Endoscopic operations on the paranasal sinuses. Removal of a maxillary sinus cyst: types of operations and what is best to choose. Endoscopic sinus surgery

Sinusitis is a very common problem in ENT practice. One tenth of the adult population suffers from it in one form or another. And half of the cases of all nasal pathologies are sinusitis - inflammation of the maxillary sinus. Considering the mass unpleasant moments that the disease brings to patients, increased attention is paid to its treatment. But often conservative methods turn out to be powerless, and the issue can only be resolved surgically. What operations happen, when they are carried out, how exactly and what they give afterwards - these are the main questions that should be addressed.

The maxillary sinuses are paired sinuses that communicate with the nasal cavity. They have the most big sizes among the rest, occupying almost the entire volume upper jaw. The inside of the sinuses are covered with mucous membrane and filled with air. The main functions of the sinuses are: participation in nasal breathing, warming the air, creating resonance (voice formation).

If their mucous membrane of the sinuses becomes inflamed, then a disease develops - sinusitis. It occurs with the participation of a microbial factor and against the background of associated problems (anomalies in the structure and injuries of the nose, pathology of the dentofacial area, decreased immune reactivity of the body). Exudate (often purulent) begins to accumulate inside the cavity, or hyperplastic processes form. This leads to disruption of all sinus functions and the appearance of a number of unpleasant symptoms:

Difficulty in nasal breathing.
Nasal discharge.
Headache.
Temperature increase.
Weakness and malaise.

Such signs are typical for acute process or exacerbation of chronic. And in a state of remission clinical picture becomes less bright, although nasal congestion and discharge persist. Sinusitis can occur with complications, in which the inflammatory process spreads to neighboring areas (otitis media, frontal sinusitis) and develops. infectious pathology other organs (pneumonia) and neurovegetative reactions.

Indications and contraindications

Inflammation of the maxillary sinus can be treated conservatively. Antibiotics are prescribed vasoconstrictor drops into the nose, drained and washed with antiseptics using a special catheter (YAMIK therapy), physiotherapy is used. Surgical treatment of sinusitis is used when the above remedies have shown to be ineffective. In addition, indications for surgery include:

Chronic sinusitis (polypous, caseous, necrotic, cholesteatoma or mixed forms).
Secondary purulent complications(orbital, intracranial).
Structural abnormalities of the sinuses or nasal cavity (with impaired outflow of exudate).
Foreign bodies in the nasal passages and sinuses.
Odontogenic nature of the inflammatory process (problems with the dental system).

Each case is considered individually. For the patient, the doctor creates the most optimal treatment program that will suit him, taking into account all the characteristics of the body. After all, it should be understood that surgical intervention has certain limitations. Contraindications to surgical procedures may include:

Common infectious diseases.
Refractory arterial hypertension.
Blood diseases (coagulopathy).
Immunodeficiencies.
Diseases internal organs in the stage of decompensation.
Endocrine disorders (severe diabetes mellitus).

But these conditions are relative, since after appropriate correction of disorders, the intervention does not pose a danger to the body. But in any case, you need to carefully evaluate the benefits and risks and make an informed decision.

When conservative correction of sinusitis is ineffective, a decision is made on surgical intervention.

Methods

There are several techniques that can be recommended to patients. What kind of surgery for sinusitis is necessary in a particular case is decided only by the doctor. But the general essence is the same - cleansing maxillary sinuses from pus and pathological growths, elimination of anatomical defects and normalization of the outflow of natural secretions. All invasive interventions can be divided into internal (endonasal) and external (extranasal) methods.

Sinus puncture

Semi-surgical methods include puncture of the maxillary sinus. It remains widespread and effective means treatment of sinusitis. Before the procedure, the puncture site (the side wall of the middle nasal meatus) is lubricated with a local anesthetic for pain relief. Then the doctor uses a puncture needle to make a hole, penetrating the sinus.

The contents are aspirated and taken for examination, and the sinus is washed antiseptic solutions(furacillin, Dimeskid, Chlorophyllipt). Additionally, broad-spectrum antibiotics (Augmentin, Cedex) are introduced into it, if the exudate is thick, then proteolytic enzymes (trypsin, chymotrypsin), and with severe swelling - glucocorticoids (dexamethasone, hydrocortisone). In total, no more than 7–8 punctures are recommended. If purulent discharge persists, more radical treatment sinusitis.

Endoscopic method

The maxillary sinus can be accessed using endoscopy. Then the wall of the sinus is not broken, everything happens through natural openings. The endonasal method is the most gentle and is carried out using modern fiber optic technology, long-focus microscopes and special instruments. To cleanse the sinuses, various attachments are used: a coagulator, a shaver, forceps, etc. The operation is carried out under constant visual control, which makes it possible to remove pathological formations within healthy tissues without causing major damage, which reduces the risk of adverse consequences.

For two weeks after endoscopic surgery on the maxillary sinus was performed, the patient should be observed by an ENT doctor. He will prescribe a preventative course of antibiotics and monitor how healing is progressing. To improve the removal of crusts and secretions, the maxillary sinuses can be washed with antiseptics and saline. And for another six months you will have to instill drops from topical corticosteroids to prevent the inflammatory process.

Traditional operation

Most radical method surgical treatment is considered a traditional operation for sinusitis (according to Caldwell-Luc). It is performed in a hospital under local or general anesthesia. Access for maxillary sinusotomy is carried out from the vestibule of the oral cavity, above the alveolar process of the upper jaw (right or left). A small hole is made in this place, through which the sinus cavity is inspected and pathological formations are eliminated.

In chronic sinusitis, the cells of the ethmoidal labyrinth are also changed, which are also removed. For adequate drainage, an anastomosis is placed between the sinus and the lower nasal passage, and a gauze swab moistened with an antiseptic or antibacterial ointment is left in the cavity. A day later it is removed. In case of odontogenic sinusitis, surgery may be accompanied by plastic surgery of the defect in the lower wall of the sinus. The patient remains in the hospital for a week. He is given rinses and prescribed antibiotics, anti-inflammatory and antihistamines.

Radical surgery gives surgeons more freedom and allows the sinuses to be thoroughly cleaned, but it is also more traumatic for the patient.

Consequences

When deciding to undergo surgery, you should be prepared for its consequences. But it is not at all necessary that they will arise. It all depends on the technique of performing the operation, preparation for it, rehabilitation measures, qualifications and experience of the doctor. The most common complications are the following:

Bleeding.
Secondary infection.
Loss of sensitivity in the nose and upper lip.
Decreased sense of smell.
Visual impairment.
Formation of fistulas.

To avoid negative consequences After surgery, it is important to follow the doctor’s recommendations in everything. Great importance is given to oral hygiene and rinsing with antiseptics (especially with radical maxillary sinusotomy). In addition, you must take all prescribed medications and show up for examination on time.

Thus, operations for sinusitis can be different. Only a doctor can tell you what treatment is indicated in a particular case. After an appropriate examination, he determines the type and extent of surgical intervention in order to make it as effective and safe as possible. minimal risks cure sinus inflammation.

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.

Sinusitis is by far the most common type of sinusitis and is an inflammatory process in the maxillary paranasal sinuses nose They are paired, so the disease can affect each of them separately, or two at once. At the same time, complications of sinusitis can affect the nasopharynx, orbit, skull bones and even the brain due to the fact that there are a lot of different passages in the skull that connect almost all the structures in it. It should be noted that with a high risk of such complications, as well as with severe course diseases, surgical treatment of sinusitis is very often used.

Treatment of sinusitis in adults and children involves A complex approach, that is, the effect on the purulent inflammatory process occurs with different sides. The following types of treatment are usually used:

etiological, aimed at the causative agent of the process or elimination of factors in the development of the disease;
symptomatic, allowing to combat the main clinical manifestations;
preventive, consolidating the effect of the therapy.

Complex treatment can be carried out conservatively - with the help of medicines. In severe cases, it can be surgical - a puncture of the maxillary cavity is performed, or a maxillary sinusotomy is an operation to remove the mucous membrane. The name lies in the process of opening the sinus. It can be done like traditional method, and endoscopically. Endoscopic surgery for sinusitis eliminates the need to open the sinus through the mouth. It allows you to normalize aeration (enrichment with air) of the sinuses and other structures of the respiratory system.

Surgery on the maxillary sinus involves the removal of structures such as:

soft tissues subjected to inflammatory processes, infection and damage;
foreign bodies that served as a trigger for the disease. These may also include carious teeth, in which case the operation should be performed together with an oral and maxillofacial surgeon;
destroyed bones or sections of bones to create artificial connecting passages in order to improve the outflow of mucus and aeration;
cysts and polyps located in cavities.

Sinus puncture

In addition to surgical treatment by maxillary sinusotomy or endoscopic surgery, a technique called puncture is widely used. It can be prescribed for both therapeutic and diagnostic purposes, and is very effective method treatment of pathology. A puncture can effectively treat purulent sinusitis if performed correctly.

The manipulation is done under local anesthesia. In addition to eliminating the contents of the cavity, it is washed and irrigated with antibacterial and antiseptic solutions. After the puncture, a course is prescribed antibacterial therapy drugs that have wide range actions. This is due to the fact that pathology can develop due to the introduction of various microorganisms.

Local anesthesia is done by introducing a turunda with an anesthetic into the nasal passage. It allows you to eliminate pain and discomfort. Sometimes a sensation of a foreign body in the nose may develop during the procedure. It should be noted that the doctor relies solely on his tactile sensations and experience during manipulation, and his wrong actions may lead to undesirable consequences.

An ordinary syringe can be used as equipment to remove the contents of the sinus. They also introduce antibacterial agents and antiseptic solutions in the maxillary sinus.

Endoscopic surgery is a minimally invasive technique and allows for intervention with minimal consequences. After performing such treatment, there are no visible consequences of the intervention, since the endoscope (device for performing the operation) is inserted through the nasal opening and does not damage the mucous membrane of the nasal passages. Video images are usually displayed on a monitor connected to the device.

According to medical statistics, sinusitis after such an operation is much less likely to be complicated or worsened. It should also be noted that the price for this method of treatment is much lower than for traditional maxillary sinusotomy. This allows it to be used much more often. However, there is also a negative point - not all hospitals are equipped with devices for endoscopic surgery, which means that sometimes it is necessary to treat sinusitis with a conventional operation, and the patient will have to pay full price such treatment.

The duration of the intervention takes from half an hour to one and a half hours, depending on how severe the inflammatory process has developed. Play a role and individual characteristics person. Only an experienced specialist will tell you how long the operation will take, but not always, and he will be able to predict exact time the patient's stay on the operating table.

More often, this method of treatment is used in adults, due to anatomical and psychological characteristics child's body.

The procedure involves inserting an endoscope, an optical device, into the nose. Using this device, the doctor can see the condition of the mucous membranes, the presence of pus, foreign objects and other defects. The device can be equipped with cameras that allow you to display video on a special monitor, as well as take photos and record the progress of the operation. This allows you to save information for use for study.

Using an endoscope, you can insert instruments for the treatment of sinusitis - a laser, a scalpel and scissors - into the maxillary sinus. Such an intervention usually proceeds without any painful sensations, so it does not require additional anesthesia. Local anesthesia can be used in case of low pain threshold at the patient.

Maxillary sinusotomy

In case of low efficiency conservative therapy, as well as the lack of effects from puncture of the maxillary sinus and endoscopic treatment of sinusitis, is usually prescribed surgical treatment diseases - sinusotomy. Very often it can be called the most effective, but also the most dangerous method treatment of pathology. The essence of this operation is to open the maxillary sinuses through the oral cavity and eliminate the inflammatory focus and affected soft tissues and foreign bodies. Very often it requires such an operation.

It consists of two stages: opening access and cleaning the sinus. Depending on where the inflammatory focus is localized, two methods are used - through the oral cavity (used much more often) and through access on the face. It should be noted that such an operation is very difficult to perform, since the area of the intervention is very limited external structures, and the walls of the cavity itself are lined with mucous membrane, which can very easily be damaged, causing complications of the disease.

Today, access through the oral cavity is in first place, which is due to its cosmetic viability. The second option can be done if it is necessary to better examine the contents of the sinus. Combination treatment is also possible, when through external access or through access oral cavity An endoscope is inserted into the maxillary sinus.

The operation is performed under anesthesia.

The contents of the affected maxillary sinuses are removed using surgical instruments - a Volkmann spoon, which looks very similar to an ordinary spoon.

Since surgical treatment takes place under anesthesia, it is absolutely painless. The sinus is completely open in front of the doctor, which allows him to perform everything necessary procedures to treat the disease and prevent the development of relapse processes. You can also carry out healing procedures and in other departments respiratory system, which are located in close proximity to the maxillary sinus.

ENT surgeons at SM-Clinic perform all types of operations, but in most cases they prefer microsurgical maxillary sinusotomy as the safest and most effective method.

Microsurgical maxillary sinusotomy

Microsurgical technique

General anesthesia

Operation time - 30-60 minutes

Cost of the operation: from 40,000 rubles*

Microsurgical micromaxillary sinusotomy. The surgeon makes a small – 4 mm – hole in the anterior wall of the maxillary sinus. Access to it is carried out under the lip, from the vestibule of the oral cavity, above 4–5 teeth. Under the control of a microscope with different viewing angles and using micro-instruments, the doctor inspects the sinus cavity and performs the necessary manipulations: removes pus, cysts, polyps or foreign body, washes the cavity medicinal solution. After maxillary sinusotomy, the access hole is sutured. For several days, slight swelling of the cheek tissue on the access side may be observed.

Microsurgical endonasal maxillary sinusotomy. In this case, access to the maxillary sinus is achieved without punctures. The doctor expands the natural or creates an artificial anastomosis in the area of the middle or lower nasal passage and inserts a microscope and micro-instruments into it. Further manipulations are similar to those performed during microsurgical microsinusrotomy.

If there are contraindications to microsurgical intervention, ENT surgeons of the Center perform a classic operation.

Radical maxillary sinusotomy according to Caldwell-Luke.

General anesthesia

Operation time - 10-15 minutes

Time of hospital stay - 1 day

Cost of the operation: from 20,000 rubles. *

(excluding the cost of anesthesia and hospital stay)

Radical maxillary sinusotomy according to Caldwell-Luke. With the classic method, the surgeon makes a 5–6 cm incision in the mucous membrane under upper lip to the bone and moves the tissue to the side. Then using a drill or chisel in the front bone wall A hole is made in the sinus for the insertion of instruments. After this, the doctor installs drainage through the anastomosis into the middle nasal passage, removes purulent contents from the sinus, and rinses the cavity. The operation is completed by suturing the mucosal incision.

As a rule, all types of maxillary sinusotomy at the Center are performed under general anesthesia (endotracheal anesthesia). If contraindications to this type of anesthesia are identified, the patient’s wishes or small volumes of surgery, we use local anesthesia.

Our specialists are professionals high level with impressive experience surgical interventions and have a perfect command of classical and modern techniques carrying out operations.

* the indicated prices are preliminary and may change if additional services are necessary; the price also does not include preoperative examination.

Cysts and foreign bodies of the paranasal sinuses

A cyst is a benign neoplasm, which is a thin-walled bubble filled with fluid. The size of the cyst and its location can be very different, which suggests that clinical manifestations(patient complaints) may vary. The mechanism of cyst formation is quite simple. The mucous membrane lining the inside of the nasal sinuses has glands that produce secretions (mucus) throughout a person’s life; each gland has its own excretory duct, which opens on the surface of the mucous membrane. When for any reason the gland duct stops functioning, the gland does not stop working, i.e. mucus continues to be produced and accumulates, so the walls of the gland expand under pressure, which over time leads to the formation of the formation described above in the sinus. A cyst can disrupt the natural flow of mucus from the sinus and lead to inflammation.

A person can have a sinus cyst all his life and not know about its existence. The patient may visit the ENT doctor repeatedly, both during preventive examinations, and due to illness, but without additional research it is impossible to diagnose a cyst. The doctor can only make an assumption about its presence. Foreign bodies penetrate into the paranasal sinuses either as a result open injury sinuses, or as a result medical manipulations(filling the canals of the teeth of the upper jaw). A foreign body usually leads to the development chronic inflammation sinuses.

The most diagnostically significant study is computed tomography of the paranasal sinuses. This method allows you to determine the size of the cyst, foreign body, and location in the sinus with millimeter accuracy, which is very important for choosing a removal method. IN mandatory A diagnostic endoscopy of the nose is performed to assess the condition of the intranasal structures.

Complaints

There may be no complaints at all and the patient can live his life calmly without treatment from an ENT doctor. Very often patients who have undergone computed tomography or magnetic resonance imaging of other organs (brain, ear) and during the examination they discovered a cyst. This depends on the size and location of the cyst, as well as on the structure of the maxillary or other sinus itself. In other cases, the following symptoms occur:

Nasal congestion, which can be constant or variable;
Recurrent or constant headaches. They arise due to the fact that the growing cyst puts pressure on the nerve endings of the mucous membrane;
Discomfort in the upper jaw area;
In patients engaged in aquatic species sports, when diving to depths pain may appear or intensify;
Periodically occurring inflammatory processes in the sinuses - sinusitis, which occurs due to a violation of the aerodynamics of air flow in the sinus by the cyst;
Flowing down back wall throats of mucus or mucopurulent discharge, which can be constant. This happens because when the position of the body changes, the cyst, irritating the mucous membrane, causes increased mucus secretion.

The described complaints are not always a sign of a cyst, so in most cases it is carried out additional research in a specialized ENT clinic.

Treatment

The cyst or foreign body must be removed surgically. Unlike traditional operations that create a large hole in the sinus wall, we perform endoscopic exploration of the sinus through a small hole with a diameter of 4 mm using special micro-instruments

Elimination of inflammatory processes of the maxillary sinus

It's not always possible to get positive result from conservative treatment. The reasons for this: incorrect choice of antibiotic, inaccurate determination of microflora, narrow natural anastomosis, violation of the architectonics of the nasal cavity, ridges and spines of the septum, the presence of polyps, hyperplasia of the mucous membrane.
Emptying the sinuses from purulent discharge can be achieved by washing through the natural opening and a test puncture, used as a diagnostic and therapeutic method. In the latter case, after the sinus has been emptied, medications are injected into it.

If conservative treatment fails, there is every reason to use surgical methods. The operation involves restoring the architecture of the nasal cavity to create normal nasal breathing and aeration of the sinuses. The patency of the natural anastomosis is restored using minimally invasive (endoscopic) surgery methods. TO radical surgery on maxillary sinus should be used as a last resort.

Advantages of the endoscopic method

One of the advantages of endoscopic sinus surgery over the traditional method is that it does not require a surgical incision. It is carried out using an endoscope, which allows you to observe the pathological process occurring in the sinus.

Another advantage endoscopic method is that it allows you to treat directly the very cause of sinusitis. The doctor can directly see the pathological focus and remove it without resorting to cutting normal tissue, which significantly reduces unnecessary trauma and speeds up postoperative period, reduces the risk of the operation itself and postoperative complications.

The method is characterized by the absence of an external scar, slight swelling after surgery and less pain intensity.

The goal of endoscopic surgery is to widen the sinus openings. Typically, the paranasal sinuses open into the nasal cavity through a thin bony canal covered with mucous membrane. When inflamed, this membrane swells, and thus the exit from the sinus is closed. Endoscopic surgery allows you to widen the bony sinus canal. Therefore, even if the patient subsequently experiences inflammation of the nasal mucosa and sinus outlet or allergic swelling, there will be no blockage of the paranasal sinus opening. This greatly facilitates further treatment of inflammation of the paranasal sinuses.

In addition, the instruments of endoscopic technology make it possible to easily remove all kinds of tissue in the sinus cavity, for example, polyps or cysts.

Recent improvements in endoscopic techniques surgical interventions for diseases of the paranasal sinuses - a computer navigation system. It allows you to create a three-dimensional image of the paranasal sinuses on the monitor screen, which facilitates diagnosis and surgical intervention.