RU2799043C1 - Method of reconstructing the back of the nose in congenital malformations in children - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology; reconstructive and plastic surgery.

SUBSTANCE: under intubation anesthesia and infiltration anesthesia, a catheter filled with a brilliant green solution is inserted into the fistulous tract to the pathological formation located in the back of the nose. Then, an elliptical incision of the skin and subcutaneous fat is performed around the fistulous opening. The incision of the skin and subcutaneous fat is continued along the fistulous tract, visualized by means of the inserted catheter. After that, the walls of the fistulous tract and the formation capsule are separated from the surrounding tissues along the entire length, without damaging the integrity of their walls. Then, in the region of the columella and the bottom of the nasal cavity, an incision is made along the transitional fold on the left, and the mucoperichondria and mucoperioste of the nasal septum are separated with a raspator along the entire length, providing endonasal access to the formation. Through the incision, the formation capsule is also separated from the surrounding tissues without damaging it. After complete separation, the fistulous tract is completely excised. Under the control of endoscopic technique, a control examination of the nasal cavity is performed up to the posterior wall of the frontal sinus in order to revise the remains of the pathological formation. After that, the reconstruction of the back of the nose is performed by mobilizing the nasal bones, bringing them together and fixing them using suture material. Layer-by-layer suturing of the wound from the outside is carried out with the installation of drainage with output to the outer surface of the nose in the area of the excised outlet of the fistulous tract and the second drainage with output to the nasal cavity through the counter-opening formed by dissection of the mucoperichondria at the transition site of the cartilaginous section of the nasal septum to the bone. Then the mucous membrane is sutured in the area of the vestibule of the nose. Latex swabs lubricated with antibacterial ointment are placed in the nasal cavity.

EFFECT: method allows to radically excise the pathological formation, and to exclude the development of relapses.

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Description

Technical field

The invention relates to otorhinolaryngology and reconstructive plastic surgery and can be used in the surgical treatment of children with congenital malformations of the nose.

State of the art

Currently, various methods of treating patients with congenital pathology of the development of the nose and intranasal structures (dermoid cyst of the back of the nose, congenital glioma, etc.) are known and widely used in pediatric otorhinolaryngology. Dorsal dermoid cyst is a rare congenital anomaly of the development of the nose, which most often manifests itself in childhood. This pathology, according to foreign authors, occurs in 1 out of 20-40 thousand newborns [Pratt L.W., 1965, Hughes G.B. et al., 1980], which accounts for only 3.7-12.6% of dermoid cysts of the head and neck [El-fattah A.M.A. et al., 2016]. Violation of the development of the rudiments of the epithelium in the embryonic period is the cause of the neoplasm. Dermoid cysts can occur anywhere along the midline, from the root of the nose to the columella, which explains their etiological origin. In childhood, there is a risk of intracranial spread or infection of the formation; at an older age, the anomaly under discussion may be accompanied by various social and psychological problems.

Treatment of congenital heterotopias in the nose area is exclusively surgical. Known sources mainly describe the surgical treatment of patients of childhood or young age, since the onset of the disease is not typical for adult patients.

An important point in the treatment of congenital heterotopias in the nasal region is the complete removal of a formation with a shell with various accesses to achieve adequate visualization and an acceptable cosmetic result (vertical median, transverse, lateral rhinotomy, inverted U-shaped incision, open rhinoplasty or endoscopic approaches) [Rahbar R. et al., 2003, Pollock R.A., 1983]. In the case of partial removal of the formation, the remaining epithelial fragment can again lead to a relapse with a probability of 30 to 100% according to various authors. As a result, minimally invasive interventions (partial cyst removal, drainage, aspiration or curettage) are ineffective [Rahbar R. et al., 2003].

All known methods of surgical treatment have their advantages and disadvantages. The disadvantage of almost all surgical approaches to remove congenital heterotopias in the nose area is the presence of cosmetic facial defects after treatment.

External nasal cysts increase with age, which can lead to deformation of the nasal bones and lower lateral cartilage, stretching and skin changes. In childhood, foreign colleagues suggest using an open rhinoplasty access and a fat graft to solve the emerging problem after surgical treatment in order to achieve a better aesthetic result, which is not justified in children of a younger age group [Pierce S.A., 2016].

Given the rarity of heterotopias in the nasal region, there are only a few large studies on this topic in the literature [V.E. Hartley, et al., Nasal dermoids in children: a proposal for a new classification based on 103 cases at Great Ormond Street Hospital, Int. J. Pediatr. Otorhinolaryngol. 79 (1) (2015) 18-22; H. Herrington, et al., Update on current evaluation and management of pediatric nasal dermoid, Laryngoscope 126 (9) (2016) 2151-2160] and a small number of publications on the restoration of the aesthetic function of the nose after resection. Foreign literature describes a method for restoring the back of the nose, including the use of an ear cartilage graft to support a deformed bone and/or cartilaginous framework of the nose. [R. Locke, H. Kubba, The external rhinoplasty approach for congenital nasal lesions in children, Int. J. Pediatr. Otorhinolaryngol. 75 (3) (2011) 337-341]. In cases where a nasal mass appears already in late adolescence or adulthood, septal cartilage can be used for reconstruction [RJ. Rohrich, J.B. Lowe, M.R. Schwartz, The role of open rhinoplasty in the management of nasal dermoid cysts, Plast. Reconstr. Surg. 104 (7) (1999) 2163-2170, quiz 2171., D.K. Loke, T.J. Woolford, Open septorhinoplasty approach for the excision of a dermoid cyst and sinus with primary dorsal reconstruction, J. Laryngol. Otol. 115 (8) (2001) 657-659.]. The use of costal cartilage is also known, with good results in the immediate and long-term postoperative period [L.A. Mankarious, R.J. Smith, External rhinoplasty approach for extirpation and immediate reconstruction of congenital midline nasal dermoids, Ann. Otol. Rhinol. Laryngol. 107 (9 Pt 1) (1998) 786-789], however, when using this method, an additional scar remains on the donor site, and there is also a risk of complications in the form of pneumothorax, especially in children of a younger age group. It is possible to use synthetic implants, but this method has its drawbacks in the form of postoperative infection, as well as the displacement of the implant and its extrusion as the child grows.

Given the above in relation to the described surgical approaches and their shortcomings, it remains relevant to search for new methods for reconstructing the back of the nose after surgical removal of congenital heterotopias in the nasal region.

The method closest to our proposed method is a method for reconstructing the back of the nose with congenital malformations of the nose in children, which consists in the fact that the surgical access is performed from a vertical median incision [The presentation and management of nasal dermoid: a 30-year experience / Rahbar R. et al. // Arch Otolaryngol Head Neck Surg. 2003; 129(4):464-471], which is a very convenient approach for removing nasal heterotopias, since they do not expand intraosseously and are rather small in length. For nasal lesions with a fistulous opening involving the skin, a vertical midline incision may be used with or without concomitant external rhinoplasty. In such cases, a vertical incision along the midline immediately excised the fistulous opening.

The disadvantages of this method are: unsatisfactory aesthetic results, scar expansion when using this approach, as well as a large defect between the bones of the nose at the site of the removed nasal heterotopia.

The problem solved by the present invention is to develop a method for the reconstruction of the back of the nose with congenital malformations of the nose in children, in which the development of relapses would not be observed and a good cosmetic result would take place.

To solve this problem, we propose a method developed by us for reconstructing the back of the nose with congenital malformations of the nose in children, which consists in the fact that under intubation anesthesia and infiltration anesthesia, a catheter filled with a solution of diamond green, to visualize the fistulous tract, then an elliptical incision of the skin and subcutaneous fat is performed around the fistulous opening, the incision of the skin and subcutaneous fat is continued along the fistulous tract, visualized by means of the inserted catheter, after which the walls of the fistulous tract and the capsule of formation are separated from surrounding tissues throughout, without damaging the integrity of their walls, then in the region of the columella and the bottom of the nasal cavity on the left, an incision is made along the transitional fold and the mucoperiost and the mucoperioste of the nasal septum are separated with a raspator along the entire length, providing endonasal access to the formation, through which the capsule is also separated formations from the surrounding tissues without damaging it, after complete separation, the fistulous tract and the formation are completely excised, under the control of endoscopic techniques, a control examination of the nasal cavity is performed to the posterior wall of the frontal sinus in order to revise the remnants of the pathological formation, after which the nasal dorsum is reconstructed by mobilizing the nasal bones , bringing them together and fixing them using suture material, after fixing the bones, layer-by-layer suturing of the wound from the outside is carried out with the installation of drainage with output to the outer surface of the nose in the area of the excised outlet of the fistulous tract and the second drainage with output into the nasal cavity through the counter-opening, formed by dissection of the mucoperichondria at the junction of the cartilaginous section of the nasal septum into the bone, then the mucous membrane is sutured in the area of the vestibule of the nose, latex swabs lubricated with antibacterial ointment are placed in the nasal cavity.

The technical result of the claimed invention is as follows.

Radical excision of the pathological formation is carried out using a combined approach, namely from the outside of the nose and endonasally. This provides good visualization during the control examination of the nasal cavity in order to revise the remnants of the pathological formation, which makes it possible to exclude the development of relapses.

The introduction of a catheter filled with a dye - brilliant green into the cavity of the fistula ensures its visualization, the incision is made exactly along the course of the fistula, which reduces the likelihood of damage to its walls, facilitates further separation and removal, and minimizes trauma to the skin in the region of the back of the nose. This technique, together with the formation of the back of the nose by mobilization and further reduction of the nasal bones, previously divorced by a pathological formation, provides a good cosmetic result of the operation.

Brief description of explanatory materials

Rice. 1 - Introduction of a guide catheter into the fistulous opening.

Rice. 2 - Elliptical incision of the skin and subcutaneous tissue along the midline along the "guide".

Rice. 3 - Separation of the fistula along its entire length.

Rice. 4 - Stages of the operation: a - excision of the fistulous tract; b - control examination of the nasal cavity using endoscopic technique.

Rice. 5 - Type of patient: a - during exacerbation; b - before the operation; c - before discharge.

Rice. 6 - for Example 1: MRI data of the brain before surgery: a - in the coronal projection; b - in the sagittal projection; c - in the axial projection (the formation is indicated by an arrow).

Rice. 7 - MRI diagnostics before surgical treatment: a - sagittal view, b - coronal view, c - axial view.

Rice. 8 - Stages of surgical treatment.

Rice. 9 - View of the child: a - after surgery (drainage removal), b - before discharge, c - 1 month after surgery.

Rice. 10 - for Example No. 3: Stages of the operation: a - the process of highlighting education; b - view of the resulting cavity after removal of the neoplasm; c - view of the child after suturing the wound and installing a drain.

Implementation of the invention

Before surgical treatment, all patients underwent computed tomography of the nose and paranasal sinuses, and if intracranial spread was suspected, MRI of the brain was performed.

Under intubation anesthesia and infiltration anesthesia using Ultracaine, a catheter for the subclavian artery ("guide") (for example, Sintez OAO, 1 mm in diameter) filled with 1% brilliant green solution was inserted into the fistula opening (Fig. 1). Then, an elliptical incision of the skin and subcutaneous fat was performed around the fistulous opening, which continued along the midline along the "guide" (Fig. 2) until a pathological formation. Thanks to the introduction of such a "guide" catheter, the fistulous tract is well visualized during the operation, which makes it possible not to damage the wall of the fistulous tract when separating the skin and subcutaneous fat along the fistulous tract. After that, the fistulous tract was separated along its entire length up to its formation, trying not to damage its integrity (Fig. 3). At the second stage, an incision was made along the transitional fold in the region of the columella and the floor of the nasal cavity of the nasal vestibule on the left, then the remains of the mucoperichondria and mucoperioste of the nasal septum were separated with a rasp, thereby providing a better visualization of the area where nasal heterotopias were located. After complete excision of the formation under the control of endoscopic technique, a control examination of the nasal cavity was performed up to the posterior wall of the frontal sinus in order to revise the remnants of a dermoid cyst or other pathological formation to prevent recurrence (Fig. 4).

The third step is the reconstruction of the dorsum of the nose by mobilizing and bringing the nasal bones together using a suture material such as Vicryl 4.0. After fixation of the bones, layer-by-layer stitching of the wound is carried out with the installation of drainage in the area of the remote formation of the cavity that has arisen and endonasally through a pre-prepared counter-opening. The contraperture is created after complete excision of the formation under the control of endoscopic technique, thus providing communication with the nasal cavity by dissecting the mucoperichondria at the junction of the cartilaginous part of the nasal septum into the bone one with the installation of one drain in the area of the remote formation with the output to the outer surface of the nose in the area of the excised outlet fistulous passage and the second drainage, endonasally removed through the prepared contra-opening.

After stitching the mucous membrane in the area of the vestibule of the nose to fix the nasal septum, latex tampons lubricated with antibacterial ointment are placed in the nasal cavity. The tampons are removed one day after the operation. Latex drains are removed in the absence of discharge also on the first day after the operation, if it is present, on the 2nd-3rd day after the operation. An aseptic dressing was applied to the postoperative area for 5 days. The sutures were removed on the 5th-7th day after the operation.

The invention is illustrated by the following examples.

Clinical case #1

Patient I., 6 years old, was hospitalized in the pediatric otorhinolaryngology department from 03/10/2020 to 03/20/2020.

Clinical diagnosis: Congenital malformation of the nose (congenital fistula of the back of the nose and dermoid cyst of the back of the nose).

Complaints at admission: periodic discharge of mucopurulent or cheesy nature from the hole on the back of the nose, frequent abscess formation in the back of the nose.

Anamnesis: for the first time, attention was paid to a punctate formation on the back of the nose from birth, from which a discharge of a mucopurulent nature periodically appeared, no abscesses were observed until 2019. After suffering a nose injury in kindergarten in August 2019, abscesses of the back of the nose began to appear every month with a rise in high temperature (Fig. 5a). In August, reposition of the nasal bones and opening of the abscess of the back of the nose were performed at the place of residence in August. Periodically, a cheesy discharge is noted from the fistula of the back of the nose. Conservative treatment without effect. Performed CT of the nose and SNP and MRI of the brain. According to the CT scan of the nose and SNP dated November 8, 2019, no organic pathology from the brain was detected. Conclusion of MRI of the brain dated November 12, 2019: Additional education in the area of the cockscomb. No focal lesions of the brain substance (GM) were detected (Fig. 6). Consulted by a neurosurgeon at the Research Institute of Neurosurgery. N.N. Burdenko: According to the CT and MRI data, there is a suspicion of destruction and a cystic cavity in the upper parts of the nasal cavity. Focal pathology was not revealed. Consulted in 2019 at the polyclinic of the Federal State Budgetary Institution NCCO FMBA of Russia, the diagnosis was made: Congenital fistula of the back of the nose (Fig. 5b). Surgical treatment is recommended.

Allergological history: not burdened.

Past diseases: ARVI, chickenpox - 2017, otitis media.

Injuries: Nose injury in August 2019

Operations: 08/19/2019 - reposition of the nasal bones, 2020 - surgery for inguinal hernia.

Status praesens at admission: Satisfactory condition. The skin and visible mucous membranes are clean, pale. On palpation, the peripheral lymph nodes were not enlarged. Breathing in the lungs is vesicular, carried out in both lungs, there are no wheezing. RR 21 per minute. Heart sounds are clear, loud, rhythmic. Heart rate 80 per minute. Pulse of satisfactory qualities. BP 110/65 mm Hg The abdomen is soft, accessible to palpation in all departments. The liver is palpated at the costal margin, does not protrude. There was no local pain on palpation. On the part of the genitourinary system, no pathology was detected. There are no dysuric disorders. The symptom of tapping is negative. Urination free, painless. From the side of the nervous system, no pathology was detected. Consciousness is clear. There are no meningeal symptoms. ENT status:

Nose: the shape of the external nose is not changed (a fistulous opening with a diameter of 1-1.5 mm and a scar on the bridge of the nose are determined on the back of the nose). At rhinoscopy: the nasal mucosa is pale pink. Scanty mucous discharge in nasal passages. The inferior turbinates are moderately edematous and shrink. Their mucous membrane is pale pink. Septum without significant deformations. The area of the paranasal sinuses (PN) is not changed, percussion and palpation of the projection of the PN is painless. Nasal breathing is moderately difficult.

Oropharynx: oral mucosa is not changed. The language is clean. Palatolingual and palatopharyngeal arches are changed, normal color, without infiltration. Zev is symmetrical. Tonsils of the I degree, their mucous is not changed. There is no pathological discharge in the lacunae. There are no raids. The back wall of the pharynx is pink, moist.

Ears: AS -AD - the auricle is not changed. The area of the mastoid process is not changed. Percussion and palpation are painless. The ear canal is wide on otoscopy. There is no pathological discharge in the lumen of the passage.

Otomicroscopy: The tympanic membrane is translucent, does not bulge. The light reflex is shortened. Identification contours are shortened.

Survey carried out:

1. General clinical blood test on March 9, 2020 - within the age norm.

2. Biochemical blood test March 7, 2020 - within the age norm.

3. General clinical analysis of urine on March 7, 2020 - within the age norm.

4. Coagulogram "7" March 2020 - within the age norm.

Treatment: an operation was performed on March 12, 2020 - excision of the fistula and dermoid cyst of the back of the nose with a combined approach under the control of video endoscopic technology.

Under intubation anesthesia and infiltration anesthesia of Ultracaine, a catheter for the subclavian artery ("guide"), stained with 1% brilliant green solution, was inserted into the fistula opening to determine the course of the fistula. Then, an elliptical incision was made around the fistulous opening, which continued vertically along the midline along the "guide". The next step was the separation of the fistulous tract along its entire length until the very formation. At the second stage, an incision was made along the transitional fold in the region of the columella and the floor of the nasal cavity of the vestibule region on the left, then the remains of the mucoperichondria and mucoperioste were separated with a rasp, thereby providing a better visualization of the area where nasal heterotopias were located. After complete excision of the formation under the control of endoscopic techniques at 0° and 30°, we perform a follow-up examination in order to identify the remnants of the cyst membranes to prevent recurrence.

The third stage is the reconstruction of the nasal bones by bringing them together using Vicryl 4.0 suture material. After fixing the sutures, layer-by-layer stitching of the wound is carried out with the installation of drainage in the area of the remote formation of the cavity that has arisen and endonasally through a pre-prepared counter-opening.

After suturing the mucous membrane in the area of the vestibule of the nose, latex tampons lubricated with Levomekol ointment were installed in the nasal cavity to fix the nasal septum.

On the following day after the operation, the toilet of the nasal cavity was carried out daily, endoscopic monitoring, the patient received antibiotic therapy. The sutures were removed in stages on the 5th - 7th day after the operation.

The postoperative period was uneventful, without complications. The toilet of the nasal cavity was performed daily.

As a result of the treatment, the child is discharged with recovery (Fig. 5c).

At discharge: satisfactory condition. There are no complaints. Body temperature 36.5°C. Consciousness is clear. There are no meningeal symptoms. On the internal organs without negative dynamics. Peripheral lymph nodes are not enlarged.

Nose: Nasal breathing is free. There are no signs of inflammation of the postoperative wound on the back of the nose, there is no diastasis of the edges of the wound. At rhinoscopy: the mucous membrane is pasty, pink, there is no pathological discharge in the nasal passages.

For the rest of the ENT organs without negative dynamics.

The outcome of the disease with recovery. During the subsequent follow-up observation for 3 years, it was noted that the back of the nose did not deform with age and corresponds to the age-related anatomical parameters of the child's nose, no relapses of pathological formations were observed.

Clinical case #2

Patient P., 4 years old, was hospitalized in the Scientific and Clinical Department of Pediatric Otorhinolaryngology from 02/08/2021 to 02/18/2021.

Clinical diagnosis: Congenital malformation of the nose (congenital fistula of the back of the nose and dermoid cyst of the back of the nose).

Complaints at admission: periodic discharge of mucopurulent or cheesy nature from the hole on the back of the nose, frequent abscess formation in the back of the nose.

Anamnesis: education in the area of the back of the nose was noticed in September 2020. He was in the Regional Children's Hospital at the place of residence from 01.02.2021 to 05.02.2021, where he was diagnosed with Abscess of the back of the nose. Performing an opening of the abscess of the back of the nose. After surgical treatment, periodic purulent discharge from the postoperative wound was noted. Then conservative treatment was carried out on an outpatient basis, without a pronounced positive effect. A CT scan of the nose and SNP and MRI were performed on December 29, 2020, which revealed a defect in the bones of the back of the nose, the development of osteomyelitis is not excluded (Fig. 7). The extract was sent for a correspondence consultation to the Federal State Budgetary Institution NMICCO FMBA of Russia. The child was recommended to be hospitalized at the Federal State Budgetary Institution National Medical Research Center for further surgical treatment (removal of the dorsum of the nose).

Status praesens at admission: Satisfactory condition. The skin and visible mucous membranes are clean, of normal color. On palpation, the peripheral lymph nodes were not enlarged. Breathing in the lungs is vesicular, carried out in both lungs, there are no wheezing. RR 23 per minute. Heart sounds are clear, loud, rhythmic. Heart rate 95 per minute. Pulse of satisfactory qualities. BP 100 / 60 mmHg The abdomen is soft, accessible to palpation in all departments. The liver is palpated at the costal margin, does not protrude. There was no local pain on palpation. The chair is normal, regular. On the part of the genitourinary system, no pathology was detected. There are no dysuric disorders. The symptom of tapping is negative. Urination free, painless. From the side of the nervous system, no pathology was detected. Consciousness is clear. There are no meningeal symptoms.

ENT status:

Nose: the shape of the external nose was changed due to the formation of 0.5 × 0.3 cm in the region of the back of the nose on the right, there was no discharge from the fistulous opening at the time of examination. The mucous membrane of the nasal cavity is pale pink. Nasal breathing is difficult. There is no pathological discharge in the nasal passages. The lower and middle nasals are enlarged, with anemia they are poorly reduced. Mucous cyanotic. The nasal septum is displaced to the right due to the crest and dislocation of the quadrangular cartilage. The area of the paranasal sinuses is not changed, percussion and palpation of the projection of the RPN is painless.

Oropharynx: the oral mucosa is pink, clean, moist. Palatine tonsils I-II degree. Anterior and posterior palatine arches pink, clean. There are no raids. The mucous membrane of the posterior wall of the pharynx is clean, pink, moist.

Ears: AS -AD - the auricle is not changed. The area of the mastoid process is not changed. Percussion and palpation are painless. The ear canal is wide on otoscopy. There is no pathological discharge in the lumen of the passage.

Otomicroscopy: Mt AD-pale gray, retracted. Identification marks are contoured.

Mt AS - pale gray, retracted. Identification marks are contoured.

Treatment: an operation was performed on February 10, 2021 - excision of the fistula and dermoid cyst of the back of the nose with a combined approach under the control of video endoscopic technology (Fig. 8).

At discharge: satisfactory condition. There are no complaints. Body temperature 36.6°C. Consciousness is clear. There are no meningeal symptoms. On the internal organs without negative dynamics. Peripheral lymph nodes are not enlarged.

Nose: Nasal breathing is free. There are no signs of inflammation of the postoperative wound on the back of the nose, there is no diastasis of the wound edges (Fig. 9). At rhinoscopy: the mucous membrane is pasty, pink, there is no pathological discharge in the nasal passages.

For the rest of the ENT - organs without negative dynamics.

The outcome of the disease with recovery. During the subsequent follow-up observation for 1 year, it was noted that the back of the nose did not deform with age and corresponds to the age-related anatomical parameters of the child's nose; no recurrences of pathological formations were observed.

Clinical case #3

Patient S., 10 months old, was hospitalized in the pediatric otorhinolaryngology department from 01/24/2017 to 02/03/2017.

Clinical diagnosis: Benign neoplasm of the back of the nose and nasal cavity (glioma).

Complaints at admission: deformity of the external nose. Anamnesis: according to the parents, the child had a deformity of the external nose from birth, the diagnosis was made in the maternity hospital: Closed fracture of the bones of the nose with displacement. On April 12, 2016, the nasal bones were repositioned. The shape of the nose and the external defect did not change. Performed CT and MRI - revealed a neoplasm of the nose in the area of the back of the nose. CT scan of the paranasal sinuses dated 11/16/2016: CT volumetric formation of cartilaginous density of the back of the nose with splitting of the nasal bones emerging from the cartilaginous part of the nasal septum with filling of the gratings on the left. He was consulted at the Federal State Budgetary Institution NKCO, hospitalization was recommended for examination and surgical treatment (removal of a neoplasm of the back of the nose).

Condition upon admission is satisfactory. Body temperature 36.7°C. The shape of the external nose is changed due to a rounded moderately mobile bulge in the area of the back of the nose, the skin over the formation is not changed. Breathing through the nose is not difficult. The nasal passages are wide and free. Oropharynx: In the oropharynx, the hard palate bulges in the projection area of the right maxillary sinus, the mucous membrane of the vestibule and oral cavity is pink, clean. Palatine tonsils of the 1st degree, without overlaps and pathological contents in the lacunae. The pharynx is symmetrical, the palate is movable. The back wall of the pharynx is pink, clean. Ears: AD et AS behind the ear and preauricular areas are not changed, painless. The external auditory canals are wide and free. Otomicroscopy: AD and AS Mt gray.

Treatment: an operation was performed on January 25, 2017 - removal of a neoplasm of the back of the nose by a combined approach under the control of video endoscopic technology (Fig. 10).

At discharge: satisfactory condition. There are no complaints. Body temperature 36.6°C. Consciousness is clear. There are no meningeal symptoms. On the internal organs without negative dynamics. Peripheral lymph nodes are not enlarged.

Nose: Nasal breathing is free. There are no signs of inflammation of the postoperative wound on the back of the nose, there is no diastasis of the edges of the wound. At rhinoscopy: the mucous membrane is pasty, pink, there is no pathological discharge in the nasal passages.

For the rest of the ENT organs without negative dynamics.

The outcome of the disease with recovery.

During the subsequent follow-up observation for 2 years, it was noted that the back of the nose was not deformed with age, it corresponded to the age-related anatomical parameters of the child's nose, and no recurrence of the neoplasm was detected.

Over a 5-year period (2016-2021), 12 children aged 10 months to 13 years (6 boys and 6 girls) with congenital nasal heterotopia were examined and operated on, namely: dermoid cyst, glioma, encephalocele, meningoencephalocele. During the subsequent follow-up observation from 1 to 3 years, it was noted that the back of the nose does not deform with age and corresponds to the age-related anatomical parameters of the child's nose, no relapses of pathological formations were observed.

Claims (1)

A method for reconstructing the back of the nose in congenital malformations of the nose in children, which consists in the fact that under intubation anesthesia and infiltration anesthesia, a catheter filled with a brilliant green solution is inserted into the fistulous tract to the pathological formation located in the area of the back of the nose to visualize the fistulous tract, then around the fistulous opening, an elliptical incision of the skin and subcutaneous fat is performed, the incision of the skin and subcutaneous fat is continued along the fistulous tract, visualized by means of the inserted catheter, after which the walls of the fistulous tract and the formation capsule are separated from the surrounding tissues throughout, without damaging the integrity of their walls, then in the region of the columella and the bottom of the nasal cavity on the left, an incision is made along the transitional fold and the mucoperiosteum and mucoperioste of the nasal septum are separated with a raspator throughout, providing endonasal access to the formation, through which the capsule of the formation is also separated from the surrounding tissues without damaging it , after complete separation, the fistulous tract and formation are completely excised, under the control of endoscopic technique, a control examination of the nasal cavity is performed up to the posterior wall of the frontal sinus in order to revise the remnants of the pathological formation, after which the bridge of the nose is reconstructed by mobilizing the nasal bones, bringing them together and fixing using suture material, after fixing the bones, layer-by-layer suturing of the wound from the outside is carried out with the installation of a drain with output to the outer surface of the nose in the area of the excised outlet of the fistulous tract and a second drain with output into the nasal cavity through the counter-opening formed by dissecting the mucoperichondria at the junction of the cartilaginous section of the nasal septum into the bone, then the mucous membrane is sutured in the area of the vestibule of the nose, latex tampons lubricated with antibacterial ointment are placed in the nasal cavity.

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