Home Coated tongue What kind of surgery is there when the sinuses are large? Surgery on the maxillary sinus

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What kind of surgery is there when the sinuses are large? Surgery on the maxillary sinus

Operation on maxillary sinus(sinusrotomy) - rhino surgical intervention carried out for the purpose of sanitation, elimination of pathological contents and foreign bodies from the maxillary sinuses. In addition to eliminating the inflammatory process, this operation is aimed at restoring full nasal breathing. With a successful maxillary sinusotomy, full recovery drainage function anastomosis of the maxillary sinus.

Kinds

Exist various ways surgical intervention on the maxillary sinus:

classic Caldwell-Luc operation (performed through an incision under the upper lip);
endoscopic maxillary sinusotomy (performed via endonasal access, without incisions);
minor surgical procedures (puncture of the maxillary sinus and its alternative - balloon sinuplasty using the YAMIK sinus catheter).

Indications

Factors and diseases that are direct indications for surgery:

no effect from conservative methods treatment of chronic sinusitis;
maxillary sinus cysts (formations in the form of bubbles filled with liquid);
the presence of polyps inside the sinus;
presence of neoplasms (if suspected malignant tumor a biopsy is performed);
foreign bodies of the maxillary sinus, which are a complication of dental interventions (fragments of tooth roots, particles of dental implants, particles of filling material);
the presence of blood clots and granulations in the cavity;
damage to the walls of the maxillary sinus.

Most common cause The reason for which surgery on the maxillary sinuses is prescribed is sinusitis - inflammation of the mucous membrane of the maxillary sinus, as a result of which there is an accumulation of purulent exudate and the formation of hyperplastic changes in the mucous membrane.

Main symptoms

nasal congestion;
mucopurulent discharge;
increased body temperature;
symptoms of general intoxication of the body (weakness, drowsiness, malaise, headache);
pain in the projection of the maxillary sinuses.

Preoperative preparation

Preparation for surgery on the maxillary sinuses includes a number of instrumental and laboratory research. Before surgery you will need:

computed tomography or radiography paranasal sinuses nose;
rhinoscopy;
general blood test (including leukocyte formula and platelet count);
study of hemostatic function of the blood - coagulogram;
general urine analysis;
analysis for the presence of HIV, syphilis, markers of viral hepatitis;
determination of blood group and Rh factor.

If an operation is planned under general anesthesia, it is additionally necessary to do an electrocardiogram and consult with an anesthesiologist. It is very important to strictly follow the instructions given by this doctor, since their violation entails serious consequences.

Contraindications to maxillary sinusotomy:

the presence of serious somatic pathology;
bleeding disorders ( hemorrhagic diathesis, hemoblastosis);
acute infectious diseases;
exacerbation of chronic diseases;
acute sinusitis (relative contraindication).

How is the operation performed?

Minor operations: puncture and its alternative - balloon sinuplasty

The simplest surgical intervention on the maxillary sinus is a puncture (puncture), which is performed through the wall of the nasal passage with diagnostic or therapeutic purpose. A more progressive method of restoring drainage of the maxillary sinus is balloon sinuplasty using a YAMIK catheter. The essence of this method is the atraumatic expansion of anastomoses by introducing and inflating a flexible catheter. Next, a vacuum is created in the sinus cavity, this makes it possible effective removal accumulated purulent exudate. The next step after cleansing is the introduction of a solution into the sinus cavity medicines. This manipulation is carried out under video control endoscopic equipment, but can be performed without it, which makes it accessible to most patients. The undeniable advantages of this method are:

painlessness;
no bleeding;
maintaining the integrity of anatomical structures;
minimal risk of complications;
no need for hospital stay.

Endoscopic maxillary sinusotomy

This surgical intervention is performed through endonasal access, without violating the integrity of the wall of the maxillary sinus. Modern endoscopic technology allows highly effective rhinosurgical procedures. Thanks to the use of long-focus microscopes and high-quality fiber optic technology, high-quality visualization is achieved surgical field, which minimizes the risk of injury to healthy tissue.

The procedure for cleansing the sinuses is carried out using modern rhinosurgical equipment: a coagulator (performing the function of cauterizing tissues and blood vessels), a shaver (a tissue grinder with the function of instant suction), forceps and other surgical instruments. Next comes rinsing. antiseptic solutions with addition antibacterial drugs wide range action, proteolytic enzymes and corticosteroid hormones (in case of severe edema).

Classic surgical method

The classic Caldwell-Luc procedure is performed via an intraoral approach. Most often, this method uses general anesthesia.

Main stages:

Creation of access to the maxillary paranasal sinus by excision of soft tissue.
Sanitation of the pathological focus (removal of polyps, granulations, sequestration, foreign bodies).
Collection of material for histological examination.
Formation of a complete communication between the maxillary sinus and the lower nasal passage.
Installation of a drainage catheter for irrigation of the cavity with medicinal solutions.

Complications of radical maxillary sinusotomy:

the possibility of developing intense bleeding;
trigeminal nerve damage;
fistula formation;
pronounced swelling of the nasal mucosa;
loss of sensitivity of the dentition and cheekbones due to surgical intervention;
decreased sense of smell;
sensations of heaviness and pain in the maxillary sinuses.

With minimally invasive interventions (endoscopic maxillary sinusotomy, puncture and balloon sinuplasty, complications occur quite rarely.

Postoperative period

There are a number of measures to reduce the risk of relapse of the disease and the occurrence of various complications:

irrigation of the nasal cavity with water-salt solutions;
desensitizing therapy (taking antihistamines);
local use of topical corticosteroids;
antibacterial therapy;
taking medications that strengthen the walls of blood vessels.

Typically, the period postoperative rehabilitation lasts about one month. It is not advisable at this time

eating hot, cold, spicy foods;
do heavy physical work(especially associated with heavy lifting);
visiting baths and saunas, swimming in the pool.

You should also avoid hypothermia and contact with ARVI patients. Good ending rehabilitation period will sanatorium treatment on seaside resort or visit salt cave. Within a year after surgery, you should be observed by an otolaryngologist.

Maxillary sinusotomy– This is the most common endoscopic ENT surgery and is effective for chronic sinusitis, cysts, antrochoanal polyps, fungal and foreign bodies of the maxillary sinus. A maxillary sinus is performed through the natural opening of the maxillary sinus in the nasal cavity: first it is widened by several millimeters, and then the sinus is examined with an endoscope. The pathological contents from the sinus are removed, and the mucous membrane remains intact.

Maxillary ethmoidotomy – this operation is larger in volume than a maxillary sinus because it affects the neighboring sinuses - the cells of the ethmoid labyrinth. Maxillary ethmoidotomy is necessary for chronic purulent and polypous sinusitis.

Polysinusotomy – This is an extensive endoscopic operation in which several or all paranasal sinuses are operated simultaneously on both sides: the maxillary sinuses, the frontal and sphenoid sinuses, and the ethmoid labyrinth. Endoscopic polysinusotomy is most often performed for polypous rhinosinusitis.

To treat such ailments, surgery on the maxillary sinus is often prescribed. Despite the fact that this is an extreme measure of therapy, it is still quite common due to the specifics of the disease. Let us consider in more detail the features and consequences of such an operation.

They got their name in honor of the English anatomist surgeon Nathaniel Gaymora, who studied the pathologies of the paranasal sinuses. It was he who first described the disease, which was later called sinusitis.

The sinuses in question, as mentioned earlier, are the largest and occupy almost the entire cavity upper jaw . Each person has individual indicators of their shape and volume. They depend on anatomical features structure of the skull.

The structure of the paranasal sinuses

The paranasal sinuses are connected to the nasal cavity using a narrow channel - anastomosis. The sinuses are covered with a mucous membrane, which ensures the removal of pathogenic microorganisms, and in a healthy state filled with air.

Reference. If the anastomosis long time clogged, this contributes to the accumulation of mucus and its thickening, after which it turns into pus. This process is fraught with inflammation of the walls of the sinuses, which leads to the development various diseases.

Consists of inner, front and back, top and bottom walls, and any violation in each of them leads to certain health complications.

The maxillary sinuses perform the following functions:

purifying the air while breathing– the air mass, before entering the lungs, is purified and heated to required temperature and increases the humidity level;
odor recognition– a feature of the surface of the sinuses is that they are able to enhance the functioning of olfactory receptors;
protective function– lies in the fact that all harmful microbes and viruses settle on the mucous membrane, which are subsequently removed from the body.

In addition, the paranasal sinus takes part during the formation of voice and timbre. It is the emptiness of the nasal sinuses that are responsible for performing resonant function.

The mucous membrane of the sinuses facilitates the rapid delivery of medications due to rapid absorption into the branched system of blood vessels located in it.

In what cases is surgery necessary?

Before prescribing an operation, the doctor analyzes all the characteristics of the disease and the need for the procedure in each case.

Without a justified need, endoscopic surgery on the maxillary sinus is not performed.

This is an extreme method of treatment that specialists in such cases have to resort to. reasons:

For chronic pathology, that is, long-term treatment of the patient is unsuccessful, while various inflammatory processes in the nose do not stop.
The presence in the maxillary sinuses of various neoplasms and growths, the removal of which occurs only mechanically.
Inflammatory processes in the maxillary sinuses are provoked by various jaw pathologies or other dental diseases.
When complications with sinusitis, for example, when there is a threat of purulent masses entering the skull, which leads to more severe consequences.

Based on the above, we can conclude that endoscopy is performed only when necessary, mainly in a situation where there is a threat of more serious health consequences.

Carrying out endoscopic surgery

Endoscopic or intranasal surgery– type of surgical intervention belonging to the group minimally invasive, since after its implementation there is no obvious tissue damage or serious violations in anatomical structure nose

Negative consequences with this type of surgical intervention develop much less frequently than with abdominal surgery. Among other things, this type of treatment is suitable for most patients because it is less expensive.

This procedure can be performed as in inpatient conditions, and in outpatient settings.

Reference. Endoscopic surgery duration is from 30 min. up to 1 hour 30 minutes. The duration depends on the anatomical features of the patient’s maxillary sinuses and the doctor’s experience.

The procedure for the surgeon to perform the operation is as follows::

An endoscope is placed in the nose(special optical device). With its help, the doctor visually monitors the progress of the operation;
a surgical instrument is inserted into the nose, with the help of which the procedure itself is performed. The choice of instruments depends on the type of disease. Typically used: laser– burning of tissues, scalpel or hangnails– removal of formations.

This operation is performed without anesthesia, as it is painless. In some cases, when the patient has a low pain threshold, the procedure is performed under local anesthesia.

Scheme of endoscopic surgery on the maxillary sinus

After endoscopic surgery, as well as after abdominal surgery, observation of the patient for several weeks. This is necessary so that the specialist can monitor the patient’s condition and remove blood clots and mucous masses in a timely manner. During this period, the patient must comply special diet necessary to increase the body’s regenerative capabilities.

Endoscopic surgery on the maxillary sinus: consequences

The consequences of refusing surgery may be much more severe than possible complications. postoperative period

After the operation, you should prepare for the fact that in the first few days breathing through your nose will be impossible, and on the first day after removing the tampons, tears will flow uncontrollably.

But such phenomena pass very quickly.

Attention! The use of nasal drops with a vasoconstrictor effect after surgery is strictly prohibited without the permission of a doctor.

Practice shows that endoscopy rarely causes any complications. However, such a factor cannot be completely excluded, since sometimes there may be the following consequences:

Bleeding from the nose. The phenomenon is not terrible and can be easily stopped by a doctor using a regular tampon.
Blood in the eyelid area. Sometimes blood gets into the eye sockets, but goes away on its own and does not cause any problems.
The occurrence of inflammation in the sinuses. If there is obvious discomfort, you should immediately inform your doctor.
Formation of crusts in the nose.
Re-formation of a purulent cyst, which leads to another operation.
Adhesion formation between the wall and septum of the nose.
Headache, in case of damage to nerves during surgery.

The above consequences are observed extremely rarely, but if this happens, then a timely contact with a specialist will help eliminate the problem.

Of course, any operation for the body is stressful, and specialists do not prescribe surgery. However, there are cases when such a procedure cannot be avoided.

In this regard, endoscopy is the most gentle method of treating various diseases of the maxillary sinuses.

Endoscopy - from the ancient Greek "looking inside" - is a magnificent modern method diagnostics based on examination of natural cavities with a special endoscope. The method is based on a fiber optic optical system, which in modern endoscopes is equipped with a miniature camera with a monitor output and a set of various surgical manipulators: wire cutters, scalpels, needles and others.

In fact, the first endoscope was designed back in 1806. The instrument was a rigid metal tube with a system of refracting mirrors, and the light source was a banal candle. Modern endoscopes are flexible tubes with extremely precise optical systems, equipped with computer software and surgical manipulators. Every year, medical equipment manufacturing companies improve endoscopic equipment, opening latest features for endoscopy. One of these relative innovations is endoscopy of the nasal sinuses, including the maxillary sinuses.

Why do endoscopy of the paranasal sinuses?

The main problem of otorhinolaryngology is that the structures of the nose, ear and paranasal sinuses are extremely narrow structures compactly hidden in the bony skeleton of the skull. It is extremely difficult to reach them using a standard set of ENT instruments. With the advent of a new generation of thinnest guides, it has become possible to penetrate the endoscope through the natural anastomosis between the nasal cavity and the sinus to examine the internal contents of the sinuses.

Examination of the nasal cavity using an endoscope

For what purposes can endoscopy be used?

First thing, endoscopic examination maxillary and other paranasal sinuses - this is a high diagnostic standard. Compared with computed tomography and especially, x-ray, the value of endoscopy is enormous. Agree, what could be better than literally looking into the affected sinus with your eye and assessing the condition of its mucous membrane and character pathological process? The doctor assesses the condition of the mucous membrane, the plethora of its vessels, the degree of edema, the presence of fluid or pus in the sinus cavity, and notices abnormal tissue growths, polyps, cysts and other “plus tissues”.
The endoscope can also be used to take samples of the mucous membrane and its discharge (pus, exudate) for bacteriological research. It is used to determine the pathogen that caused sinusitis or other sinusitis, as well as the sensitivity of the microbe to antibiotics. This helps to competently and precisely prescribe a course of antibacterial therapy.
Except diagnostic studies, endoscopic technology is widely used in operations and manipulations of the sinuses. We will talk about the types of such operations in the next section.

Advantages and disadvantages of endoscopic interventions

Previously, before the era of endoscopy, ENT doctors widely used standard surgery methods for sinus pathology: trephine puncture and options various operations with disruption of the bone structures of the sinuses. These operations are quite technically complex, fraught with bleeding and disruption of the anatomy of the ENT organs.

Endoscopic surgery on the maxillary sinus is the gold standard of minimally invasive surgery throughout the civilized world. Let's list all its advantages:

Safety. Endoscopy rarely causes significant bleeding and does not disrupt the structure and anatomy of the sinuses, since in the vast majority of cases the instrument is inserted into the sinus cavity through its natural anastomosis.
Physiological. Precisely because it is possible to insert the thinnest instrument under the control of the eye into the natural anastomosis, there is no need to destroy the bone walls and partitions.
Efficiency. Since the endoscopic technique is equipped with a micro-camera, the doctor carries out all manipulations not blindly, as before, but under the control of the eye on a large screen.
Fast post-operative recovery. It is logical that the low traumatic nature of the operation implies fast healing and tissue repair.

Like any, even the most excellent method, endoscopy of the paranasal sinuses has a number of limitations and disadvantages. Disadvantages of the method:

Endoscopic technology is very expensive and also requires very gentle processing and sterilization methods. Therefore, not everyone public clinic has such technologies in its arsenal.
The method also requires special training and internship for specialists.
Sometimes, in the case of severe tissue swelling or natural narrowness of the anastomosis, it is impossible to insert a conductor into the sinus cavity. It is also impossible to remove a large fragment of a tooth root or a fragment of filling material from the maxillary sinus using an endoscope through the narrow passage of the nasal passage. In such cases, it is necessary to expand the scope of the operation and crush the bone plate, as in normal operation. The wide opening is also very convenient to use with an endoscope.

Types of endoscopic interventions for sinusitis

We list the main options for using endoscopic manipulations for pathology of the maxillary sinuses:

Removing pus, draining and rinsing the sinuses. This technique is also called. It is indicated for the accumulation and increase in pressure of pus in the sinus cavity when the natural anastomosis is closed by inflamed tissues. As opposed to traditional puncture or puncture, pus is evacuated by expanding the natural anastomosis with a special inflatable balloon. Next, the cavity is washed repeatedly with antiseptics until completely clean.
Options for operations. As a rule, a chronic inflammatory process in the sinus is accompanied by the formation of various “plus tissues”: cysts, polyps, growths of the mucous membrane. These abnormal inclusions in the cavity interfere with adequate ventilation and drainage of the cavity and exacerbate inflammation. With the help of surgical endoscope attachments, it is possible to quickly and bloodlessly remove these tissues under the supervision of a specialist eye.
Options for operations to remove various foreign bodies of the maxillary sinus. Such foreign inclusions are filling material, bone fragments, fragments of teeth, pins and other dental paraphernalia. Unfortunately, most often the natural anastomosis is too narrow for the safe removal of large particles, so in such cases the operation is expanded: a hole is created in the bony septa of the sinus with access from the wall of the nose or upper jaw.

How does endoscopic surgery occur?

I would like to immediately note that each patient may have his own nuances of the operation, its technique and preparation, so we will only briefly outline the main stages of endoscopic manipulations:

Maximum preoperative preparation of the patient. Of course, in case of acute purulent sinusitis, drainage must be done as quickly as possible. But with planned intervention, for example, during removal or plastic surgery excretory duct quality preparation is the key to success. Such operations are best done during the “cold period”, when swelling and inflammation are minimal.
The patient must undergo blood tests, urine tests, and a blood clotting test to prevent possible complications. In the case of general anesthesia, an electrocardiogram and examination by a therapist are also required.
Operations are carried out as under general anesthesia, so local anesthesia. Most often it depends on the extent of the operation and the need for transosseous access.
Before the operation, the patient is informed about the potential of surgery, its possible consequences, explain the course of the operation and the features of the postoperative period. The patient must sign informed consent for medical intervention.
Before the operation, the patient is repeatedly washed with antiseptic solutions, then instilled in the nasal cavity and sinuses. vasoconstrictor drops to reduce swelling and vasospasm.
Next, depending on the surgical plan, either a window is created in the bone walls of the cavity, or an endoscope is inserted into the natural anastomosis.
Once in the sinus cavity, the doctor, looking at the screen, assesses the condition of its mucosa, finds abnormal tissues and begins to remove them with special tweezers and scalpels - a kind of cleaning of the cavity occurs.
After removing all excess, the cavity is washed with antiseptics, and sometimes antibiotics are injected into it. The doctor removes the instruments. The operation is over. The rehabilitation period begins.
Each patient's rehabilitation features are completely individual. As a rule, recovery programs include: taking antibiotics, constant nasal rinsing, instillation vasoconstrictor drops, physical therapy and regular monitoring by an ENT doctor.

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Today, we establish indications for endoscopy of the maxillary sinus much less frequently than just a few years ago. Mainly in cases where such a study is necessary to clarify the diagnosis of suspected isolated lesions of the maxillary sinus, i.e., mainly when a tumor is suspected. In addition, under endoscopic control, foreign bodies that have entered there can be removed from the maxillary sinus. Pathological changes resulting from inflammatory processes and in the maxillary sinus, today in most cases it is treated by transethmoidal access along the middle meatus.

We perform endoscopic examination almost exclusively through the canine fossa. After injection of a local anesthetic under the mucous membrane, the anterior wall of the canine fossa is perforated using a trocar for puncturing the maxillary sinus, advanced uniformly alternately left and right rotational movement. The mucous membrane does not need to be cut for this. Under no circumstances should you try to “push” the trocar through the anterior wall of the maxillary sinus without a rotational movement. It is clearly felt how the trocar penetrates the mucous membrane of the vestibule of the mouth and “drills” the anterior wall of the maxillary sinus. The advantage of this access route is the large radius of rotation of the trocar, creating optimal conditions for research and intervention (see Figures 1 and 2).

Rice. 1. Insertion of the trocar with a rotational movement into the maxillary sinus through the canine fossa.

Rice. 2. Schematic representation of the radius of rotation of the inserted trocar sleeve.

Tissue sampling from the maxillary sinus can be done blindly or using optical biopsy and grasping forceps. To do this, use 0° optics to guide the trocar sleeve to the biopsy site, remove the endoscope and keep the sleeve fixed. Straight biopsy forceps are then inserted, a tissue sample is taken, and the correct biopsy site is checked through an endoscope. In this way, cysts are also easily opened. The described route of access through the canine fossa is also optimal for studying the routes of transport of secretions in the maxillary sinus.

Provided that it is performed correctly (perforation is usually performed at the level between the roots of the 3rd and 4th teeth and as lateral as possible), complications such as irreversible dysesthesia or paresthesia occur extremely rarely. At the end of the examination and/or intervention, the trocar sleeve is pulled out with the same careful rotational movement as during insertion. There is no need to stitch up the perforation site. The patient is only asked to refrain from intensive nose blowing for a while.

Endoscopy of the maxillary sinus is extremely rarely indicated for children. The surgical approach should be chosen taking into account the child’s age and the degree of development of the maxillary sinus.