see DI Tarasov, GI Markov, BC Kozlov "Instructions for use of the Yamik-321 sinus catheter", guidelines, YAGMI, Yaroslavl , 1987, p. 15-19).

When implementing this method, the installation of a sinus catheter in the nasal cavity is performed after anemization of the nasal mucosa and application anesthesia with 10% lidocaine solution. Then, with a syringe, air (about 10 ml) is introduced into the posterior balloon and the anterior. After checking the system for leaks, the syringe creates alternately negative and positive pressure in the SNP, with the help of which the pathological contents are evacuated, while the patient's head is tilted forward and in the direction opposite to that half of the nose where the sinus catheter is installed. After this, the patient is transferred to the "lying on his side" position, the head hangs from the shoulder towards the affected sinuses. Then, in a similar manner, a drug is administered into the SNP cavity.

The use of the JAMIC sinus catheter (Yaroslavl Markov and Kozlov) improves drainage from SNPs by creating negative pressure in the nasal cavity, allows for simultaneous rehabilitation of the maxillary, frontal, sphenoid sinuses.

The disadvantages of this method is that:

- drainage is carried out without visual endoscopic control and is of a short-term nature;

- the effect of drugs on the mucous membrane of the sinus is short-lived, there is no technical possibility of prolonged administration of the drug solution in the sinus cavity;

- the implementation of the method is impossible in the treatment of complicated forms of sinusitis;

- the use of the method in patients with impaired consciousness is not possible due to the forced horizontal position of the body and the inability to change the position of the head;

- the method has a large number of contraindications: violations of the blood coagulation system, deformities and abnormalities of the nasal septum, old age, etc., which significantly limits the possibility of its use.

The closest in technical essence to the claimed solution is a method for draining SNP, including performing drainage from the sinus cavity through a two-channel drainage element using positive and negative pressure during drainage (see Ukrainian patent No. 23622, MKI A61M 25/00, 1998).

When implementing this method, a two-channel catheter is used. The catheter is made of a polyvinyl chloride two-channel tube with cannulas and is expanded in the form of olive at the working end of the catheter. A conductor is located in one of the channels of the tube. The conductor consists of a handle and a flexible steel wire having two bends in the same plane, which allows to install a catheter with various anatomical options for the structure of the nasal cavity. In order to reduce trauma, the catheter protrudes 0.7-1 mm from the distal end of the conductor. A tube is attached to the handle of the conductor, through which air flows through the hole in the handle and along the entire length of the device between the conductor and one of the catheter channels.

After local application anesthesia of the upper nasal passage and anemization of the mucous membrane of the common nasal passage, the device is inserted into the upper nasal passage and moves along it until a feeling of obstruction appears, indicating that the device is in contact with the anterior wall of the sphenoid sinus. Then the device is installed in a lateral position and, sliding along the mucous membrane of the front wall of the main sinus, is carried forward to the sensation of a feeling of failure (falling into the anastomosis of the main sinus). During the entire process of catheterization, the supplied air stream enters through the hole in the handle of the conductor along its entire length, between one channel of the catheter and the conductor, and exits at the working end of the catheter, expanded in the form of olive.

After completion of the catheterization, the conductor is removed, and through the left catheter, the main sinus is rinsed, and through one of the tubes, a solution is introduced into the sphenoid sinus, which subsequently flows through the second tube.

The disadvantages of this method is that:

- technical characteristics of the two-channel tube, its configuration, the claimed technique for the implementation of drainage - allow drainage of only one sphenoid sinus; if the patient reveals multiple lesions of the paranasal sinuses (polysinusitis), the presented method does not allow drainage of the frontal, maxillary sinuses;

- the introduction of a double-lumen catheter into the cavity of the sphenoid sinus is carried out without endoscopic visual control, which is associated with a high risk of damage to the sieve of the ethmoid bone with the development of iatrogenic intracranial complications;

- when washing, the therapeutic effect of drugs on the sinus mucosa is of a short-term nature - during the time the solution is injected with a syringe through a syringe cannula;

- in the absence of active evacuation (aspiration) of the wash solution from the sinus cavity, it lingers in it, which increases the risk of infection of the sinus contents with a worsening of the clinical course of the disease.

The technical result of the proposed solution is to increase the efficiency of drainage of SNPs in patients with impaired consciousness by reducing the number of complications in the patient in the postoperative period and shortening the time of his rehabilitation.

To achieve the specified technical result in the method of drainage of the paranasal sinuses, including performing drainage from the sinus cavity by means of a drainage element using positive and negative pressure during drainage, according to the invention, a flow-washing drainage element consisting of two tubes with a diameter of 4 mm is used as a drainage element made of elastic material with rounded ends, one of the tubes being suctioned and made with an end having perforation in the form of side holes, and the other tube is used as an irrigator tube, while after performing endonasal endoscopic surgery under endoscopic control, a drainage tube for aspiration is inserted into the affected paranasal sinus or sinuses, while the suction tube is installed so that it is perforated the end did not go beyond the sinus, and a vacuum aspirator connected to a perforated end of the suction tube was connected, operating in a constant low vacuum mode, namely is higher than 20 kPa, and a system for drip administration of drugs is connected to the irrigator tube, then through the above-mentioned element of flow-washing drainage, sinus drainage is performed with continuous aspiration of the washing liquid for 4-6 days, while sterile water is introduced simultaneously with aspiration a solution of 0.05% chlorhexidine from a system for drip drug administration, which is administered at a rate of 60 drops per minute.

The use of flow-flushing drainage of the maxillary, frontal, sphenoid sinuses with continuous aspiration of the flushing fluid allows this method to be applied in any position of the patient’s head and body, including in patients with purulent-inflammatory rhinosinusogenic intracranial complications with various forms of impaired consciousness and in forced horizontal position. Continuous aspiration of the washing fluid eliminates the possibility of the solution leaving the sinus into the nasal cavity, nasopharynx, respiratory tract and aspiration of the washing fluid in patients with impaired consciousness in a forced horizontal position.

A constant dosed supply of washing fluid into the cavity of the affected sinus provides long-term (prolonged) contact of the solution with the walls of the sinus and an effective anti-inflammatory effect.

Due to the possibility of using a drip system for continuous administration of drugs and antiseptics into the sinus cavity with their simultaneous aspiration, their prolonged effect on the mucous membrane is achieved, which accelerates the rehabilitation of the purulent focus, shortens the treatment time of the patient, the rehabilitation time, and reduces the frequency of mortality and disability.

The use of the FESS (Functional endoscopic sinus surgery) technique and endoscopic control during the installation of irrigation and suction drainage can reduce the morbidity and risk of iatrogenic complications (damage to the base of the skull, ICF, etc.), as the doctor has the ability to visually monitoring the process of conducting and installing drainages. If the patient reveals polysinusitis (lesions of several sinuses at the same time), the use of the FESS technique allows, if indicated, drainage of several sinuses: frontal, maxillary, sphenoid. The use of endoscopic control (FESS technique) during the installation of drains provides the possibility of their reliable fixation in the mouth and lumen of the affected sinus and the possibility of long-term (prolonged - up to 4-6 days) irrigation-aspiration, exposure to the inflammatory focus. It allows you to speed up the healing process by constantly removing tissue detritus and pathological discharge from the sinus cavity, exposure to pathogenic microflora. Simultaneous, along with irrigation, aspiration from the sinus cavity improves its aeration and prevents flushing water from entering the respiratory tract in patients with impaired consciousness.

Thus, prolonged flow washing provides mechanical cleaning of the wound from tissue detritus and pathological discharge, provides air into the sinus cavity and provides sufficient sinus aeration, and the use of antibacterial solutions has a direct inhibitory effect on microflora. Due to the possibility of using a drip system for continuous administration of drugs and antiseptics into the sinus cavity with their simultaneous aspiration, their prolonged effect on the mucous membrane is achieved, which accelerates the rehabilitation of the purulent focus, shortens the treatment time of the patient, the rehabilitation time, and reduces the frequency of mortality and disability.

The inventive method of drainage of the maxillary, frontal, sphenoid sinuses in patients with impaired consciousness through the use of FESS and endoscopic control during the installation of drainage in the cavity of the affected sinus due to prolonged and continuous irrigation and aspiration in the sinus cavity allows to reduce the number of complications in the postoperative period, to speed up the time sanitation of the focus of infection.

From the foregoing, it follows that the introduced distinguishing features affect the specified technical result, are with him in a causal relationship.

The method is illustrated in the drawing, where in FIG. 1 shows a diagram of the element of flow-washing drainage, its installation in the cavity of the sphenoid sinus. The following positions are used in the drawings: 1 - sinus cavity; 2 - tube for aspiration; 3 - perforated end of the tube 2 for aspiration; 4 - tube irrigator; 5 - a system of drip administration of drugs; 6 - vacuum aspirator.

The method is as follows.

The patient is in a horizontal position on his back. Local anesthesia with lidocaine solution 10% with preliminary application of 0.1% adrenaline solution on the mucosal surface (anemization of the mucosa) is used for anesthesia. Endotracheal anesthesia can also be used for pain relief. Sinus drainage is performed after the completion of surgical rehabilitation of the paranasal sinuses using the FESS technique, in the early or late postoperative period after the endonasal endoscopic polysinusotomy according to the FESS technique, and also without prior surgical intervention on the paranasal sinuses during conservative treatment.

When performing the claimed method under video endoscopic control using the FESS technique, a natural or formed anastomosis of the affected sinus is visualized. Under visual endoscopic control, an element of flow-washing drainage is introduced into the sinus cavity 1 from two tubes with a diameter of 4 mm from an elastic material with rounded ends. One of the tubes 2 is designed for suction, the end 3 of which is made with perforation in the form of side holes. When this tube for aspiration 2 is set so that its perforated end 3 does not extend beyond the cavity of the sinus 1.

Aspiration from the sinus cavity through the tube 2 for aspiration is carried out simultaneously through all the lateral openings made in the tube 2 at the end 3 to prevent stagnation of the washing fluid in the sinus cavity, ensuring that the washing fluid does not enter the sinus 1 into the respiratory tract with the development of aspiration. This is of great importance when carrying out sinus aspiration-drainage in patients with rhinosinusogenic purulent-inflammatory intracranial complications with impaired consciousness, for a long time in a forced horizontal position on the back to prevent aspiration of the washing fluid in the lower respiratory tract.

Another tube is used as an irrigator tube 4, and salt solutions or antiseptics are supplied through it. The patency of tubes 2 and 4 is checked on the operating table by irrigation and aspiration using a 20.0 ml syringe. Both tubes 2 and 4 are connected together by a Prolen 3.0 thread, the ends of the threads are brought to the back of the nose and fixed with an adhesive plaster. A system for drip administration of drugs 5 is connected to the irrigator tube 4. A sterile 0.05% chlorhexidine aqueous solution is injected dropwise into the sinus cavity 1 at a rate of 60 drops per minute.

A vacuum aspirator 6 is connected to the perforated end 3 of the suction pipe 2, which operates in a constant low vacuum mode (less than 20 kPa according to GOST ISO 10079-3-2012). The washing liquid under the influence of low negative pressure is collected in a container of transparent glass. The condition of the washing fluid from the sinus cavity is monitored visually. When the wash solution of a sterile aqueous solution of chlorhexidine 0.05% in the bottle ends, replace with a full bottle with the wash solution. During the entire drainage time, endoscopic control of the correct installation of the tubes 2 and 4 of the flow-washing drainage element is carried out daily. The duration of the drainage of the paranasal sinuses using the claimed method in patients with rhinosinusogenic purulent-inflammatory intracranial complications, accompanied by various forms of impaired consciousness, is determined on the basis of complex clinical and laboratory indicators of the dynamics of the patient's condition.

The dynamics of the patient’s condition is assessed after examination by specialist doctors: an otorhinolaryngologist, neurosurgeon, neurologist, resuscitator, therapist, clinical pharmacologist. Calculation of integral scales for assessing the patient's condition: Glasgow, SOFA, ARESNEII. Hourly, they monitor the state of the washing fluid collected in the vacuum aspirator 6. If the patient has positive clinical dynamics in general condition, specialized otorhinolaryngological and neurological status, confirmed by digital indicators of integral assessment scales, as well as if the vacuum aspirator 6 has clean ( transparent) washing liquid without impurities of purulent contents, drainage is stopped. The element of flow-washing drainage from the sinus cavity 1 is removed.

The method is illustrated by the following example.

Patient Sh., 32 years old, was admitted to the St. Petersburg Research Institute of Ear, Throat, Nose, and Speech with complaints of severe spilled headache, pain in the frontal region, general weakness.

From the anamnesis: sick for 10 days, after hypothermia and SARS. Severe headaches, febrile temperature appeared 2 days before hospitalization.

Claims (2)

1. The method of drainage of the paranasal sinuses in patients with impaired consciousness, including performing drainage from the sinus cavity through a drainage element using positive and negative pressure during drainage, characterized in that as a drainage element using a flow-washing drainage element consisting of two tubes made of elastic material with rounded ends, one of the tubes being suction and made with an end having perforation in the form of side holes and the other tube is used as an irrigator tube, while after performing an endonasal endoscopic operation under endoscopic control, a drainage tube for aspiration is inserted into the affected paranasal sinus or sinuses, while the suction tube is installed so that its perforated end does not go beyond sinuses, moreover, a vacuum aspirator operating in a constant low vacuum mode, namely less than 20 kPa, is connected to the perforated end of the tube for aspiration, and to the irrigator tube they turn off the system for the drip administration of drugs, then through the above-mentioned element of flow-washing drainage, sinus drainage is performed with continuous aspiration of the washing liquid for 4-6 days, while at the same time the sterile aqueous solution of 0.05% chlorhexidine is introduced from the system for drip administration of drugs, which is administered at a rate of 60 drops per minute. 2. A method for drainage of the paranasal sinuses in patients with impaired consciousness according to claim 1, characterized in that tubes with a diameter of 4 mm are used in the element of flow-flushing drainage.

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