Invasive endoscopic surgery for sinus cysts. Surgery on the maxillary sinus. Complications after endoscopic sinus surgery

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

If, nevertheless, the suspicion of the presence of atheroma is confirmed, its removal is carried out only surgically, that is, endoscopic surgery of the sinuses.

How do atheromas form in the sinus?

The membrane inside the nose has glands that produce mucus 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 occurrence of the above-described atheroma of the sinuses.

It is not easy to identify a sinus cyst. For many years a person 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 this that makes it possible to accurately name the size of the atheroma and its location, and this is very important factors. Knowing them, it is much easier to choose a method for removing such a cyst.

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

Complaints.

As mentioned earlier, a person can live his whole life and not know about the cyst. But symptoms may 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 allow air to pass through.
2. Atheroma, growing, newly created, can cause frequent headaches, because it touches the nerve points of the mucous membrane.
3. In the area upper jaw There is often a feeling of discomfort and pain.
4. Drivers or other athletes whose activities involve water may experience suffocation, increased pain, and pain.
5. Frequent illnesses nasopharynx: sore throat, sinusitis and others can occur because the atheroma begins to change its location, which disrupts the aerodynamic function.
6.In the area back wall the pharynx has the ability to alternately or always drain mucus, possibly pus. When the location is modified, the cyst initiates irritation of the mucous membrane, thereby causing inflammatory processes.

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

The goal of endoscopic sinus surgery is to increase the passage of the sinuses. As a rule, the paranasal sinuses open into the nasal microcavity with a bone canal covered with a mucous layer. The above significantly simplifies the subsequent treatment of irritation of the paranasal sinuses.
In addition, the endoscopic technical instrument makes it possible to quite easily remove various substances 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.

Rationale. Surgical correction intranasal structures and sinus surgery with the development of endoscopic technology have reached new level compared with the work of pre-endoscopic rhinology. The founders of endoscopic rhinosurgery, developing various techniques, based it on 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 capabilities of the pediatric rhinologist when choosing the type of operations: from the usual displacement of the middle turbinate medially, which is sufficient in children younger age, to extended ethmoidectomy, necessary only for total sinus polyposis, severe syndromic diseases (Kartagener syndrome, aspirin triad, cystic fibrosis).

Target.

Endoscopic operations in the nasal cavity must meet four fundamental principles of sinus surgery:
after surgery, the sinus should retain its physiological mechanism;
If possible, the natural sinus anastomosis should be left intact;
the operation must be performed so that the air stream through the operated anastomosis does not fall directly into the cavity of the operated sinus;
Interventions on the turbinates should not allow air flow into the area of natural openings.

Indications. Spicy and chronic diseases upper respiratory tract, congenital and acquired anomalies 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 correspond to: general criteria preparing a child for surgical interventions (blood clotting indicators undergone infectious diseases, hereditary diseases, acute and chronic diseases of internal organs - according to the conclusion of a specialist).

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

Methodology and aftercare. The characteristics 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 development of future sinuses;
only after exhausting all the possibilities of endoscopic functional surgery can the operation be performed using external access aesthetic defect;
if classic conservative treatment is insufficient or ineffective for chronic rhinosinusitis, then functional operation must first remove obstacles to mucociliary transport and air flow in the area of the nasopharynx, turbinates, and then you can resort to gentle surgical interventions in the area of the ostiomeatal complex;
by doing surgical interventions it is necessary to spare the mucous membrane of the contacting surfaces, especially in the area of the funnel and formations of the ostiomeatal complex.

Damage to cells of the anterior ethmoid group and maxillary sinus due to anatomical changes in the ostiomeatal complex, it prevails in children over lesions of other sinuses in all age groups. Both the nasal turbinates (inferior and middle) and elements of the lateral wall of the nose (uncinate process, ethmoidal bulla, less commonly Haller’s cell, nasal shaft cells) are involved in stenosis of the ostiomeatal complex; therefore, surgical interventions for recurrent and chronic sinusitis children have the following operations:
elimination of postnasal occlusion (adenotomy);
intervention in the area of the nasal concha;
correction of elements of the lateral wall of the nose involved in the formation of natural anastomoses of the paranasal sinuses;
elimination of deformations 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 area of the prechambers is optimal in childhood, because she herself age group the child being operated on is indicated by the extent of the operation. If in adult patients a reasonable and sufficient volume of surgery, even with chronic purulent-polyposis sinusitis, frontal sinusitis, can be infundibulotomy with partial opening of the anterior ethmoid group without maxillary sinus, 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 .

A number of operations can be performed 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, opening the anterior chambers in the anterior ethmoid group is sufficient to obtain positive results in the treatment of chronic sinusitis, sinusitis, 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 operation, it is recommended to treat the nasal mucosa with oxymetazoline, ensuring a long-lasting anti-edematous effect. In the operating room, under endoscopic control, turundas soaked in oxymetazoline or phenylephrine and a topical anesthetic are introduced. Immediately after achieving superficial anesthesia, an injection of 2% lidocaine with a 1:200,000 epinephrine solution is performed using a special needle for endoscopic sinus surgery, or a dental needle and syringe or an insulin syringe are used.

The injection is made in the following areas:
along the attachment of the uncinate process (three injections);
to the place of fixation of the middle turbinate;
to the lateral and medial surface middle turbinate;
further, depending on the volume of surgical intervention (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 posterosuperior parts of the lateral wall of the nose and septum, as well as the branches of the sphenopalatine nerve, passing with the main vessels from the sphenopalatine foramen and supplying the lateral wall of the nose. It is important that the process of administering the anesthetic is carried out slowly, and the operation does not begin until the anesthetic has produced the desired effect. The combined action of the topical anesthetic, the injected local anesthetic and the surface action of the decongestant provides a reliable blood-free field in most cases.

Endoscopic surgery is becoming more and more popular among practicing surgeons every day. Doctors of various specialties are trained in endoscopic surgery techniques, since the undeniable advantages of this type of surgical intervention have already been proven more than once. Endoscopic surgery is widely used in otorhinolaryngology as one of the methods of surgical intervention. Endoscopic sinus surgery is one of the most effective methods treatment inflammatory diseases nasal sinuses, which wins the love of an increasing number of doctors who prefer this type of surgical intervention.

Indications and contraindications for endoscopic sinus surgery

The very concept of functional endoscopic surgery is based on minimal surgical intervention on the structures of the nasal cavity with maximum restoration of them physiological functions. There are certain indications and contraindications for endoscopic sinus surgery. Indications for the operation are as follows:

acute and chronic, serous and exudative sinusitis;
limited polypous sinusitis;
fungal inflammation of the sinuses;
sinus cysts;
foreign bodies in the nasal cavity and paranasal sinuses;
bullae and hyperplasia of the nasal mucosa;
Dacryocystorhinostomy.

Endoscopic sinus surgery is not recommended for the following conditions:

intracranial and orbital rhinogenic complications;
malignant neoplasms of the nasal cavity and sinuses;
osteomyelitis in the paranasal sinuses;
scar and bone obliteration of the anastomosis area after previous operations on the nasal sinuses.

Technique for endoscopic sinus surgery according to Messerklinger

There are two main techniques for endoscopic sinus surgery. The most widely used technique is the Messerklinger technique. The technique of this surgical intervention consists of step-by-step opening of the structures of the nose in the direction from front to back. The nasal sinuses are sequentially opened and those discovered during surgery pathological changes. Step by step, the structures are revealed in the following order:

uncinate process;
ethmoid bulla;
Anterior cells of the ethmoidal labyrinth;
infundibulum and anastomosis of the maxillary sinus;
frontal bay;
middle grid cells;
rear grid cells;
sphenoid sinus.

Technique for performing endoscopic surgery according to Wiegand

The second most common endoscopic sinus surgery is the Wiegand technique. According to this technique, surgical intervention begins from the deep parts of the nasal cavity and moves from back to front. First, the sphenoid sinus is opened, then the posterior and middle cells of the ethmoidal labyrinth, then an infundibulotomy is performed and at the end of the operation the anterior cells of the ethmoidal labyrinth are opened. A feature of the Wiegand method of endoscopic sinus surgery is its great radicality, since a total opening of the cells of the ethmoidal labyrinth is performed and an anastomosis with the maxillary sinus is created under the inferior nasal concha. This is done for almost all forms of sinusitis.

Benefits of endoscopic sinus surgery

Endoscopic sinus surgery has particular advantages over other types of sinus surgery. First of all, only endoscopic surgery guarantees maximum constant visual control over the progress of the entire operation, and thereby ensures high accuracy and the functionality of all actions performed by the operating surgeon. In addition, endoscopic intervention ensures minimal bleeding and preservation of the mucous membrane pathologically unchanged. Postoperative period For patients it is also much faster and painless. Thus, endoscopic sinus surgery is one of the most effective methods for treating sinusitis.

Surgery on the maxillary sinus (maxillary sinus) is a rhinosurgical intervention performed 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 of the 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 message between 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 a visit to the salt cave. Within a year after surgery, you should be observed by an otolaryngologist.

Currently, endoscopic surgery of the paranasal sinuses is rapidly developing and has already gained the status of minimally invasive surgery, functional surgery, etc. in otorhinolaryngology and head and neck surgery.

Most of the works devoted to endoscopic surgery for pathological conditions of the nasal cavity and its paranasal sinuses, concerns its use in diseases of an inflammatory nature. D. Kennedy and B. Senior state that the use of endoscopic technologies for such conditions of the nasal cavity and its paranasal sinuses is a progressive method that allows limiting the scope of surgical intervention with sufficient access.

In addition to the improvement and development of diagnostic methods, an important role in the achievements of endoscopic surgery in general and surgical interventions in the nasal cavity and paranasal sinuses in particular is played by the progress of scientific and technical thought in the creation of new instruments.

Development of methods for diagnosing and treating paranasal sinuses

Article by N. Krouse et al. contains general discussions about mechanical-power instruments, which have gained popularity in otorhinolaryngology due to their safety and effectiveness in sinus surgery. Understanding of the principles and techniques of mechanical-force dissection in the paranasal sinuses, exposure, installation and management of instruments, pre- and post-operative care necessary for otorhinolaryngologists treating such patients. More detailed and important information on the issue of interest is available in the works discussed below.

It is known that during endoscopic operations, stereoscopic vision and tactile information about tissue consistency are not always available to the surgeon. To overcome this drawback, P. Plinkert and H. Lowenheim propose a technique for characterizing various tissues with an electromechanical sensor that determines their resonant frequencies. In the future, the electromechanical sensor is expected to be connected to surgical instrument, providing the surgeon with information about the tactile properties of tissues. The authors studied using this method the density of tissues removed during surgery (nasal polyps, The lymph nodes, cartilage, bone), as well as various bony structures of the skull.

The studies were carried out under experimental modeling conditions and subsequently with a prototype tactile sensor. The authors concluded that resonant frequencies increase with increasing tissue density. Measurements on experimental model showed that the resonant frequencies for soft tissues are in the range of 15-30 Hz, for the bony septum of the ethmoidal labyrinth - 240-320 Hz, and for denser bone structures base of the skull – 780-930 Hz. Characteristics of tumor tissue upper sections respiratory tract and initial sections digestive tract indicate the possibility of distinguishing between healthy mucosa, tumor-infiltrated mucosa, and tumor-infiltrated tissue under the mucosa. In the latter cases, the resonance frequencies of the tumor were 1/3 higher than those of the healthy mucosa. The results obtained in the experiment were reproduced using a sensor prototype. The authors emphasize that the use of information about the tactile characteristics of tissues in endoscopic otorhinolaryngological surgery may improve the discrimination of tissue structures during surgery in the future. In addition, it will improve the safety of minimally invasive interventions in head and neck surgery.

Instruments for removing pathological tissue in sinus surgery have also improved.

Thus, G. McGarry et al. reported the invention of a microdebrider (microforceps) for endonasal surgery, which allows for accurate and precise tissue removal without damaging the surrounding mucosa. However, it should be emphasized that a conventional instrument can render the tissue being removed unsuitable for histological examination. This problem is made even more apparent by the fact that the Hummer microdebrider does not have a mechanism to collect the tissue pieces being removed. Using a microdebrider, 21 people were operated on for polyposis of the paranasal sinuses. During the intervention, the removed drugs were collected in a special trap. At the same time, tissue biopsies from surrounding areas were performed for comparison. Pathoanatomical diagnosis was established in all patients. In one observation, transitional cell papilloma was detected, in the remaining 20 cases, inflammatory polyposis, and in 2 of them, granuloma. Traces of injury were limited to the respiratory epithelium. Subepithelial tissues were not affected, the metaplastic epithelium was intact.

The use of a microdebrider makes histological examination impossible. The removed tissues have minor “artifacts” and are preserved for pathological diagnosis.

The work of D. Becker discusses the engineering and technical aspects of the problem of cutting devices - “razors” for soft tissues and drills for bone. An in-depth understanding of the principles of their operation will allow the surgeon to optimize the effectiveness of the instruments used. These mechanical instruments can be used not only within the sinuses, but also for mental lipectomy (“razor” for soft tissues), reshaping the nasal wall (drill for bone tissue). The authors touch upon the issues of changing the design of tools for these and other purposes.

Some aspects of these issues relating to children's practice are covered by M. Mendelsohn and S. Gross. They presented the latest examples of mechanical instrumentation for various areas of nasal and sinus surgery, especially in children. Anatomical spaces in children are smaller and much closer to vital structures. The advantage of the “razor” apparatus for soft tissues is the possibility of simultaneous suction, which increases the accuracy of manipulation.

J. Chow and J. Stankiewicz used similar mechanical instruments to decompress the orbit and optic nerve. This toolkit helps to perform operations as safely, functionally and fully as possible. The use of a microdebrider and drill under endoscopic visualization allows one to achieve the necessary drainage and decompression for orbital abscesses, ophthalmopathy, and injury to the optic nerve.

J. Bernstein et al. studied the effect of a microdebrider on tissue healing after use in endoscopic sinus surgery. The formation of synechiae, often observed after endoscopic operations on the paranasal sinuses, can cause exudative manifestations in the sinus area. To reduce the incidence of this complication, different approaches: careful and careful surgical technique, partial resection of the middle turbinate, insertion of tampons or stents into the middle nasal passage, postoperative sanitation. A microdebrider is a mechanically rotating cutting device for precise tissue removal, minimizing mucosal trauma and crushing. The authors presented the experience of 40 endoscopic operations on the paranasal sinuses performed using a microdebrider. The patients were observed for 5 months. Marked fast healing mucous membrane, minimal formation of scabs and crusts, as well as low frequency adhesions - synechiae. These initial results suggest some benefits of microdebriders in chronic sinusitis surgery.

W. Richtsmeier and R. Scher used Hopkins angled endoscopes to expand surgical capabilities during endoscopic surgery, in particular in the area of the larynx and hypopharynx. Typically, surgical interventions in these areas are performed directly, under the naked eye, or under an operating microscope. 48 cases in which solid endoscopes were used were analyzed. The authors found significant advantages of endoscopic systems when operating on surfaces that are not in the direct line of sight of the surgeon, such as the walls of the hypopharynx, the base of the epiglottis, the ventricles and the posterior commissure. Endoscopes with viewing angles of 30° and 70° were recognized as convenient to use, but in these cases appropriate tools were required. To remove lesions on vertical surfaces, it is advantageous to use a laser (titanophosphate oxide) through a flexible fiber-optic conductor. Endoscopes also allow the use of instruments large sizes, proposed for intra-abdominal and intrathoracic surgery, blocking the view through the operating microscope. Telescopic visualization of the larynx and hypopharynx brings surgical manipulation to a more traditional form of endoscopic surgery.

Anesthesia in endoscopic nasal surgery

A certain place in the organization of interventions in endoscopic surgery of the nasal cavity and its paranasal sinuses, in addition to the provision of instruments, is occupied by the issues of adequate pain relief. Its form - local or general - is determined by the localization and extent of the object of surgical intervention and the type of pathological focus.

For the nasal cavity and paranasal sinuses it is often used local anesthesia. M. Jorissen et al. studied the possibilities of such anesthesia and contraindications to its use. When performing endoscopic surgical interventions in the area of the paranasal sinuses, the authors do one intramuscular injection as a systemic premedication (pethidine and promethazine) and carry out local anesthetic treatment (a few drops in the nose, lubrication with cocaine, infiltration with lidocaine). This anesthesia is well tolerated by 95% of patients. Blood loss is minimal with adequate anesthesia.

Long-term results of endoscopic interventions

An analysis of long-term results and complications of miniendoscopic interventions on all paranasal sinuses in chronic polypous sinusitis was carried out by R. Weber et al. The study included 170 patients who underwent bilateral endonasal miniendoscopic sinus surgeries or ethmoidectomy. The observation period ranged from 20 months. up to 10 years. A study conducted by calibrating the results, i.e. comparison of clinical findings and surgical material to be evaluated showed the effectiveness of the intervention in 92% of cases. When analyzing complications, the frequency of injuries to the hard meninges ranged from 2.3 to 2.55%, periorbital formations - from 1.4 to 3.4%. In 2 cases there was bleeding from the internal carotid artery. According to the authors, the problem of vascular complications should be carefully studied and discussed. In conclusion, the work emphasizes that more than 90% of patients with chronic polypous sinusitis can achieve satisfactory long-term results after endonasal ethmoidectomies using a microscope and endoscope. To minimize the risk of injury to the optic nerve or internal carotid artery, it is necessary to carry out in the preoperative period computed tomography. Also recommended special program training and education.

The issues of healing of the mucous membrane of the paranasal sinuses after endoscopic intervention were studied in an experiment by D. Ingrams et al. They studied the effect of mitomidine C on the healing processes and concluded that it has an antiproliferative effect on fibroblasts.

Y. Guo et al. investigated the effect of functional endoscopic surgical treatment of sinuses on the epithelial cover of the mucous membrane of the maxillary sinus. We studied biopsy samples of the mucous membrane of the supralateral wall and the area of the bone foramen, which were taken during surgery and after 6 and 12 months. after it (on average after 7.6 months). The study of the integumentary epithelium was carried out by scanning electron microscope and an image analyzer, which was enhanced in the area of the integumentary epithelium, where the surface of the mucous membrane was covered with ciliated (integumentary) epithelium. In 20 cases of chronic maxillary sinusitis (16 patients), functional endoscopic operations. The saturation of the ciliated epithelium on the right and left sides before surgery was 60.7 + 28.8 and 39.9 + 21.5%, respectively, in the area of the supralateral wall of the maxillary sinus and in the area of the opening. The saturation of the ciliated epithelium of the supralateral wall was significantly higher than in the area of the opening of the maxillary sinus (p<0,01). После операции основная насыщенность эпителиального покрова составила 74,3+22,6% в области супралатеральной стенки и 51,3+16,1% в области отверстия верхнечелюстной пазухи, т.е. значительно превышала предоперационную (р<0,01). Исследование показало, что слизистая оболочка верхнечелюстной пазухи при хронических синуситах способна регенерировать, а разрушенный реснитчатый эпителий может восстановиться до нормы с улучшением условий вентиляции и дренирования верхнечелюстной пазухи после эндоскопического хирургического вмешательства.

The lack of timely and adequate treatment of inflammatory processes in the nasal cavity and paranasal sinuses is often the cause of the development of polyposis of these structures. The effectiveness of endoscopic technologies here is obvious.

R. Jankowski et al. conducted a comparative study of the functional results of ethmoidectomy and nasalization (imposition of a wide anastomosis to restore the passage of air masses) in patients with diffuse polyposis. By “nasalization” the authors mean radical ethmoidectomy with the systematic removal of all bone cells and the mucous membrane of the ethmoid labyrinth with extended antrostomy, sphenoidectomy, frontotomy and removal of the middle turbinate (R. Jankowski operated on 39 patients between March and September 1991) . Ethmoidectomy was used less systematically, but was adequate to the extent of the pathological process (the second author, D. Pigret, performed 37 operations between October and November 1994). In May 1994, the third author, F. Decroocq, mailed a questionnaire to patients participating in the study: 34 out of 39 in the “nasalization” group (age 28-71 years, including 20 “asthmatics”, follow-up period 32-36 months. ) and 29 out of 37 in the “ethmoidectomy” group (age 26-55 years, including 9 “asthmatics”, follow-up period 18-31 months). The total number of cases of improved breathing was 8.8+0.2 after nasalization and 5.9+0.6 after ethmoidectomy. The improvement in sense of smell was similar between groups after 6 months. after surgery and remained at the same level for 36 months. after nasalization (6.9+0.7 patients), while after ethmoidectomy the sense of smell worsened to 4.2+1 after 24 months.

The improvement in the condition of patients with asthma was significantly more pronounced in the “nasalization” group; their need for steroid hormones was lower. The results of this study show that in the treatment of nasal polyposis and paranasal sinuses, the more radical the surgical intervention, the better the functional results.

The treatment of polyposis of the nasal cavity and its paranasal sinuses is also addressed in a study by J. Klossek et al. The authors note that, despite the progress achieved in endonasal surgery in recent years, diffuse polyposis of the nose and its paranasal sinuses remains an urgent problem. The purpose of this work was to evaluate the results of treatment of diffuse polyposis by radical full sphenoethmoidectomy with pre- and postoperative irrigation of the frontal sinus. The authors examined 50 patients with diffuse polyposis, manifested by nasal obstruction, anosmia and other symptoms of chronic sinusitis. All patients underwent endoscopic sphenoethmoidectomy, which included total opening and sanitation of the cells of the ethmoidal labyrinth and its pathologically altered mucous membrane. Preoperative and postoperative irrigation of the frontal sinus was performed. No complications were noted. In 39 out of 50 patients, a satisfactory sense of smell was achieved. Partial nasal obstruction occurred in 4 patients. By endoscopic examination, recurrence of polyposis was noted in 3% of cases in the posterior cells, in 23% in the anterior cells of the ethmoidal labyrinth, and in 50% in the frontal sinus. The authors conclude that for common polyposis of the nasal cavity and paranasal sinuses, total sphenoethmoidectomy with perioperative (before and after intervention), as well as subsequent postoperative therapy with the most effective steroid hormones is indicated, which helps improve the general condition and local status or ensures a lasting recovery.

R. Bolt et al. (1995) reported the results of endoscopic surgical treatment of polyps of the nasal cavity and paranasal sinuses in children. 21 children with nasal polyps were operated on endoscopically; 34 total operations and 65 unilateral operations were performed. The symptoms of the preoperative period, examination data, as well as the results of functional endoscopic treatment of the nasal cavity and its paranasal sinuses were analyzed. The diagnosis was made based on data from anterior rhinoscopy and computed tomographic scanning. An allergic component was identified in 24% of cases. Half of the children (52%) had previously been operated on for nasal polyps. They had a higher frequency of relapses and worse treatment results compared to children in whom endoscopic surgery was primary. Subjective treatment results were good in 77% of patients with a follow-up period of more than 2 years. However, a weak correlation between subjective and objective results was noted. Minor complications were observed in 9.2% of 65 patients operated on on one side. The advantages of endoscopic operations in children are noted.

The work of J. Triglia and R. Nicollas is devoted to the same topic. The authors state that polyposis of the nasal cavity and paranasal sinuses in children is still little known and its etiology is not clear enough. Based on data from an 11-year study, the authors highlight etiological factors and evaluate the effectiveness of endoscopic surgery of the nasal cavity and paranasal sinuses in 46 children. No surgical complications were noted. Most patients reported improved quality of life, reduction in nasal congestion (83%) and nasal discharge (61%). Small asymptomatic relapses (several micropolyps) were noted in 24% of cases, large relapses with the same symptoms as before surgery - in 12%. However, the number of relapses was higher in the group of patients with fibrous cyst formation. At the same time, small relapses without any clinical manifestations were observed in 32% of these cases, and large relapses (with obvious clinical symptoms) - in 16%. Endoscopic sinus surgery problems should be addressed in collaboration with the pediatrician and pulmonologist, and solutions should be carefully worked out. The long-term results of treatment of these patients over a follow-up period of 3.7 years are encouraging.

Endoscopic operations in the treatment of benign tumors and oncology

A number of works are devoted to endoscopic transnasal surgical treatment of benign tumor processes, in particular angiofibromas.

M. Mitskavich et al. A juvenile angiofibroma was removed intranasally endoscopically from a 13-year-old girl. Within 24 months. There were no signs of relapse after surgery. According to the authors, endoscopic surgical techniques have been used to treat some benign nasal tumors, such as invertible papilloma, while endoscopic removal of verified juvenile angiofibroma has not previously been reported. This technique is acceptable for tumors that are limited to the size of the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa.

Back in 1996, R. Kamel reported a case of angiofibroma of the posterior parts of the nasal cavity on the right, nasopharynx and pterygopalatine fossa, which was completely removed without complications using a transnasal approach under endoscopic control. Over the course of 2 years, endoscopic examinations and contrast-enhanced computed tomography (CT) revealed no signs of continued tumor growth or recurrence. The author noted the advantages, limitations, and possible complications of this approach. It was found that limited-sized angiofibromas accessible to a transnasal endoscopic approach can be removed by an experienced surgeon.

J. Klossek et al. published data on the removal of 109 mycetomas of the paranasal sinuses using functional endoscopic surgery. These tumors are most often diagnosed with the widespread use of nasal endoscopy and CT. Tumors of all locations were visible, 7 of them were located in several places (multicentric growth). Several clinical localizations involving all paranasal sinuses have been noted. Heterogeneous inclusions with microcalcifications detected by CT allow a diagnosis to be made with sufficient confidence, while homogeneous inclusions can even be regarded as bone lesions. Functional endonasal endoscopic sinus surgery was used in all cases to perform a wide dissection and overview of the affected paranasal sinuses, allowing for careful and thorough removal of the tumor-affected areas. In the postoperative period, drug treatment was not prescribed. Long-term results were followed for 29 months: only 4 relapses were noted. This study, according to the authors, has increased interest in the use of endonasal endoscopic surgery for mycetomas of the paranasal sinuses.

Having characterized various aspects of the multifaceted problem of using functional endoscopic surgery of the nasal cavity and its paranasal sinuses in the treatment of chronic inflammatory processes of a benign nature, we cannot ignore the issue of using the endoscopic method in other areas of medicine, in particular in oncology.

In the above-mentioned work by R. Kamel, the study included 17 observations of inverted papilloma of the upper jaw and nasal cavity, which the author divided into two groups.

The first group included 8 cases with lesions of the maxillary sinus; these patients underwent endoscopic resection within healthy tissue.

The second group included 9 cases of lesions of the maxillary sinus with or without extension into the nasal cavity; the patients were operated on using transnasal endoscopic medial maxillectomy.

Follow-up – an average of 43 months. in the first group and 28 months. in the second, with the exception of 5 cases with less than 2-year study of long-term results, no relapses of the disease were revealed.

The author concluded that invertible papilloma can be divided into two groups from an anatomical and behavioral point of view, and should be treated differently accordingly. For cases without maxillary sinus involvement, intranasal endoscopic resection is effective. In cases where the maxillary sinus is affected, transnasal maxillectomy is recommended, which can be safely performed under endoscopic control.

M. Tutino expanded the range of endoscopic interventions, including, in addition to endoscopy, also minimal craniotomies, combining osteotomies and removal of bone fragments to increase the accuracy of manipulations and reduce the number of complications in craniofacial surgery. When introduced into intracranial structures, the author opposes the widespread use of endoscopic techniques to reduce the incidence of complications and mortality during neurosurgical intracranial and plastic surgeries.

Functional transnasal endosurgery of the paranasal sinuses is quickly being introduced into otorhinolaryngology and maxillofacial surgery, developing in many ways as its component. Naturally, there are differences in the description of the complications that occur, which vary in frequency and severity.

Complications of transnasal endosurgery

R. Gross et al. note that complications were significantly more serious when interventions were performed under general anesthesia compared to those performed under local anesthesia. Estimated blood loss was also significantly higher during operations performed under general anesthesia.

A broader and more detailed study of the problem of endoscopic sinus surgery was carried out by H. Rudert et al. An analysis of the clinical characteristics of patients was undertaken to determine and develop directions for safe surgical techniques. We studied data on 1172 patients (2010 operations) from the head and neck departments of the University of Cologne, who were operated on for chronic sinusitis from 1986 to 1990. The following postoperative complications were observed:

damage to the dura mater - in 0.8% of patients (0.5% including operations on the sides);

retrobulbar hematomas – in 0.25% (0.15% taking into account operations on the sides);

bleeding requiring blood transfusion - in 0.8% of cases (0.5% taking into account operations on the sides).

There were no cases of injury to the orbital muscles, optic nerve, or carotid artery. 195 patients underwent dacryocystorhinostomy (15% of them had previously been operated on in the nasal area and paranasal sinuses).

Proponents of the endonasal technique must recognize the variability of results, especially in cases where bone formations (thickened bone walls of the sinuses) become the subject of surgical activity and the doctor faces great technical difficulties.

The most serious complication during and after the use of this method of endoscopic interventions is bleeding of various types, degrees, duration and volume.

Park et al. published a protocol for complications of endoscopic transnasal sinus surgery: injuries to the internal carotid artery. Damage to it in the area of the cavernous sinus is a well-known terrible complication of endoscopic endonasal sinus surgery. However, information regarding the prevention and treatment of this complication is very scarce in the literature. The authors of the mentioned work discuss issues of topographic anatomy, preventive measures, and treatment approaches.

Bleeding events with less tragic consequences were analyzed by D. Barlow et al. They retrospectively analyzed 44 cases of epistaxis that required hospitalization at the Neonatal Care Center. The study set itself the following goals:

determine indications for surgical treatment in such situations;

compare the effectiveness of different types of surgical interventions. In addition, length of hospital stay, complications and cost of services provided were assessed.

In 18 patients, conservative methods of stopping nosebleeds were successful; in 26, surgical methods had to be resorted to. It was found that late nosebleeds (p<0,05) и величина гематокрита менее 38% (p<0,05) являются важными показателями для реализации необходимого хирургического лечения. Повторные кровотечения после первого хирургического вмешательства отмечены в 33% случаев после эмболизации, в 33% после эндоскопической гальванокаустики, в 20% после лигирования сосудов. В то время как эмболизация, перевязка и эндоскопическая гальванокаустика приблизительно схожи по проценту неудач, такие факторы анализа, как стоимость услуг, а также экспертиза в институте, могут оказаться решающими доводами в пользу хирургического метода лечения.

Conservative methods of stopping nosebleeds are very diverse and involve the use of hemostatic medications, including numerous types of tamponade of the nasal and nasopharyngeal cavities. One of the latest proposed methods is the introduction of hemostatic sponges.

A. Shikani attempted to characterize the bacterial flora of chronically infected sinuses and evaluate the possibility of directly administering antibiotics to the spongy tissue to prevent the development of infection.

During surgical intervention on the sinuses, bacterial flora is sown in 89% of cases. The same flora is determined in 67% of cases when cultured from the nasal cavity and paranasal sinuses after 1 week. after operation. By saturating the spongy structures of the Merocel type introduced into the sinuses with polymyxin, neomycin and hydrocortisone, it is possible to reduce this percentage by 36. At the same time, the pain when removing the sponge from the sinuses during dressings is reduced. This confirms the advisability of using antibiotics when using expanding sponges during endoscopic operations in the nasal cavity and paranasal sinuses.

The measures to prevent and eliminate complications of endoscopic surgery in this area from the orbital side are somewhat unique. This is due to the high sensitivity of the anatomical formations of the orbit to any changes in their physiological status caused by surgical manipulations in the surrounding areas, both directly and indirectly. The topographic relationships of the anatomical structures of this part of the head, located in close proximity to each other, also play an important role.

Despite the fact that ophthalmological complications during endoscopic operations in the nasal cavity and paranasal sinuses are well known, they are rare in clinical practice. Therefore, any messages on this topic are of undoubted interest to specialists.

Thus, I. Dunya et al. To study the frequency of complications from the orbit after intranasal interventions on the ethmoidal labyrinth, 372 observations were analyzed. Most of them performed bilateral operations. The authors found 5 ophthalmological complications. In their opinion, the following practical recommendations can help surgeons avoid complications:

if there is a suspicion of a violation of the integrity of the orbital wall (both according to CT data and during surgery, especially during repeated surgical interventions), extreme care must be taken not to enter the periorbital tissue;

if the fatty tissue of the orbit falls into the surgical field, it should not be injured (compressed, twisted) when trying to remove it;

During the treatment of the patient, the surgeon and the anesthesiologist must work closely together;

good knowledge of anatomical variants helps to avoid iatrogenic complications;

the surgeon is able to prevent a serious complication if he is able to recognize it at an early stage and take the necessary measures.

It is known how dangerous inflammatory complications from the orbit can be (up to meningitis and thrombosis of the cavernous sinus through v. ophthalmica) if countermeasures are not taken in a timely manner. From this point of view, periorbital cellulitis requires serious attention, although its localization is often limited to the preseptal region. In the absence of adequate therapeutic measures, they may be accompanied by post-septal inflammation and orbital subperiosteal abscesses (SPA). Surgical treatment of SPA consists of wide drainage - removal of ethmoidal labyrinth cells using an external approach. The use of endoscopic techniques for this purpose has recently been reported.

E. Page and B. Wiatrak studied the incidence and clinical picture of post-septal cellulitis and orbital SPA in patients with periorbital cellulitis, as well as the effectiveness of endoscopic technology in orbital SPA. In the period 1989-1994. observed 154 patients diagnosed with periorbital cellulitis. Postseptal inflammation was detected in 19 of them. 14 patients underwent surgical treatment - using an external approach, endoscopic intervention, or a combination of both. The authors were able to establish the following:

the role of paranasal sinus pathology as a cause of periorbital cellulitis;

the role of CT as a diagnostic test;

the effectiveness of aggressive active and timely drug therapy;

results of endoscopic drainage of orbital SPA in comparison with those after using an external approach.

In this regard, it is impossible not to mention bleeding in this area as one of the reasons for the development of inflammation, as well as in view of their independent danger and the seriousness of the consequences, including loss of vision, etc.

S. Saussez et al. We encountered in our practice 2 similar cases of orbital complications after intranasal endoscopic surgery. One complication arose in the immediate postoperative period - an orbital hematoma, which required urgent decompression by lateral canthotomy. The second complication was acute bleeding in the orbital area, which also required urgent lateral canthotomy. Both observations demonstrate the ability to quickly and safely surgically (lateral canthotomy) reduce intraorbital (intraocular) pressure.

Among the causes of increased intraorbital pressure may be not only bleeding, but also swelling of the retrobulbar and periorbital tissue of various origins. All anatomical structures of the orbit, in particular nerve tissue, can be subject to compression. Its compression, leading to optic neuropathy, can also occur in patients with pathology of the thyroid gland - thyrotoxicosis, the so-called Graves' disease. In other words, this condition can be called “orbitopathy of thyroid origin.”

To treat this dangerous complication, many surgical approaches have been proposed, thanks to which it is possible to achieve intraorbital decompression.

S. Graham and K. Carter described the technique of subciliary anterior orbitotomy - approach to the floor of the orbit with endoscopic resection of its medial wall. This allows the bone tissue of the orbital floor to be removed medial and lateral to the infraorbital canal (inferior orbital nerve canal). The anterior part of the orbital floor is left to support the eyeball.

This combined approach has a low complication rate. At the same time, it is possible to achieve an increase in the height (apex) of the medial wall of the orbit and decompression in the area of its bottom. The authors cite as an illustration 2 clinical observations where this approach was able to achieve a lasting improvement in vision. Surgical interventions with such a combined approach have technical advantages over other operations for compression optic neuropathies of thyroid origin.

Complications, including blindness, that have developed as a result of various causes, in particular trauma, in some cases can be eliminated surgically. Sometimes, in case of traumatic blindness, the use of endoscopic techniques for decompression of the optic nerve is effective.

Some of the most serious complications in paranasal sinus surgery are complications after operations in areas close to the bone structures of the skull or its contents - the brain. Surgical interventions in these areas, either endoscopically assisted or performed entirely endoscopically, require both a thorough knowledge of anatomy and exceptional surgical technique. Due to the complexity and significance of this object of surgical intervention, even perfect knowledge and technology cannot guarantee against the occurrence of complications of different nature and consequences. One of the most dangerous is damage to the meninges and leakage of cerebrospinal fluid (CSF). The question of technology for eliminating this complication is largely controversial. Most researchers prefer either an endoscopic or an external-extracranial approach, which depends on the preference, experience and capabilities of the surgeon.

T. Kelley et al. presented to the readers a work whose main objective was to create an alternative technique for combating CSF leakage in the area of defects in the anterior cranial fossa. The study also aims to reflect the authors’ own experience and present their technical techniques, which have been maximally developed in practice. Case histories were analyzed. Elimination of areas of CSF leakage that occurred after surgery was required in 8 patients. Of these, 7 patients succeeded on the first attempt, 1 patient on the second. There were no complications during the follow-up period from 1.5 to 4 years. None of the patients had acute or delayed (late) meningitis. The authors conclude on the safety and effectiveness of the technique of endoscopic closure of postoperative defects - fistulas in the area of the anterior cranial fossa, if it is performed by an experienced surgeon.

M. Wax et al. studied modern methods of treating spinal rhinorrhea since 1990. Of 18 cases, in 7 cases the complication arose during endoscopic surgery, in 3 cases – during lateral (side) rhinotomy with excision of a benign tumor of the nasal cavity, in 1 case – during secondary plastic surgery after intranasal ethmoidectomy, in 7 cases it developed spontaneously. In 11 patients, CSF leakage was detected during surgery. In 10 of them, plastic surgery of the defect was performed immediately during the intervention; 1 patient required secondary plastic surgery after unsuccessful conservative treatment. In 7 patients there was a rupture of the spinal membrane with spontaneous leakage of CSF. In 4 patients the defect was detected by CT, in 2 – by cisternography. Magnetic resonance cisternography was performed in one patient. The presence of a defect identified cisternographically was confirmed during surgery in both cases. For plastic surgery of defects, a pedicled flap from the mucous membrane of the nasal septum was used in 4 patients, a free graft from the mucous membrane of the nasal septum was used in 7 patients, and the middle turbinate was used in 5 patients. In 2 patients, obliteration of the sinus was achieved using a muscle-fascial and fibrin sponge. 8 patients were operated on endoscopically, the rest used an external approach. In 17 patients (follow-up period of at least 1 year) there was no leakage of CSF from the nasal cavity - rhinorrhea; one required repeat plastic surgery after 8 months. after operation.

Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Immediate diagnosis of this complication and the use of the most gentle approach are necessary. This ensures success in 95% of cases. The preference for an endoscopic or external approach is determined by the knowledge, experience and capabilities of the surgeon.

H. Valtonen et al. investigated ways to prevent CSF leakage during suboccipital acoustic neuroma removal. The purpose of the study was to determine the feasibility of direct examination of temporal bone air cells using endoscopic techniques. This, in turn, may create the prerequisites for reducing the frequency of CSF leakage during operations for suboccipital acoustic neuroma, in which such a complication occurs most often. With the introduction of nuclear magnetic resonance into the clinic, which has made it possible to improve the diagnosis of the smallest tumors - acoustic neuromas, the suboccipital approach is being increasingly used. With its use, the average frequency of liquorrhea is 12%, sometimes reaching 27%, and the most common complication is presented in the form of rhinorrhea.

Ideally, this complication can be avoided by carefully closing all air cells exposed during the incision using this approach. They are especially often opened in the area of the posterior wall of the internal auditory canal, as well as in the retrosigmoid region. Typically, these cells are plugged with various materials, often indirectly, since their visualization through operating microscopes is impossible. The inability to recognize potentially dangerous cells may be an important reason for the development of liquorrhea after surgery. The study examined 38 cases of cerebrospinal rhinorrhea during operations for suboccipital acoustic neuromas, during which a conventional (adapted to these conditions) technique was used. In this case, tamponade of the temporal bone was performed around the internal auditory canal. For comparison, 24 corresponding operations were analyzed using an endoscope to directly and directly visualize all exposed cells. After assessing the location of all potentially dangerous cells using an endoscope, they were filled with bone wax. Fat grafts taken from the edges of the wound were then used to fill the remaining defect. Postoperative cerebrospinal rhinorrhea was observed in 7 (18.4%) of 38 cases in which endoscopic techniques were not used. Of the 28 operations using an endoscope, there was not a single case of CSF leakage. The authors conclude that the use of endoscopes to visualize the air cells of the temporal bone, which are not directly visible by other means, can reduce the incidence of postoperative CSF leakage during operations for acoustic neuromas performed through the suboccipital approach.

Despite the achieved standardization of the intervention technique, this type of operation is associated with a certain risk. Most reports of complications note their minimality. However, serious complications require immediate comprehensive medical and surgical treatment in order to reduce dangerous consequences. A complete preoperative examination and accurate assessment of its results, good preparation of the patient, “soft”, adapted technique and experience acquired by regular practice in this field of surgery play a big role in reducing the risk of complications.