Sinusitis Symptoms Treatment

Sinusitis is an inflammatory disease of the paranasal sinuses, one or more of the four sinuses in the facial bones.

The sinusitis is the most common disease in ENT practice, they constitute 25 to 38% of all patients in the otorhinolaryngological hospital, and this indicator tends to increase every year. About 5% of the European population suffers from chronic sinusitis .Most often, the maxillary sinus( maxillary sinusitis) is affected, the inflammation of the cells of the latticed labyrinth( etmoiditis) is on the second place, the frontal sinusitis( frontitis) in the third place, and the sphenoiditis inflammation on the fourth.

In children up to 3 years of age, the cells of the latticed bone( etmoiditis) are usually affected; in children from 3 to 7 years old, the combined damage of the latticel and maxillary sinuses is more often observed. Combined inflammation of several sinuses is designated as polisinusit, the defeat of all sinuses on one side - hemisinusitis, all sinuses on both sides - pansinusitis.

Below are some terms that also characterize the damage to the paranasal sinuses.

Piоsinus - a congestion of a sore pus in the sinus( for example, the flow of pus from the cells of the latticed maze and the frontal sinus into the maxillary).

Piocele - cystic sinus dilatation with purulent contents.

Mukocele - cystic sprain of the sinus with mucous contents.

Pneumatosus - cystic sprain of the sinus with air.

Hematoceles - same with blood.

Closed empyema - inflammation of the sinus, isolated from the nasal cavity.

Open empyema - sinus inflammation in the breakdown of pus through the skin or mucous membrane.

According to the nature of the flow, acute and chronic sinusitis are distinguished, depending on the causes and pathways of infection - rhinogenic, odontogenic, nosocomial and fungal sinusitis.

In case of irritation, the mucous membrane lining the sinus may swell and block small channels that allow the mucus to drain into the nose. Increased pressure often causes headache, a stuffy nose and pain in the face area.

The nasal cavity communicates with the paranasal sinuses, or the sinuses of the skeleton. These sinuses are called gaymorovymi. They can be exposed to infection, and as a result, inflame and cause discomfort and even pain. Predecessors of sinusitis can be acute respiratory disease, runny nose, cold.

Normally the sinuses are filled with air coming in through the nose. If they get an infection, there is inflammation - sinusitis. Especially often sinusitis is observed after the flu. Viruses penetrate into the sinuses or directly from the nose, or are carried by a current of blood. Often, germs fall into the sinuses during an acute cold. Sinusitis occurs sometimes as a result of trauma.

Sinusitis can be acute and chronic. Signs of them are very diverse and are due to where exactly the inflammatory process originated, one or more sinuses are involved in it.

• A viral or bacterial infection that spreads into the sinuses from the nose.

• Anatomical abnormalities such as curvature of the nasal septum.

• Allergy leading to swelling and formation of polyps.

• Swimming in dirty water.

• Spread of infection from abscesses in the upper teeth.

• Chronic sinusitis can be caused by irritation from dust, air pollutants, prolonged exposure to tobacco smoke or the result of an untreated acute illness.

Recent studies indicate a link between sinusitis and vitamin A deficiency.

Cold and dampness are additional factors.

In the development of sinusitis, there is a violation of local and general immunity, a decrease in the protective function of the mucous membrane of the nasal cavity and sinuses.

In acute respiratory-viral diseases of the upper respiratory tract, pathogenic microflora penetrates into these or those sinuses through natural anastomoses, and then the so-called rhinogenic sinusitis develops. In acute infectious diseases( diphtheria, scarlet fever, measles, etc.), a hematogenic pathway of infection into the sinuses is also possible. In addition, a frequent source of inflammation of the maxillary sinuses are diseases of the roots of the teeth adjacent to the lower wall of the sinus, in these cases the developed sinusitis is designated as odontogenic.

Important predisposing factors, in particular, anatomical abnormalities of intra-nasal structures: curvatures, crests, spines of the septum of the nose, as well as acute and chronic rhinitis, adenoid vegetations, polyps. This creates conditions that disrupt the aeration and drainage of the paranasal sinuses.

When examining the contents of the inflamed maxillary sinus, first of all, the bacterial flora - Streptococcus pneumoniae, Haemophilus influenzae, Moraxella cataralis, Staphylococcus aureus, hemolytic streptococcus, Escherichia coli, less often anaerobes. Very often the cause of sinusitis is a mixed infection, fungi, viruses. A role is played by hard-to-cultivate bacteria - chlamidia pneumoniae and mycoplasma pneumoniae. With nosocomial( nosocomial) sinusitis, which recently occurs more often and is associated usually with prolonged nasotracheal intubation, crops often reveal Pseudomonas aeruginosa, Klebsiella pneumoniae and other gram-negative bacteria.

The frontal and maxillary sinuses communicate with the nasal cavity through a complex system of narrow spaces that ensure their drainage and ventilation. The frontal sinus frontal pocket and the cranial funnel of the maxillary sinus play a key role in ensuring the physiological state of the large sinuses. These spaces are lined, like the entire nasal cavity, with a ciliary epithelium, but since they are very narrow, the epithelial surfaces are very close to each other.

It is established that if in these narrow spaces there is edema and the opposite surfaces of the mucous membrane begin to touch, then the ciliary activity of the epithelium cells sharply decreases, and these spaces are completely blocked. Disturbed ventilation and evacuation of mucus from the sinuses, the partial pressure of oxygen decreases, all this further depresses the mucociliary clearance until its complete stop. Very quickly develops microbial flora and signs of infectious inflammation of the adjacent sinuses. Thus, in the development of acute and chronic sinusitis, the violation of the secretory and transport functions of the mucociliary apparatus of the mucous membrane of the nasal cavity is of no small importance.

It is necessary to take into account that under unfavorable environmental conditions( gas contamination, dust, industrial emissions), also oppression of glandular cells and directional movement of cilia of ciliated epithelium( mucociliary clearance) also occurs. This leads to stagnation of mucus, violation of the evacuation of foreign bodies from the nasal cavity and paranasal sinuses, which, in turn, provokes the further development of infection and inflammation in them.

In the catarrhal form of acute sinusitis serous impregnation of the mucous membrane occurs and pronounced edema develops. Sharply, in dozens of times, the thickness of the mucous membrane increases, it can fill the entire sinus, pseudocysts are formed in its thickness. Swelling of the mucous membrane leads to complete obstruction of the anastomosis. Cilia of ciliated epithelium disappear.

In the purulent form of sinusitis, not only the mucous membrane but also the periosteal layer is involved in the inflammatory process, and in severe cases the inflammation also extends to the bone. Periostitis develops, which causes a prolonged course and the transition of the disease into a chronic form, and sometimes the formation of rhinogenic complications.

There are various classifications of inflammatory diseases of the ONP, but the most rational for clinical practice is the modified classification of BS.Preobrazhensky. It involves the division of sinusitis in accordance with pathohistological changes in the mucous membrane of the sinus of the nose and tentatively determines the therapeutic tactics for each form.

A constant symptom of sinusitis is a headache: dull or sharp, limited to a specific area( forehead, nape) or spilled. In acute sinusitis, the corresponding half of the nose is often laid, the sense of smell decreases, the person does not feel the taste of food. Discharge from the nose, initially mucous, becomes purulent. Sometimes there is photophobia and lacrimation, which is associated with a narrowing or plugging of the nose - a tear duct.

Acute sinusitis develops often after a cold or flu. Often, sinusitis passes by itself and responds well to treatment at home. How to use folk remedies for this disease look here.

Occasionally, the infection can spread to the eyes or brain and lead to loss of vision, meningitis or brain abscess.

If the appearance of signs of sinusitis does not address the doctor in a timely manner, the disease can become chronic. Chronic sinusitis is a permanent or recurring disease, which is generally more mild than acute sinusitis. The headache is less intense, diffuse, but the rhinitis does not stop, sometimes accompanied by an unpleasant odor. Often, taste sensations are lost, and then the appetite disappears. In addition, the constant flow of purulent discharge into the pharynx and stomach can cause heartburn, bad taste in the mouth, nausea and even vomiting. In some patients with chronic sinusitis, working capacity decreases, mood deteriorates.

• A medical history and physical examination are needed.

• Removal of fluid from the maxillary sinus with a needle or suction device may be necessary to determine the type of bacterial infection.

• X-rays can be used to identify an infected site or patches.

Symptoms of sinusitis largely depends on the localization of the inflammatory process, but there are common symptoms common to all types of sinusitis. This is explained, in particular, by the frequent combined lesion of several paranasal sinuses.

Common symptoms are fever to subfebrile or febrile, poor health, loss of appetite. Typically, the patient notes a one- or two-sided obstruction of nasal breathing, mucous or purulent discharge from the nose, a headache, a violation of the sense of smell of varying severity.

Headache can be localized in the frontal areas, especially with frontal sinus disease. When the maxillary sinus is affected, the pain is projected into the area of ​​the upper jaw, the temple, and irradiates into the teeth;when the cells of the latticed labyrinth become inflamed - into the region of the root of the nose and temples;with sphenoiditis, into the occiput and crown area. The intensity of pain is different - from a mild feeling of severity to severe pain, disturbing well-being and decreasing the patient's ability to work. Characteristic increase in pain when the head is tilted.

Blood test( left shift, moderate leukocytosis, acceleration of ESR) usually indicates the development of inflammation.

In acute sinusitis, inflammatory swelling of the soft tissues of the face can develop. So, with genyantritis, edema usually spreads to the lower eyelid and soft cheek tissues;with etmoiditis and frontis - it seizes the upper eyelid, sometimes soft tissues of the superciliary area.

Palpable tenderness in the canine fossa region( with sinusitis), lateral slope of the nose( with etmoiditis), in the area of ​​the frontal sinus projection( at the front) can be detected.

The duration of the disease can be small - up to 2 weeks. However, with inadequate therapy, the process is delayed, taking a chronic course.

Diagnostics. The diagnosis is established taking into account complaints, examination data, palpation of the walls of the paranasal sinuses, the results of a rhinoscopy, including optical, performed using endoscopes. Of great importance in the diagnosis are the results of diaphanoscopy and radiation research methods - traditional radiography and computed tomography( CT) scan of the paranasal sinuses, less often - magnetic resonance imaging( MRI).If necessary, perform a catheterization or diagnostic puncture of the nasal sinuses.

With anterior rhinoscopy, the swelling of the nasal mucosa is revealed, which is more pronounced in the region of the middle nasal passage, here purulent discharge is determined. With posterior rinoscopy, pus flowing from the anterior paranasal sinuses is seen in the middle nasal passage, and pus from the posterior cells of the latticed labyrinth and the sphenoid sinus is in the upper nasal passage. Sometimes pus in the nasal passages is detected only after anemia( lubrication with vasoconstrictor) of the mucosa.

Radiological picture in acute inflammation of the anterior paranasal sinuses is quite typical. Usually, radiographs are performed in a straight line( nasolobnoy and nosopubborodochnoy) and lateral projections. With catarrhal sinusitis and front on radiographs, one can see a parietal thickening of the mucous membrane of the sinuses, sometimes an easy reduction in their pneumatic properties;purulent process is manifested by a homogeneous darkening of the sinus. If the picture is made in the vertical position of the patient, the level of the liquid can be seen in the lumen of the maxillary sinus. To identify inflammatory changes in the posterior cells of the latticed bone and the sphenoid sinuses, the traditional X-ray projections are poorly informative, in this case, a computed tomography is shown.

With a diagnostic( and therapeutic) purpose, the puncture of the maxillary and trepanopuncture of the frontal sinuses is performed.

Puncture of the maxillary sinus. To facilitate the evacuation of the fluid through the natural sinus anastomosis with the nose, anemia of the mucous membrane of the nasal cavity is produced before the puncture, especially in the area of ​​the middle nasal passage. For this purpose, vasoconstrictive drugs are used. The mucous membrane of the lower nasal passage is lubricated with application anesthetics( 10% solution of lidocaine or diphenhydramine, 5% cocaine solution, etc.).

The optimal puncture site is at the upper point of the arch of the lower nasal passage at a distance of about 2 -2.5 cm from the anterior end of the inferior nasal shell. Here, the thickness of the lateral bone wall of the nasal cavity is minimal, and this facilitates the performance of the puncture. After the Kulikovsky's needle is placed under the inferior nasal concha, its head is withdrawn in the medial direction, so that the needle itself is located as much as possible vertically to the lateral wall of the nose, and its sharp end was directed toward the outer corner of the eye on the same side. The needle is grasped with the entire hand of the right hand so that its head rests against the palm of your hand, and the index finger is on the needle, fixing and guiding it. Applying moderate strength and producing light rotational movements with a needle, produce a puncture of the sinus wall, penetrating into its cavity to a depth of about 10-15 mm.

After making sure that the end of the needle is in the sinus, the contents are syringed with a syringe, then it is washed with a solution of antiseptic( furacilin, octenisept, chlorophyllipt, etc.).Fluid poured into the bosom through the needle, and poured out - through the natural sinus sinus with the nose, dragging its contents out. When rinsing, the patient's head is tipped forward and downward so that the liquid pours out through the vestibule of the nose into the inserted tray. In those cases when the anastomosis is obturated as a result of a pathological process, a second needle( also through the lower nasal passage) is inserted into the sinus and the flushing is performed through two needles. The presence of pathological contents in the washing liquid allows to reliably recognize the nature of the disease.

If necessary, treatment with punctures followed by sinus washing with solutions of antiseptics and administration of antibiotics is carried out daily for 7 to 8 days. At the first puncture, through a thick needle or special trocar, you can insert a synthetic tubule( catheter) and leave it in the sinus for subsequent rinsing, fixing the outside with adhesive plaster.

Complications of the maxillary sinus punctures, both local and general, are relatively rare. As a rule, they are associated with a violation of the puncturing technique.

Small bleeding is stopped with a swab inserted into the nasal cavity.

Incorrectly made puncture leads to the fact that the puncture needle does not get into the sinus. If through the anterior wall of the sinus it penetrates into the soft tissues of the buccal region, then the puncture is called a "cheek" puncture, and when the needle hits the orbital nasolacrimal wall into the orbit, it is called an "ophthalmic" puncture. Such punctures can lead to fluid injection into the orbit or soft tissue of the cheek and cause abscessing.

To control the correct position of the tip of the needle after puncture, the sinus walls make small light swinging movements;If the needle has passed through two walls, then such movements can not be performed.

To very rare, but severe complications include air embolism of the vessels of the brain or heart. In the literature, single cases of such complications are described. It occurs only when air is pumped into the sinus after a puncture. Therefore, when performing a puncture, certain rules must be observed. In particular, to avoid air embolism, after rinsing the sinuses, it should not be purged. Trepanopuncture of the frontal sinus. In the presence of a festering process in the frontal sinusa, which is confirmed by X-ray or CT data, the frontal sinus is probed with a special curved cannula( Ritter's canula) or shrapanopuncture of the frontal sinus. Probing of the frontal sinus is not always possible due to several reasons: the crimp of the frontal-nasal canal, the presence of a hyperplastic hook-shaped process, an enlarged grating bull, etc. Therefore, today, the most effective means of evacuating purulent contents from the frontal sinus remains trepanopuncture.

Device for Trepanopuncture, developed by M.E.Antonyuk includes drills, a device for manual rotation of the drill and a restriction of its penetration into the depth of tissues, as well as a set of special cannulas for fixation in the hole and rinsing the sinuses.

Trepanopuncle is produced both in stationary and in polyclinic conditions. Previously, based on the direct and profile radiographs of the frontal sinuses, determine the location and depth of the sinus to be punctured.

Before the operation, marking out the forehead skin in the area of ​​the brow to determine the trepanopuncture point. First, a vertical median line is made in the center of the forehead and the back of the nose, the second line, horizontal, is perpendicular to the first on the bone edge of the brow. The third line is the bisectrix of the right angle between the first and second lines. Stepping back 1 - 1.5 cm from the corner, mark the point for imposing trephine( Figure 4.6).

Under local infiltration anesthesia( 1% solution of novocaine, 2% solution of lidocaine, etc.) with a trepanopuncture device, drill a hole in the anterior wall of the frontal sinus at a predetermined point. The moment of passage by a drill of the thick bone wall of the frontal sinus is determined by the sensation of "failure".Through the formed hole with the inserted probe control the back wall and the depth of the sinus. A special cannula is inserted into it, through which, in the course of 2 to 7 days later, the frontal sinus is washed and medicinal preparations are injected into it. In some cases, the position of the cannula in the sinus after trepanopuncture is monitored by an X-ray in the lateral projection.

The frontal sinus can also be punctured with a specially sharpened needle through its lower( orbital), thinner wall. A graduate( subclavian catheter) is inserted into the lumen of the needle, the needle is removed, the catheter is fixed on the skin and the sinus is then washed through it. However, the proximity of the orbit makes the puncture through the lower wall of the frontal sinus more dangerous.

In recent years, a wide-spread non-point-based method of removing purulent contents from the paranasal sinuses, washing them with antiseptics and introducing into the sinuses of medicinal substances. The method is performed using a sinus catheter "Yamik"( Yaroslavl, Markov and Kozlov).This device allows you to create a negative pressure in the nasal cavity, remove the pathological secret from all the paranasal sinuses of one half of the nose, and also introduce medications into them for diagnostic and therapeutic purposes.

Treatment. In the treatment of acute sinusitis or exacerbation of the chronic form of the disease, the following objectives are pursued:

Locally, vasoconstrictive drugs are used that promote the opening of the sinus sinus with the nasal cavity, improve its drainage and nasal breathing.

In a purulent process, treatment with sinus punctures or aspiration of their purulent contents using a sinus catheter "Yamik" is indicated. The device is equipped with two inflatable balloons, one of which is placed distally behind the choana, the other - proximally on the threshold of the nose. From each of the cylinders leaves a tube equipped with a valve, and between the balloons on the surface of the sine-catheter opens the opening of the third tube. After the application of anesthesia of the mucous membrane of the nasal cavity and anemia of the exit points of the sinus of the paranasal sinuses, a sinus catheter is inserted into the nasal cavity.

To distinguish the nasal cavity from the nasopharynx and the entrance to the nose, the balloons( first distal, then proximal) are inflated with a syringe. Then, through the third tube, air is aspirated from the nasal cavity, thereby creating a negative pressure there. By changing this pressure, simultaneously tilt the patient's head so that the excretory ducts of the inflamed sinuses are at the lowest possible position relative to their bottom. With the help of a syringe, a pathological secret from the sinuses is extracted and then filled with a medicine or a contrast solution.

In acute sinusitis, accompanied by intoxication of the body, as well as by the involvement of several sinuses or adjacent organs( acute otitis) or the spread of inflammation to other parts of the respiratory system( bronchitis, pneumonia), antibiotic therapy with broad spectrum agents is indicated. The choice of an antibiotic depends on its pharmacokinetic properties, which should ensure the achievement of the required concentration of the drug in the localization of infection.

Given that the main pathogens of sinusitis are pneumococcus and hemophilic rod, the drugs of choice are oral antibiotics of the penicillin group: amoxicillin( 3 times a day for 0.5 g), amoxicillin / clavulanate( 3 times a day for 625 mg), flemoxin solutab( 2 times a day but 500 mg) in tablets or in the form of a syrup. In the presence of an allergy to the antibiotics of the penicillin group, macrolides( azithromycin, roxithromycin, CP) are used, the advantage of which is that they are sensitive to gram-positive, gram-negative microorganisms and representatives of the atypical flora( chlamydia).Third-generation cephalosporins( cefotaxime, ceftriaxone), respiratory fluoroquinolones( ciprofloxacin, ofloxacin, sparfloxacin) are also used. If the effect is absent within 72 hours after the appointment of one antibiotic, it is advisable to switch to another antibiotic.

To improve the effectiveness of treatment, immunocorrection is performed. For this purpose, appoint polyoxidonium( in ampoules of 3 and 6 mg for intramuscular injection or in suppositories for 6 mg);Derinat( in ampoules of 5 ml for intramuscular injection);IRS-19( spray in vials for intranasal administration).

Simultaneously, prescribed antihistamine therapy( suprastin, pifolen, tavegil), analgesics, drugs.

Physiotherapeutic procedures for the area of ​​the paranasal sinuses are shown with some limitations: they can be performed in the absence of a complete block of anastomosis, elevated temperature and signs of intoxication of the body. Effective UHF on the sinus area( 8-12 procedures), UFO, electrophoresis, pulsed currents, etc.

Surgical treatment is performed in case of prolonged( more than 3 to 4 weeks) course of acute sinusitis or persistent blockade of natural anastomosis. With the help of endoscopes, endonasal dissection of the maxillary or frontal sinuses, of the cells of the latticed bone is performed, and in the development of intra-orbital and intracranial complications, a radical operation is performed on one or another paranasal sinus.

Chronic sinusitis - inflammation of the mucosa of one or more paranasal sinuses, which lasts for 1 month or more. The most common causes of chronic sinusitis of a rhinogenous etiology are untreated acute sinusitis and persistent disruption of the natural sinus anastomosis. Predisposing factors include deformity of the septum of the nose and hypertrophy of the middle or inferior nasal concha causing the block of the osteomeal complex, nasal polyposis, etc.

Depending on the causes and ways of getting the infection in the nasal sinuses, chronic sinusitis, as mentioned above, is divided into a narogenic,odontogenic, nosocomial and fungal.

Odontogenic sinusitis is an inflammation of the maxillary and sinuses adjacent to it, which has developed as a result of the disease of the roots of the teeth. Nosocomial( hospital, or hospital, sinusitis) is associated with long( more than 3 - 4 days) finding in the nasal cavity of foreign objects( such as the intubation tube, nasal swabs, etc.).Finally, fungal sinusitis caused by various fungi is also more often manifested in chronic form. These three forms of the disease occupy a special place and will be considered below.

Clinical manifestations of chronic rhinogenic sinusitis resemble the symptoms of acute sinusitis, however, they are less pronounced and depend more on which particular sinus is affected. Characterized by prolonged mucous or mucopurulent discharge from the nose on the side of the lesion or from both sides, difficulty in nasal breathing, periodic headaches of limited or diffuse nature. In bilateral processes, especially the polyposic nature, the sense of smell( hyposmia) goes down, down to its complete loss( anosmia).Difficult nasal breathing entails dry mouth, decreased performance, periodic stuffiness in the ears, possibly lowering the hearing.

During the period of remission, the general condition and well-being of patients are usually quite satisfactory, during this period they rarely seek help. During the exacerbation of the chronic process, the body temperature rises, the state of health worsens, the headache and purulent discharge from the nose increase. The appearance of a painful swelling around the eye and in the soft tissues of the face on the side of the lesion indicates a complicated course of the disease.

With forward rhinoscopy, the flow of mucopurulent discharge from under the middle nasal concha is usually observed, which can be intensified by tilting the head in the opposite direction, the presence of a purulent discharge on the bottom and walls of the nasal cavity, hyperemia of the mucosa, anatomical changes in various sections of the osteomeal complex. However, more informative examination by endoscopes, which allows to increase the detail of the presence of predisposing factors and signs of inflammation in the area of ​​sinus anastomies.

The diagnosis is made on the basis of a comprehensive clinical and local examination, including endoscopic. Obligatory is the radiography of paranasal sinuses, and with an unclear picture - a diagnostic puncture in combination with contrast radiography of the sinus. In difficult cases, CT of paranasal sinuses is performed. This method is especially effective in diagnosing chronic inflammation of the deep posterior cells of the trellis and the sphenoid sinus.

Catarrhal-serous, purulent or hyperplastic forms of chronic sinusitis are characterized by a significant thickening and hyperplasia of the mucous membrane, as well as polypous metaplasia of the mucosa in the region of the middle nasal passage, which is especially evident in endoscopic examination of the patient.

The cause of polyposis degeneration of the mucous membrane is considered to be a long-term irritation with its pathologic detachable and local allergic reactions. Polyps are often plural, of different sizes, sometimes they can encircle the entire nasal cavity and even come out through the vestibule of the nose. Histologically, they are swelling inflammatory mucosal formations. At the same time, diffuse infiltration of the tissue with neutrophils occurs, and other cells( eosinophils, obese, plasma) also occur, focal metaplasia of multi-rowed cylindrical epithelium into a multilayered epithelium is observed.

In the case of an adverse course of acute, but more often with exacerbation of chronic sinusitis, orbital and intracranial rhinosinusogenous complications can occur, which are extremely difficult and in some cases present a threat to the life of the patient.

Infection into the cavity of the orbit and skull from the paranasal sinuses during their chronic inflammation can occur in various ways - contact, hematogenous, perineural and lymphogenic, with the contact path being the most frequent. As for the sources of infection of intracranial complications, the majority of specialists put chronic inflammation of the cells of the latticed labyrinth first, then of the frontal sinus, then of the maxillary and finally of the sphenoid sinus.

Given that the frontal and maxillary sinuses, as well as cells of the latticed labyrinth have common walls with an orbit, in the complicated course of chronic sinusitis the process can go into orbit. In such a case, swelling of the upper or lower eyelid is observed, smoothness of the soft tissues in the region of the upper or lower inner corner of the eye;the eyeball is shifted forward( exophthalmos), its movements become painful, limited. When palpation in the root of the nose and at the inner corner of the eye, pain( periostitis) occurs. Infection can penetrate into the tissue of the eyelid and through the venous canals( phlebitis).These and other complications are accompanied by significant intoxication and a general severe reaction of the body.

Rinogenous intracranial complications( meningitis, epidural and intracerebral abscesses, cavernous sinus thrombosis and rhinogenic sepsis) are less common than those of otogenic complications, but are characterized by extremely severe course. Patients with rhinogenous orbital and intracranial complications need to provide them with emergency specialized medical care in conditions of an ENT hospital.

Treatment for chronic sinusitis, as well as for acute sinusitis, can be conservative and surgical, depending on the form of the disease. Patients with chronic exudative sinusitis( catarrhal, serous or purulent) usually begin with conservative measures.

Conservative therapy for sinusitis is often combined from the beginning with various corrective intranasal operations: septoplasty, polyposomy of the nose, partial or total opening of the cells of the latticed labyrinth, partial resection of the hyperplasticized sections of the central nasal cavity, sparing resection or vasotomy of the inferior nasal concha, etc. The purpose of such operations is to restore the patency of natural anastomoses of the paranasal sinuses and normalize the functions of the mucociliary apparatus of the mucosachaques of sinuses and nose.

In some patients after polypotomy, recurrences of polyps occur. Therefore, in the postoperative period, within 3 to 5 months, local corticosteroid therapy( floxonase preparations, aldecine, nazonex, etc.) is usually prescribed and the immune status is corrected.

Surgical treatment. It is indicated for proliferative, alterative and some mixed forms of sinusitis, as well as for insufficient efficiency of conservative treatment of exudative forms. Intra-nasal surgery is advisable to carry out with the use of optical systems - rigid and flexible endoscopes, microscopes and micro instruments, which significantly increases the effectiveness of endonasal surgery.

Endonasal dissection of latticed maze cells and polypotomy is performed under local application anesthesia using 5% cocaine solution, 2% solution of dicaine or 10% lidocaine. Premedication is required( intramuscular injection of promedola 2%, atropine 0.1% and taewegil) and anemia of the operating field with adrenaline.

The patient is in a semi-sitting position in the surgical chair. First they perform polytopotomy with a loop or with final nasal forceps and create access to the trellis labyrinth. For penetration into the zone of lattice cells, it is necessary to expand the middle nasal passage by displacing( breaking) the middle nasal shell or by resecting its hyperplastic anterior end. After achieving a good overview of the middle nasal passage, the front and middle cells of the trellis labyrinth are partially opened in front of the back of the nasal forceps, the Konthom or the Hartmann instrument. When the posterior trellised cells are damaged through the basal plate of the middle nasal cavity, they penetrate into the posterior cells, thus opening the entire latticed labyrinth to the sphenoid sinus and converting it into one common cavity with good drainage and aeration conditions.

Penetration through the laminae cribrosa of the latticed bone into the cranial cavity is a great danger in the conduct of polypotomy - this leads to cerebrospinal fluid, the appearance of meningitis and other severe intracranial complications. To avoid injury to the sieve plate, it is necessary to take into account the peculiarities of its topography. Sitovid plate, located on the middle line, often lies below the arch of the trellis. Therefore, during the whole operation, when manipulating instruments, it is necessary to follow the lateral direction;Approaching the midline may damage the sieve plate. It should also be borne in mind that the location and number of cells of the trellis labyrinth are individual for each person, so it is difficult to determine when an operation is performed, whether an unopened cage has remained or not.

In most cases, it is sufficient to remove only a part of the affected cells of the latticed bone, and the sanation of the remaining can be achieved with the help of conventional conservative treatment. But with frequent relapses of polyposis, when the maxillary and frontal sinuses are encased in polyps, a radical operation is performed with removal of all pathological contents from the lumen of the sinuses. This allows either to completely eliminate the occurrence of relapses of polyposis, or to make periods of remission more prolonged.

Surgical interventions on the maxillary and frontal sinuses have their own peculiarities.

In chronic sinus anemia, in recent years, more and more widely used is the gentle technique of micro-gaymorotomy. It allows you to perform diagnostic endoscopy of the maxillary sinus( sinusoscopy), clarify the diagnosis in isolated lesions of the maxillary sinus, remove cysts from the lumen of the sinus, foreign bodies, if necessary, take material for histological examination.

With microhaimorotomy, the approach to the sinus is made through the front wall( since it is technically easier).The operation is performed under local infiltration soft tissue anesthesia in the field of the canine fossa. With the help of a special trocar with a diameter of 4 mm with uniform rotational movements, it is easy to drill the anterior wall of the maxillary sinus at the level between the roots of the 3rd and 4th teeth. Then endoscopes with 0 - 70 ° optics are inserted into the lumen of the sleeve, which allows us to carefully examine the sinus walls and perform the necessary manipulations. At the end of the study, the trocar sleeve is extended with the same careful rotational movements. Place the perforation is not sewn. The patient is asked for some time to refrain from intense blowing.

Radical operations on the maxillary sinus are usually performed according to the methods of Caldwell-Luke or Denker.

The most common clinical practice is the Caldwell-Luc method. It is produced in the position of the patient "lying on his back", under local anesthesia or under anesthesia. On the threshold of the oral cavity, under the upper lip, 0.5 cm above the transitional fold, a horizontal cut is made to the bone. The incision begins, retreating 4 to 5 mm from the bridle, and continue to the 6th tooth. The average length of the incision is approximately 4 cm. Soft tissues along with the periosteum are displaced by the rasper upward until the canine fossa is completely exposed. In the thinnest part of the anterior wall of the maxillary sinus, a small hole is formed by the grooved chisel of the

Voyachek or a chisel, which is then expanded with the aid of the Geyek bone forceps to the dimensions allowing revision of the sinus and the removal of pathologically altered tissues. On average, the diameter of the trepanation hole in the bone is about 2 cm.

Next, the pathologically altered mucosa, purulent and necrotic masses, and polyps are scraped out with a curved digester and bone spoon. In chronic inflammation of the maxillary sinus, the cells of the latticed labyrinth are usually involved in the process, so they are opened and removed pathologically altered tissues in the region of the upper medial angle of the maxillary sinus.

The operation is terminated by the application of an australia( contour) with the nasal cavity within the lower nasal passage from the side of the sinus with a size of 2.5x1.5 cm. The lower edge of the contour is smoothed with a sharp spoon at the level of the bottom of the nose so that there is not between the bottom of the nasal cavity and the bottom of the sinusthreshold.

To prevent postoperative hemorrhage, a long narrow gauze turunda impregnated with iodine or antibacterial ointment is injected into the sinus cavity and into the area of ​​the latticed labyrinth. The end of the turunda is withdrawn from the sinus through the counter-rotation into the lower nasal passage, and then through the vestibule of the nasal cavity - outwards. Turundu is removed one day after the operation. Instead of gauze turunda in the bosom, you can introduce a special rubber( latex) inflatable balloon( pneumotampon), which is also removed the next day.

After the operation, the patient is in the hospital for 6 to 7 days, during which time the sinus is washed 2-3 times through the counterperture with solutions of antiseptics. Prescribe analgesics, antihistamines, symptomatic drugs. Within a few days it is advisable to carry out antibiotic therapy.

It is also possible to endonasal dissection of the maxillary sinus, during which the lateral wall of the lower nasal passage is opened with the help of the West chisel and an artificial communication with the sinus is formed. However, with the introduction of microhaymorotomy techniques into clinical practice, this method acquires mainly historical significance.

In the diagnosis of chronic diseases of the paranasal sinuses, especially their posterior group( posterior cells of the latticed maze, sphenoid sinuses), computed tomography is of great importance at the present time. The method allowed, in particular, to diagnose sphenoiditis much more often than it was before.

In case of chronic frontitis in cases where the osteomyel region is blocked by the hyperplasic middle nasal shell, the lattice cell bile, hyperplastic hook-shaped process, polyps, etc., effectively sparing endonasal surgical intervention. In particular, the frontal-nasal canal widens and pathologically altered tissues are removed in the frontal sinus. However, with the elimination of extensive recurrent foci of infection, this operation has limited possibilities.

Radical operation in the frontal sinus is performed according to the Ritter-Jansen method with the formation of drainage according to B.S.Preobrazhensky. Other modifications( Killiana, NV Belogolovova) are rarely used.

In the Ritter-Jansen operation, the incision is made along the upper edge of the orbit from the middle of the eyebrow to the inside, bending to the side wall of the nose. The subperiosteal soft tissue is separated from the upper wall of the orbit, the superciliary arbor and the lateral wall of the nose within the incision. Chisel and forceps remove a part of the upper wall of the orbit to the brow, forming a hole in the sinus in the form of an oval size of 2x3 cm. If during the operation it is necessary to form a broad suture with the nasal cavity, the bone wound is widened downwards, the upper part of the frontal process of the upper jaw and the partially nasalto the teardrop. The abnormally altered tissues from the frontal sinus and the upper section of the latticed bone are removed by forceps and bone spoons( they are sent for histological examination).A rubber tube( 5 to 6 mm in diameter and 3 cm in length) is inserted through the nasal cavity to form a new frontal nasal channel around it( BS Preobrazhensky).The tube is fixed with a silk thread on the skin. The external wound is sewn layer by layer. Drainage in the canal is left for 3 to 4 weeks, the sinus is periodically washed through the drainage tube.

Odontogenic sinusitis ( sinusitis of dental origin) usually begins with a primary lesion of the maxillary sinus. The development of odontogenic sinusitis is associated with the topographic-anatomical relationship between the teeth of the upper jaw and its cavity. The maxillary sinus is more often affected by the pneumatic type of its structure, when the bone walls are thin, and the bottom of the sinus is below the bottom of the nasal cavity and reaches the first premolar or even the canine."Cause" can be not only a gangrenous tooth easily detectable visually. Latent odontogenic infection can intensify with exacerbation of chronic periodontitis, as well as in the presence of a "treated" tooth under the seal, if the tooth channel is not completely filled with filling material. Pathological gingival pockets containing purulent exudate can also serve as a source of infection.

Odontogenic sinusitis initially has a chronic character. Its clinical manifestations are characterized by a low-symptom, latent current. Manifestation of the pathological process is possible with respiratory infection or exacerbation of inflammation in periapical tissues against a background of reduced local and general resistance. This may increase the temperature, there is a feeling of pressure in the area of ​​the maxillary sinus, pain in the projection of the "causal" tooth.

Outside the exacerbation, patients pay attention to the secretion of thick purulent discharge from one half of the nose, while they themselves often feel an unpleasant, fetid smell of pus. In some patients, the symptoms of the neuralgia of the second branch of the trigeminal nerve( a persistent unilateral headache) or the presence of a fistula in the region of the alveolar process are observed. A characteristic sign of odontogenic sinusitis is a one-sided rhinitis.

With anterior rhinoscopy, swelling and flushing of the mucous membrane of the corresponding half of the nose are noted. In diagnostics, radiation methods, such as X-ray, CT and MRI, are a great help. If necessary, perform a diagnostic puncture of the maxillary sinus.

Treatment for odontogenic sinusitis should begin with a sanitization of teeth. First of all, you should remove the tooth, which was the source of inflammation in the sinus. Conservative treatment with this form of the disease is usually ineffective, therefore, in the presence of purulent-productive process in the maxillary sinus, a classical radical operation is shown. And with perforated odontogenic maxillary sinusitis, along with the radical operation on Caldwell-Luc, the plastic of the perforation( fistula) hole is additionally produced by moving local tissues from the mouth or from the palate.

Fungal sinusitis .Currently, mycoses of paranasal sinuses are conventionally( since one form can go into another) are divided into invasive and non-invasive. Among the invasive forms, acute( lightning) and chronic forms are isolated, among non-invasive ones - mycetoma and allergic fungal sinusitis.

Acute invasive form is found in patients with severe concomitant diseases - decompensated diabetic ketoacidosis, transplantation of organs receiving hemodialysis - and with various disorders in the immunity system. The causative agents of the disease are the fungi of the family Mucoraceae and the genus Aspergillus. Predisposing factors include elevated levels of iron and a glucose-rich acid medium.

Penetrating into the mucous membrane of the paranasal sinuses, the fungus affects the walls of the vessels and causes ischemic necrosis of the mucous membrane and bone. Infection quickly, within a few days, penetrates into the cavity of the skull, causing severe complications: meningitis, cavernous sinus thrombosis, brain abscesses, etc. The development of an acute form of fungal sinusitis is accompanied by fever, severe headache, difficulty in nasal breathing. There are bloody-serous discharge from the nose, black necrotic crusts on the septum of the nose and on the shells. Treatment of this form of the disease is surgical, including the removal of all necrotic tissues, and medicamentous, with the appointment of large doses of amphotericin B and correction of blood sugar levels.

Chronic fungal sinusitis is characterized by the development in the sinus wall of the granulomatous inflammatory process. The most common pathogens are the fungi of the genus Aspergillus or Dematiaceous, which affect mainly the maxillary sinuses and anterior cells of the latticed bone. The disease is prevalent mainly in countries with dry and hot climates.

The main manifestations are difficulty nasal breathing, headache, rarely puffiness and asymmetry of the face. A computer tomogram reveals the destruction of the bone walls, reminiscent of the development of a malignant tumor. And with endoscopy, you can sometimes find destruction of the medial wall of the sinus.

Treatment of this form of fungal sinusitis also begins with a radical surgical intervention and systemic use of amphotericin B. At the opening of the sinus, necrotic fungal masses are detected, with histological examination - signs of chronic inflammation with elements of granulomatosis and fibrosis. In the postoperative period, antifungal therapy and rinsing of the operated sinus through the formed anastomosis with an aqueous solution of quinazole are prescribed.

The mycetoma( fungal body) is the most common form of fungal sinus infection, it is with it basically identified with the concept of fungal sinusitis. Pathogens - fungi of the genus Aspergillus( in 90% of cases), less often - Candida, Alternaria, etc. When obstructing the natural sinus anomalies and mucociliary clearance violation, optimal conditions for fungal development are created. Possible and odontogenic pathway - getting into the maxillary sinus filling material, which can become a place of growth of the fungus.(The sealing material contains heavy metals, for example zinc, which are capable of catalyzing the processes of the fungus.)

The mycetoma is manifested by the symptoms of recurrent sinusitis: headache, dental pain, difficulty in nasal breathing, discharge from the nose with an unpleasant odor. But sometimes the disease is asymptomatic.

On the radiograph, against the background of a homogeneous or parietal reduction in sinus pneumatization, calcifications with a diameter of 3-4 mm, whose density is higher than even the density of tooth enamel, can be detected. To confirm the diagnosis through the puncture hole in the front wall, endoscopy of the maxillary sinus is performed. During the procedure, the sinus is released from fragments of the mycetoma, which are then sent to cytological and culture studies. The purpose of systemic antifungal drugs does not make sense, it is sufficient to wash the operated sinus several times with a solution of quinazole through superimposed anastomosis.

Nosocomial sinusitis .This nosological form of the disease attracted attention in recent years. It is proved that up to 5% of patients undergoing inpatient treatment are exposed to microorganisms constantly present in the air of hospital rooms. These pathogens are very resistant to external factors and, what is especially dangerous, are highly resistant to antibacterial drugs used in the medical institution.

Nosocomial sinusitis develops, as a rule, in severe patients residing in the intensive care unit, who have an intubation tube, nasogastric tube or other foreign object in the nasal cavity for a long time( several days).All sinuses can be affected, but more often others suffer from the maxillary, sphenoid sinus and cells of the latticed labyrinth. The development of the process is facilitated by the artificial ventilation of the lungs, the immobile position of the patient, the absence of nasal breathing.

For the treatment of nosocomial sinusitis, puncture or drainage of the affected sinuses is performed and antibacterial therapy, often combined, is prescribed.

If the patient has been undergoing artificial ventilation for a long time( IVL), one should remember about the possibility of postmortem "overdiagnosis" of paranasal sinus diseases.

• Add a few drops of Canadian or Toluansco balm, cayeput, niolium, eucalyptus oil or tea tree oil to the inhalation device.

• After inhalation, prepare a mixture of 10 ml( 2 teaspoons) of soybean oil and 4 drops of one of the above oils. Gently pat the nose inside and out.

• Good nutrition, as always, plays a very important role. You should consume more foods with a high content of vitamin A. Also, the body needs protein. Just do not eat dairy products.

• The source of vitamin A are yellow and orange fruits and vegetables, as well as egg yolks, dark green vegetables, walnuts and walnuts, millet.

• As a preventive measure, take daily cod liver oil in capsules.

• Avoid spiced food, do not drink tea, coffee and spirits and do not smoke.

• If you are allergic, limit exposure to allergens and use antihistamines and / or aerosols with nasal steroids.

• If you have a runny nose, use a humidifier that creates a cool mist, and decongestants to facilitate drainage.

• Sufferers of chronic sinusitis should drink plenty of fluids and avoid tobacco smoke and alcohol.

In order to prevent sinusitis, take active measures to eliminate the acute cold.

Timely treat your teeth, remove if the doctor recommends adenoids - these are the centers of a dormant infection in the body.

But most importantly - to temper the body, make it resistant to cooling.

Try to be more in the air, ventilate the room well before going to bed or leave the ventilator open at night, and in the morning, do the gymnastics, then proceed to the water procedures.

Unhealed chronic sinusitis is insidious in that any catarrhal disease can cause an exacerbation. The proximity of the sinuses to the brain and eye creates the danger of spreading the infection into these organs, which is fraught with serious complications.

Attention! Seek medical attention immediately if you experience redness, pain, or bulging of the eye, difficulty eye movements, or nausea and vomiting in combination with other signs of sinusitis.