Endoscopic sinus surgery. The essence and technique of endoscopic maxillary sinusotomy

Rationale. Surgical correction of intranasal structures and sinus surgery with the development of endoscopic techniques have reached a new level compared to the work of pre-endoscopic rhinology. The founders of endoscopic rhinosurgery, developing various techniques, laid the foundation for the principle of maximum preservation of the healthy mucous membrane of the nasal cavity and paranasal sinuses.

The concept of the pathogenesis of sinusitis from the prechambers to the large sinuses expands the possibilities of a pediatric rhinologist surgeon when choosing the type of operations: from the usual displacement of the middle turbinate medially, sufficient in young children, to extended ethmoidectomy, which is necessary only for total sinus polyposis, severe syndromic diseases (Kartagener's syndrome). , aspirin triad, cystic fibrosis).

Target.

Endoscopic operations in the nasal cavity must comply with the four fundamental principles of surgical intervention on the paranasal sinuses:
after surgery, the sinus should retain its physiological mechanism;
intact, if possible, it is necessary to leave the natural fistula of the sinus;
the operation must be performed in such a way that the air stream through the operated fistula does not fall directly into the cavity of the operated sinus;
interventions on the turbinates should not contribute to the entry of air flow into the region of natural openings.

Indications. Acute and chronic diseases of the upper respiratory tract, congenital and acquired anomalies in the development of the nasal cavity, lack of effect from conservative therapy, previously undergone surgical interventions on the nasal cavity and paranasal sinuses.

Contraindications. Contraindications to endoscopic operations in the nasal cavity and paranasal sinuses meet the general criteria for preparing a child for surgical interventions (blood clotting indicators, past infectious diseases, hereditary diseases, acute and chronic diseases of the internal organs - according to the conclusion of a specialist).

Training. The preparation process includes a study of the medical history, examination, diagnostic endoscopy, trial therapeutic treatment, imaging methods and preoperative examination (radiography, computed tomography, magnetic resonance imaging if indicated). In the preoperative period, it is necessary to improve the condition of the mucous membrane as much as possible due to the use of topical corticosteroids in combination with decongestants, mucoregulators, antibiotics, topical antihistamines, and irrigation therapy drugs.

Technique and aftercare. Features of childhood require the rhinosurgeon to comply with four conditions when performing the operation:
surgical interventions should not be carried out in areas of active growth of the nasal cavity and the development of future sinuses;
only having exhausted all the possibilities of endoscopic functional surgery, it is possible to perform an operation with an external access with an aesthetic defect;
if the classical conservative treatment is insufficient or ineffective in chronic rhinosinusitis, then the functional operation should first eliminate the obstacles to mucociliary transport and air flow in the nasopharynx, turbinates, and then sparing surgical interventions in the area of ​​the osteomeatal complex can be resorted to;
when performing surgical interventions, it is necessary to spare the mucous membrane of the contacting surfaces, especially in the funnel area, formations of the osteomeatal complex.

Damage to the cells of the anterior ethmoid group and the maxillary sinus due to anatomical changes in the osteomeatal complex prevails in children over lesions of other sinuses in all age groups. Both turbinates (lower and middle) and elements of the lateral wall of the nose (uncinate process, ethmoid bulla, less often Haller's cell, cells of the nasal shaft) are involved in stenosis of the osteomeatal complex, so surgical interventions for recurrent and chronic sinusitis in children are as follows operations:
elimination of postnasal occlusion (adenotomy);
intervention in the nasal concha;
correction of the elements of the lateral wall of the nose involved in the formation of natural fistulas of the paranasal sinuses;
elimination of deformities of the nasal septum.

The endonasal approach to the sanitation of the large sinuses due to limited interventions on the intranasal structures of the lateral wall in the region of the prechambers is optimal in childhood, since the age group of the operated child itself suggests the volume of operations. If in adult patients a reasonable and sufficient volume of surgery, even with chronic purulent-polypous sinusitis, frontal sinusitis, can be infundibulotomy with partial opening of the anterior ethmoid group without maxillary sinusotomy, then in children the volume of operations is dictated by the age capabilities and structure of the ethmoid labyrinth, the level and position of the maxillary sinus .

It is possible to carry out a number of operations from resection of the uncinate process to total ethmoidectomy with fenestration of the sphenoid and maxillary sinuses. However, in the vast majority of cases, even with persistent recurrent processes, it is sufficient to open the prechambers in the anterior ethmoid group to obtain positive results in the treatment of chronic frontal sinusitis, sinusitis, and ethmoiditis.

Local anesthesia for endoscopic interventions in the nasal cavity is a mandatory step, even if the operation is performed under general anesthesia. Immediately before the start of the operation, it is recommended to treat the mucous membrane of the nasal cavity with oxymetazoline, providing a long-term anti-edematous effect. In the operating room under endoscopic control, turundas moistened with oxymetazoline or phenylephrine and a topical anesthetic are administered. Immediately after achieving superficial anesthesia, an injection of 2% lidocaine with a 1:200,000 solution of epinephrine is performed with a special needle for endoscopic sinus operations, or a dental needle and syringe, an insulin syringe are used.

The injection is made in the following areas:
along the attachment of the uncinate process (three injections);
in the place of fixation of the middle turbinate;
in the lateral and medial surface of the middle turbinate;
further, depending on the volume of surgical intervention (the bottom of the nasal cavity, nasal septum, inferior turbinate).

The purpose of the injection and the process of topical anesthesia is to anesthetize the anterior and posterior ethmoidal nerves supplying the anterior and posterior superior parts of the lateral wall of the nose and septum, as well as the branches of the basilar palatine nerve, which passes with the main vessels from the main palatine opening and supplies the lateral wall of the nose. It is important that the process of administering the anesthetic is carried out slowly and that the operation is not started until the anesthetic has had the desired effect. The combined action of a topical anesthetic, an injected local anesthetic, and a superficial decongestant provides a reliable, blood-free field in most cases.

The experience of otorhinolaryngologists of the world convincingly suggests that functional intranasal endoscopic operations on the paranasal sinuses to the greatest extent meet the requirements for the improvement of the diseased organ (mucosa) and the restoration of the patient's health.

Operations on the paranasal sinuses using endoscopes have almost a century of history, but in the modern version they are about 25 years old. Modern functional endoscopic rhinosurgery began in the seventies in Austria, and then spread throughout Europe, came to America and other continents. In Russia, endoscopic rhinosurgery has been developed since the early nineties.

Diseases of the nose and paranasal sinuses have long been widespread among the population. The famous surgeon, our compatriot N.I. Pirogov performed nasal polypotomy without knowing all the functions of the nose, but he sought to restore nasal breathing, which is the main function of the nose, and for this he inserted a finger into the nasopharynx, pushed polyps and hypertrophied shells forward and removed them with forceps. What happened at that time in the nose can be imagined. Then it became possible to use a forehead reflector and remove polyps to some extent under visual control. The era of so-called radical surgery has come. The concept of this surgery was based on the fact that if the entire mucous membrane was removed, then sinusitis would also be cured. Unfortunately, this has not been confirmed in practice. Work on the study of the physiology of the nose and paranasal sinuses, the assessment of the mucous membrane as a multifunctional organ, and the development of new types of endoscopes opened the era of modern functional endoscopic surgery.

Currently, functional endoscopic surgery of the nasal cavity and paranasal sinuses is the most consistent with our understanding of the importance of the mucous membrane in human life. Some time will pass and it is not excluded the emergence of new theories and a new solution to the treatment of inflammatory diseases of the nose and paranasal sinuses. The most likely path for the development of treatment issues seems to be in the development of drug therapy. Surgical treatment will be used to a greater extent as a corrective one, aimed at eliminating the causes predisposing to the development of inflammation - congenital and acquired deformities of the intranasal structures, failure of the drainage and clearance of the sinuses, and other shortcomings. Surgical treatment will take a more preventive focus.

The classical position of N.I. Pirogov that the surgeon must know anatomy perfectly remains always relevant. For surgical operations performed in cavities using additional devices, which, in particular, are endoscopes, knowledge of anatomy is an absolute prerequisite. Personal practical experience, and numerous works of various authors, suggest that in addition to knowledge of anatomy, it is necessary to bear in mind the fact that the individual structure of the nose and paranasal sinuses varies quite widely. Therefore, it is necessary to have a clear idea of ​​what the surgeon expects during the operation.

The surgeon performing endoscopic operations must be familiar with the details of the anatomical structure and the main identifying anatomical points and structures.

Endoscopic examination of the nasal cavity is carried out in the operating room before the operation, observing the following sequence. First, the vestibule of the nose is examined. The nasal valve is evaluated. The nasal valve is the narrowest place in the nasal cavity, formed medially by the nasal septum, inferiorly by the bottom of the nasal cavity, laterally by the anterior end of the inferior turbinate, and laterally superiorly by the caudal end of the superior lateral cartilage.

When examining the nasal valve with a conventional nasal mirror, we will not receive objective information, since we move the nasal wing aside and the nasal valve expands. Inspection without instruments does not give a complete picture of the state of the nasal valve angle, the magnitude of which largely determines the ability of the nasal valve to pass the air stream. The normal angle of the nasal valve is about 15 degrees, if the angle is less, then there may be a suction effect of the wing of the nose and narrowing of the nasal valve during inspiration until it closes. Difficulty in nasal breathing with a narrow nasal valve is especially noticeable during sleep, when a person inhales deeply, the wing of the nose sticks to the septum, and snoring occurs.

The endoscope makes it possible to examine the nasal valve without changing its shape and to evaluate the significance of each structure that makes up the valve.

Next, the endoscope moves along the nasal concha along the common nasal passage, examines the condition of the mucous membrane, the spines and ridges of the nasal septum, the posterior end of the inferior concha, the choana. The surgeon receives full information and determines the amount of necessary intervention on these anatomical structures. Then, during the reverse movement, the lower edge of the middle turbinate is examined, starting from its posterior end. At the last stage, the endoscope is directed to the upper nasal passage, the superior nasal concha, fistulas of the posterior ethmoid sinuses, fistula with the sphenoid sinus are examined.

Atheroma (aka cyst) is a benign thin bubble with fluid inside. The size and location may be different, respectively, and the complaints of patients may differ from each other.

If, nevertheless, the suspicion of the presence of atheroma is confirmed, its removal is performed only surgically, that is, endoscopic sinus surgery.

How are atheromas formed in the sinus of the nose?

The lining inside the nose has mucus-producing glands throughout human existence. There are times when, due to some inflammatory process, the iron duct does not function, but despite this, all the glands continue to produce mucus, which as a result does not come out, but accumulates inside under pressure, expands the walls of the glands, which as a result lead to the appearance of the above described sinus atheroma.

It's not easy to recognize a sinus cyst. A person for many years may not know that it exists, and only computed tomography or diagnostic endoscopy of the sinus can recognize atheroma.

The best result for diagnosing a cyst is computed tomography. It is she who makes it possible to accurately name the size of the atheroma and its location, and these are very important factors. Knowing them, it is much easier to choose a method for removing such a cyst.

Diagnostic endoscopy is mandatory to clarify the condition and functionality of all nasal structures.

Complaints.

As mentioned earlier, a person can live a lifetime and not know about a cyst. But symptoms can still be:

1. The first and main symptom is constant or variable nasal congestion. There is no runny nose, but the nasal airways do not let air through.

2. Atheroma, growing, newly created, can cause frequent headaches, because it touches the nerve points of the mucosa.

3. In the region of the upper jaw, there is often a feeling of discomfort, pain.

4. Drivers, or other athletes whose activities are related to water, may experience suffocation, intensify and pain.

5. Frequent diseases of the nasopharynx: tonsillitis, sinusitis and others can occur because atheroma begins to change its location, which disrupts the function of aerodynamics.

6. In the area of ​​​​the back wall of the pharynx, mucus, possibly pus, can flow variable or always. When the location is modified, the cyst initiates irritation of the mucous membrane, causing inflammatory processes.

The above symptoms are not only related to the cyst, it can be a simple sinusitis. But to confirm the absence of a tumor, additional studies, such as diagnostic endoscopy and computed tomography, must be performed.

The goal of endoscopic sinus surgery is to enlarge the passage of the sinuses. As a rule, the paranasal sinuses open into the microcavity of the nose with a bony canal covered with a slimy layer. The above greatly simplifies the subsequent treatment of irritation of the paranasal sinuses.
In addition, the endoscopic technical tool makes it possible to quite simply eliminate various matters in the sinus cavity, for example, polyps or atheromas.

Recent modernization of endoscopic technical timely interventions in a number of diseases of the paranasal sinuses - the theory of computer navigation. The location makes it possible to form a multidimensional representation of the paranasal sinuses on the computer screen, which completely simplifies the diagnosis and surgical intervention for the doctor.

Sinusitis is a purulent process in the maxillary sinus. Among all diseases of the ENT organs, this pathology comes out on top. Unfortunately, there are no characteristic symptoms for this disease, however, you should immediately consult a doctor if you feel:

  • headache, especially in the face;
  • nasal congestion;
  • purulent discharge from the nose;
  • swelling of the eyelids, cheeks;
  • soreness in the cheekbones, cheeks;
  • temperature increase;
  • weakness;
  • dizziness.

The development of the disease can be the result of many pathogenic factors. Most often, it occurs as a complication of acute respiratory viral infections, with "children's" infections, in the presence of an odontogenic infection. The causative agents can be bacteria, viruses, and other, less likely pathogens.

The main provoking factors:

Treatment methods for acute sinusitis

It should be noted right away that isolated sinusitis is very rare, most often they are diagnosed with rhino-sinusitis, that is, there is inflammation of the nasal mucosa. Often joins inflammation and other sinuses.

Treatment of acute sinusitis begins with minimally invasive treatment methods. Be sure to prescribe the washing of the maxillary sinuses. Assign a course of antibiotic therapy, antihistamines, vasoconstrictors, vitamins.

All treatment is aimed at restoring normal outflow from the maxillary sinus. Therefore, basically therapy is symptomatic and pathogenetic. Washing of the maxillary sinuses is also prescribed to improve the outflow of purulent contents.

In the case of a severe course of acute sinusitis, the treatment is prescribed more serious - puncture. In this situation, the pus became dense, its outflow is difficult, the anastomosis with the nasal cavity is not passable. Thanks to the puncture, it is possible to pump out pus, rinse the sinus cavity, and carry out local treatment.

Endoscopic sinus surgery

The maxillary sinus puncture is indeed a classic treatment. However, this procedure has its contraindications and complications. Modern microsurgery does not stand still, and endoscopic sinus surgery is now available.

This intervention is called endoscopic maxillary sinusectomy - a sparing, painless, effective procedure. Endoscopic surgery on the maxillary sinus is prescribed in cases where conservative therapy is ineffective, there are foreign bodies, or other reasons that impede the outflow of purulent secretions from the sinus.

Advantages of endoscopic treatment of acute sinusitis:

  • The operation is carried out under the control of a high-precision video monitor;
  • The operation is gentle, low-traumatic, painless.
  • There is minimal damage - the natural sinus fistula expands to normal anatomical sizes.
  • If necessary, a biopsy is taken.
  • You can perform general or local anesthesia.
  • The number of complications is kept to a minimum.
  • Does not require a long postoperative period.

There are several basic approaches for endoscopic treatment. The choice of access will depend on the nature of the process, its localization, the state of the nasal mucosa, and nasal passages. During one operation, it is possible to combine several types of access to provide the specialist with maximum visibility of the maxillary sinus.

Currently, endoscopic sinusotomy has become not only the treatment of choice, but is also an ideal diagnostic method when it is necessary to determine the presence of cysts or tumors of the sinuses associated with acute sinusitis.

Currently, the treatment of acute sinusitis does not require punctures. Modern endoscopic techniques for the treatment of this disease are gentle, effective and less traumatic.

Diagnostics

In the Open Clinic network, specialists will conduct an examination, listen to complaints, and prescribe an examination. The main standard of examination for suspected sinusitis are:

  • Palpation of the sinuses
  • RG - maxillary sinuses
  • Rhinoscopy
  • Diaphanoscopy
  • Biopsy
  • CT, MRI
  • Blood tests
  • Fibroendoscopy.

In European countries, there is a standard examination for this disease. The main diagnostic method is radiography, but the methodology for conducting this study has changed in recent years. It has been established that isolated acute sinusitis is quite rare, so it is necessary to examine both the nasal cavity itself and the rest of the nasal sinuses. Radiography is carried out in three projections to exclude generalized inflammation.

Computer research methods - CT and MRI - are more modern methods of examination. Thanks to these techniques, it is possible to carry out differential diagnostics between sinusitis and tumors, cysts of the maxillary sinuses.

Cost of endoscopic maxillary sinus surgery

The “Open Clinic” network prefers the most effective, sparing, modern method of examination. This is an endoscopic operation.

Indeed, such procedures are carried out abroad all the time, they give good results and have no complications. However, their implementation requires high-quality equipment, highly qualified specialists, and the ability to interpret the result.

From these points, the concept of the price of endoscopic surgery on the maxillary sinus is formed. On average, prices in Moscow vary from 20,000 to 40,000 rubles. In the Open Clinic network, we provide you with various treatment programs depending on the type of intervention, degree of complexity, type of anesthesia. All our specialists are proficient in modern methods of treating acute sinusitis and achieve high and stable results!

Why should you come to us?

In the Open Clinic network:

  • A comprehensive examination of the ENT organs is carried out.
  • Operating rooms are equipped with modern, high-precision equipment.
  • Our specialists constantly improve their skills at the state and international level.
  • We practice an individual approach to the preparation of an individual treatment regimen for each patient.

Maxillary sinusectomy– this is the most common endoscopic ENT surgery, which is effective for chronic sinusitis, cysts, antrochoanal polyps, fungal and foreign bodies of the maxillary sinus. Sinusectomy is performed through the natural opening of the maxillary sinus in the nasal cavity: first, it expands by a few millimeters, and then the sinus is examined with an endoscope. Pathological contents from the sinus are removed, and the mucous membrane remains intact.

Maxilloethmoidotomy – this operation is larger in volume than maxillary sinusectomy, 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 from two sides: maxillary sinuses, frontal and sphenoid sinuses, ethmoid labyrinth. Endoscopic polysinusotomy is most often performed for polypous rhinosinusitis.