Chronic maxillary sinusitis (rhinosinusitis)
Chronic maxillary sinusitis is often associated with ethmoiditis, that causes the symptoms of the disease. The morphological changes in chronic maxillary sinusitis manifested by swelling and infiltration of the nasal mucosa, its parietal thickening.
Among the causes of chronic maxillary sinusitis attach importance to infections, allergies, adenoid growths, hereditary factors, unfavorable anatomic relationships in the nasal cavity, worsening conditions of natural ventilation and drainage of the sinuses, immunodeficiency states and lower body resistance, cooling factor, disturbances of the endocrine system function. In the formation of chronic maxillary sinusitis play the role of a frequent rhinitis, deviated septum, the magnitude of the sinuses (large sinuses more susceptible to the disease), co-morbidities.
Infection of the paranasal sinuses can be performed through natural openings in the nasal cavity, through the bloodstream (for example, infections), at least from your teeth, by contact, with the purulent leaking from the other paranasal sinuses (ethmoid sinus, frontal sinus).
Symptoms of chronic maxillary sinusitis (rhinosinusitis)
In the case of chronic maxillary sinusitis appear difficulty in nasal breathing, feeling of pressure in the paranasal sinuses, sometimes pain along the trigeminal nerve in almost the entire half of the face and teeth area. In chronic maxillary sinusitis nasal discharge, mucus or purulent, running down the back of the throat. These signs of chronic inflammation of the paranasal sinuses are usually expressed slightly. For chronic maxillary sinusitis is characterized by redness and swelling of the mucous membranes, occurrence of secretions in the middle nasal passage.
Chronic maxillary sinusitis is diagnosed on the basis of integrated clinical, otorhinolaryngological and, if necessary, allergological study.
Puncture of the maxillary sinus to produce both diagnostic and therapeutic purposes. Puncture of the maxillary sinus occurs through the lower nasal passage using a conventional needle. Technically, sinus puncture is simple. Pre-puncture of the maxillary sinus do total blood count, including determination of platelet count, blood clotting and bleeding duration. Anesthesia performed by lubricating of the nasal cavity with 2% solution of novocaine.
The volume of the maxillary sinus and bone thickness of the walls depend on the age of the child: the smaller it is, the higher is the maxillary sinus and the thicker its medial wall.
Recently puncture maxillary sinus practically perform for children of any age, but at an early age - for more strict indications.
Puncture method makes it possible not only mechanical removal of pathological content of the maxillary sinus, but also the impact on the microbial flora by drugs introduced through a needle, which usually improves the trophism of of the paranasal sinuses mucosa.
In puncture of the maxillary sinus, as complications can occur collapseб facial subcutaneous emphysema, bleeding, cheek abscess, septic condition, central retinal artery occlusion (CRAO) with the advent of blindness.
Among chronic sinusitis in children are often marked chronic catarrh, characterized by mild symptoms: small general reaction of the organism, catarrhal symptoms in the nasal cavity and sinuses. In chronic purulent inflammation the pus in the outlet of the sinuses openings can be detected with a micro-rhinoscopy, when in normal rhinoscopy it is not visible.
Among the chronic forms of serous inflammation of the paranasal sinuses distinguish idiopathic, retention, vasomotor and allergic, which differ in the etiology and genesis. Idiopathic form of inflammation of the maxillary sinuses is characterized by transsoudace of fluid, flowing after accumulation through the natural opening from the maxillary sinus. Retention form of inflammation — due to blockage of the excretory openings of the sinuses, it is characterized by the accumulation of a pale yellow color fluid in the sinus. In the serous form of inflammation the contents of the sinus has a light yellow color (as in the cyst — amber), on the surface of the wash liquid is no cholesterol crystals.
Substantial assistance in the diagnosis of inflammation of the maxillary sinuses provide x-ray images and paranasal sinuses computed tomography (CT).
Treatment of chronic maxillary sinusitis (rhinosinusitis)
It is important that therapy of chronic maxillary sinusitis (rhinosinusitis) from the beginning was comprehensive and, if necessary, extended. Use a variety of methods and tools in their rational combination or sequence. General measures of effects on the body combine with local treatment, considering in each case the form of the disease.
The main purpose of local treatment of chronic maxillary sinusitis (rhinosinusitis) is to ensure free outflow of the contents from the sinuses. If necessary, apply surgical measures (removal of polypose-changed the front ends of the turbinates, resection of the nasal septum, etc.). For better evacuation of the maxillary sinus from the contents, including after anemizatsii of the middle nasal passage, the baby's head is tilted forward and downward (especially in young children, even those who can not blow their noses). In case of swollen mucosa of the sinuses excretory openings region to facilitate the outflow of the contents produced middle nasal passages anemisation by 0.1% adrenaline solution. For mechanical cleaning of the nose of thick mucus, pus and dried crusts, the nasal cavity is irrigated by alkaline or saline solution via spray or a rubber balloon, but it can cause otitis media, with the consequence that the method has limited application.
If chronic maxillary sinusitis (rhinosinusitis) occurs on an allergic background, spend hyposensitization therapy (diphenhydramine, promethazin hydrochloride, suprastin, chloropyramine hydrochloride, etc.). Diphenhydramine is desirable to use at night, as it has a slight sedative effect. Prescribe vitamins, especially in winter and spring. The nose is injected 1% solution of diphenhydramine with silver proteinate 1–2% solution, 0.5% prednisolone solution. In the case of nasal crusts formation and heavy mucus it is advisable to lubricate the entrance to the nose indifferent ointment. In fungal infections of sinuses do washing with solutions of sodium salt of nystatin or levorin in a concentration of 5mg/ml (10 000 IU/ml), an aqueous solution of gentian violet (0.1% and 0.01%) and a solution of chinosol (0,01%), are conducting a joint therapy with antifungal drugs and antibiotics (nystatin, levorinum in combination with sulfonamides, such as aethazolum). In the case of combined pathology (purulent process in the lungs, bronchitis) is carried out appropriate treatment.
Maxillary sinus probing
Maxillary sinus probing restores patency and improves the outflow of its contents. It is carried out when the child is sitting, it is desirable that the doctor was located a bit below. The probe is introduced into the middle nasal meatus to the posterocephalic part of the lunate fissure, where the maxillary sinus hole located. All the movements of the probe produced gently, without effort, trying to bypass occuring obstacles. In the case of the occurrence of bleeding, the probing stopped because of disturbed orientation. Proposed sinus irrigation through the natural opening by the probe.
Difficulties in probing of maxillary sinus occur in the case of a snug fit of the middle turbinate to the lateral wall of the nose. In hypertrophy of the middle and lower turbinates perform their partial resection. If a deviated nasal septum, particularly in the area of the middle nasal passage, making it probing difficult, polypotomy undertake if presence of polyps in the nose and in the natural openings of the sinuses. In the event of failure of maxillary sinus probing produces surgical intervention.
Surgical treatment of maxillary chronic sinus inflammation with strictly defined indications and correctly chosen method leads to a significant reduction in the duration of the disease, preventing the serious consequences and complications. The goal of surgery is to create a broad resistant drainage and providing conditions for good content outflow from the paranasal sinuses. This not only helps to eliminate secretions, constantly irritating the nasal mucosa, but also improves blood circulation, trophism, ventilation, aeration, creating conditions for the elimination of the inflammatory process in the maxillary sinus cavity.
Complications after radical surgery, along with edema, are inflammatory infiltration of the soft tissues of the face, cheeks abscess (due to infection penetration in the soft tissue after their detachment by rasp), and others. Therefore, in recent years in pediatric practice the attitude of radical intervention on the maxillary sinus has become more restrained (especially in sorganism ensitization). Today, preference is given to sparing endonasal method having several advantages over extra-nasal. During surgery on the maxillary sinus maximum spared unaltered sinuses and nasal cavity mucous membrane, nasal cavities architectonics and teeth.
Before radical surgery on the maxillary (maxillary) sinus some children designate diazepam , sometimes neuroleptanalgesia (droperidol, fentanyl). With the goal of anesthesia the mucosa of the nasal cavity is lubricated with a solution of cocaine or tetracaine, then introduce 0.5–1% solution of novocaine under upper lip. In particularly restless children the operation is performed under general anesthesia. After anesthesia under the upper lip just above the mouth vestibule transitional fold, make a horizontal incision of the mucous membrane and periosteum, from the frenulum of the upper lip and ending at the level of the 2nd large molar tooth. Soft tissue is peeled together with the periosteum up to canine fossa. Then resected part of the maxillary sinus front wall and remove its pathological contents, then part of the nasal or medial wall in the region of the lower nasal passage, forming a fistula wide enough amonge the sinus and nasal cavity. Remove only the changed mucosa, fully preserving unaltered. Maxillary sinus after surgery usually do not swabbed (except bleeding), in an effort to prevent postoperative complications. The cotton swab is introduced only in the anastomosis, pre-soaked with synthomycin emulsion, and the next day removed.
Endonasal maxillary sinus dissection
Endonasal maxillary sinus dissection is performed under general or local anesthesia by lubricating the nasal mucosa in the area of intervention by 3% solution of cocaine. In some cases, it is advisable to topical administration of 0.25–0.5% solution of novocaine (in the front and middle of its departments to the medial and lateral sides toward the base — the place of its attachment).
Methods of maxillary sinus dissection through the middle or the lower nasal passage is technically a little differ, but the latter approach is preferable. Hypertrophied turbinates partially resected. However, bleeding interfere with further work, so sometimes the inferior turbinate is breaking only at the base and lifted up, and at the end of the operation put in place. It is most convenient for this purpose to use a Killian nasal speculum. After anesthesia lower lip of Killian nasal speculum mounted flat on the bottom of the nasal cavity, and the top is pressed against the lower division of the inferior turbinate, and then pushing the sponge and thus raise the inferior turbinate, which provides access to the medial wall of the maxillary sinus.
Maxillary sinus is opened with the help of various tools (a sharp spoon, fluted probe, trocar), usually in a place where they make it a puncture — almost at the middle part of the inferior turbinate or retreat from the front end of the inferior turbinate to 2 cm (at the thinnest part of the bone)..
The older children maxillary sinus can be opened with a special tool — trocar-punch. After the enlargement of the hole in the bone with a sharp spoon or the chisel (always at front) level threshold in the area of the former medial wall of the sinus and form a broad anastomosis. All pathological contents are removed from the sinuses. To reduce the reactive tissue edema after surgery, the sinus are not swabbed, a cotton swab is introduced only in the formed anastomosis for 1 day, after which it is removed and sinus repeatedly washed. For surgery on both maxillary sinuses their endonasal dissection carried out simultaneously.
In some cases (for example, periostitis) operation is carried out by a pear-shaped ridge. The mucous membrane and the periosteum was cut in front of the nasal cavity from the anterior end of the inferior turbinate under pyriform aperture edge. Rasp peeled soft tissue, push them, exposing the lower edge of the piriform aperture. Sinus is opened by the removal of bones, freed it from the pathological content. Hole, formed through the anteromedial corner, is not very different from that of extranasal approach.
Endoscopic maxillary sinus opening is twofold: to perform the operation more closely and examine the sinus, edge junction, outlet port of nasolacrimal canal. Under the control of an operating microscope sprained inferior turbinate using the Killian nasal speculum, resected wall of the nasal passage to the extent necessary and free of sinus from a pathological content. If the damage was extensive, heavy, and it is suspected that the pathological content is not completely removed or there is necrotic changes in the bone, the sinus may be opened and through canine fossa, since both access completely compatible and not opposed to each other.
However, in children it is irrational to produce extra-nasal opening of the sinus, because of possible violations of the sensitivity of the teeth, stretching the lower orbital nerve, the appearance of a pronounced swelling of the cheeks, etc., Instead of repeated puncture of the maxillary sinus it is advisable to use permanent sutures (most of alloplastic materials). Drainage tube (shunt) is administered to children of any age and adults through a needle, sometimes under the control of surgical optics under local or General anesthesia. Through them systematically carry out lavage of the sinuses, injected solutions of antibiotics. The shunt is introduced into the maxillary sinus beneath the lower turbinate for better fixation — point to the bottom of the sinus.
Method of treatment with shunts is more gentle than other surgical methods. With good fixation of spontaneous discharge of the shunt is not observed, existing shunts cutting ensures their retention in the lower part of the lateral wall of the nose after screwing. The introduction of a shunt is greatly simplified when using the operating microscope. In children of early age it is better to use the tube of PTFE-4, polyethylene. Tubes and shunts are located in the maxillary sinus up to 10 days (before recovery). It is convenient to introduce the tube into the sinus via the fluted probe or with him under the control of surgical optics.