Method for surgical management of maxillary sinus diseases

FIELD: medicine.

SUBSTANCE: invention can be used in the surgical management of non-inflammatory maxillary sinus diseases (MSD). An endonasal opening and sanitation of the maxillary sinus are performed. A plate of a synthetic polymer, porous polytetrafluoroethylene (ePTFE) 1 mm thick and with an open porosity of 70% is used to model a transplant of an adequate shape and by 5% more than the area of a bone postoperative defect of a posterior wall of the maxillary sinus. The transplant is laid on the residual anterior bone wall of the maxillary sinus. The soft tissues are closed completely rigidly fixing the transplant to the bone.

EFFECT: method enables preventing early postoperative complications related to an in-growth of the cicatrical tissue into the sinus lumen by forming a fibrous frame of the connective tissue closing the postoperative defect.

1 ex

 

The invention relates to the field of medicine and will find application in ENT practice in the surgical treatment of diseases of the maxillary sinus (HFI), mainly, not of an inflammatory nature.

In the late nineteenth century it was proposed surgical treatment of diseases of the HFI opening through the front wall, the so-called externally way of opening the sinuses. The front wall of the HFI covered with soft tissues of the cheeks, which are represented by the skin, subcutaneous fatty tissue and the periosteum (Corning, K. Topographic anatomy. - GMS, 1931. S. 135-136). Externally way of opening HFI involves incision of the mucous membrane and periosteum in the vestibule of the mouth on the transition to the crease, then remove part of the bone of the front wall HFI to size, allowing you to explore all of the sinus cavity, and conduct restoration activities. Complete the intervention of the restoration of the anatomical structures HFI - perform closure of bone defects.

The vast majority of relapses due to the fact that trepanation opening in the anterior bony wall of the sinus is the window for growing into its lumen scar-modified soft tissues of the cheeks, quickly leading to fibrotic degeneration of the mucous membrane (Plastic anterior bony wall of the maxillary sinus by hamartoma/ Century And. Rodin, B. N. Nechiporenko, S. M. Krut // GENRB. 1978. No. 4. - S. 95-97). The authors note that the presence of a bone defect in the anterior bony wall of the HFI leads to complications, aggravating the postoperative period, as in his cheeks are often formed infiltrates, soft tissue of the cheeks penetrate through a bony defect in the sinus cavity, they are formed granulation, in some cases, the scar tissue is fused with the walls of the sinuses, creating isolated cavity containing pus and granulation.

The number of relapses was relatively high and remained unchanged for a long time, and further, most of the proposals for the prevention of recurrence was based on this position - close trepanation opening in the anterior wall of the sinus to prevent ingrowth into its lumen scar modified soft tissues of the cheeks.

So, C. D. Malagnini ("Free transplantation of bone and cartilage tissues in otorhinolaryngology (30 years experience)" / Problems implantology in otorhinolaryngology: Sat. Tr. / IX scientific and practical use. proc. torinla. of Moscow. - M., 2000. - S. 24-26) was proposed a method of surgical treatment of diseases of the HFI, providing extranasal opening of the sinus, its restoration, filling the cavity HFI formalisation hologramm, obliterating the lumen and closing postoperative bone defect is arena sinus walls.

The disadvantage of this method is off HFI from the physiological mechanism of the nasal cavity, the interactions of the paranasal sinuses, a common mechanism of mucociliary clearance and line antibacterial defense.

Century Westemhagen (Westemhagen Century in the article "Die operative Kieferhoh-lensanierung - ein Routineemgriff?" // HN0. - 1983. - Bd.31. - H. 5. - S. 158-160) proposed a method of surgical treatment of diseases of the HFI, providing her extranasal opening, cavity sanation, and then closing the bone or freeze-dried Dura mater postoperative defect of the anterior bony wall of the HFI.

RF patent №2428944 (publ. 2011, BIPM No. 26) secured Method of surgical treatment of fractures of the upper wall of the maxillary sinus," which includes the opening of the sinuses, Redressal bone fragments of the upper wall of the sinus at the seat of fracture, elimination of interposition soft tissue at the first stage of the operation, without entering into the cavity of the orbit, soft tissue of orbit and eyeball raise and set in the anatomically correct position directly from the sinuses, eliminating the interposition of soft tissues. Form the orbital fragment demineralized bone graft (VCT) in accordance with the shape and dimensions of the upper wall HFI enter and establish in his bosom, lifting him up, locking them damaged bone fragments in the right is ulozhenie. Then cut out the reference slice VCT in the form of a rigid rectangular plate, which is injected into the sinus, straight down into the strut abutting the upper part of it in the orbital fragment, and the lower in the lower portion of the lower wall of HFI. In subsequent cut a horizontal slice VCT in the form of a trapezoidal rigid plate, put it in his bosom and wide end rests in the reference slice VCT, and narrower in the lateral Bay sinus. The surgery is completed in the usual way.

The main disadvantage of the above methods is that due to the relatively late accretion of the graft with the bone edges of the wound can enter the scar-changing soft tissue into the lumen of the sinus, which, in turn, can lead to complications, aggravating the postoperative period.

The closest in technical essence of the prototype is a method of surgical treatment of diseases of the HFI described C. A. Kozlov et al. in the article "the Way of closing the anterior wall of the maxillary sinus demineralized allogenic bone graft" / Century A. Kozlov, G. B. Troshkov, C. I. Saveliev, " Vestn. surgery to them. I. I. Grekova, - 1983. - So 130. No. 3. - S. 142). The method involves extranasal opening HFI, its restoration and plastic surgical bone defect in the anterior wall of the graft. For plastics PEFC is an operational defect in the anterior wall of HFI use VCT without his special commit.

VCT after placing them in the bone wound begin to induce osteogenesis, being replaced by newly formed bone tissue. They are flexible, easy to bend, cut and modeled. However, VCT, being a wonderful material to restore the patient's own bone, quite a long time to develop reparative processes between the native bone of the patient and graft, which is confirmed by clinical (Bogatov A. R. "Plastic bone defects of the walls of the paranasal sinuses demineralized grafts (Clinical-experimental study)." - Diss. Prof. the honey. Sciences. Rostov n/a, 2011. - 317 C.) and experimental studies (Romaszewska And. And. "Osteogenesis of the frontal bone after implantation of demineralized bone graft in experimental animals" // Rossick. torinla. - №1(56). - 2012. - S. 144-148).

The disadvantages of the prototype are: long-term formation of callus and other elements of the reparative process in the hearth transplant VCT that allows ingrowth into the lumen of the HFI scar tissue during the time interval when there is a free space between the graft and the edges of the recipient's own bone, which can cause complications in the early postoperative period.

The objective of the invention is to develop a method of surgical treatment of diseases of the HFI, preventing the th development of complications in the early postoperative period, related ingrowth into the lumen of the sinus of scar tissue.

The technical result, objectively manifested in the implementation of the proposed method is to prevent ingrowth into the lumen of the HFI scar tissue in the early postoperative period, which increases the effectiveness of treatment and prevent the development of complications in the early postoperative period

The technical result is achieved by the fact that the patient perform extranasal opening HFI, its reorganization and plasticity postoperative bone defect in the anterior wall of the graft. After readjustment of HFI plate of synthetic polymer - porous polytetrafluoroethylene (ePTFE) with a thickness of 1 mm and an open porosity of 70% model transplant, adequate in form and 5% more square postoperative bone defect in the anterior wall of the HFI. Put a graft on bone remains of the front wall HFI. Soft tissue is sutured tightly, rigidly fixing the graft to the bone.

Of numerous materials, past experimental and clinical testing, the most suitable for implantation were recognized as some polymers, including synthetic polymer polytetrafluoroethylene (ePTFE), which has outstanding biological inertness, and resistance to all known pathways of biodegradation. One of the varieties of the two which is porous polytetrafluoroethylene, which happens to be 2 types of porosity: 36 and 70%, and the spatial structure provides the ingrowth of newly formed connective tissue in his column. ePTFE - synthetic polymerization product of tetrafluoroethylene, consisting of a fluorocarbon chain. Due to its unique chemical inertness, high molecular weight, absence of ester groups and carbon-it is resistant to all the most important ways of biodegradation of polymeric materials as a noncellular: nonenzymatic and enzymatic hydrolysis, oxidative degradation, catalysis metal ions. Synthetic ePTFE polymer is produced by CJSC "Scientific-production complex "Ecoflon", , Saint Petersburg (THE 9398-007-23167010-2008) in the form of a plate which is easily modeled configuration and thickness (Nikolaenko, B. N. "the Use of PTFE implants in ophthalmology": author. Diss. Kida. the honey. of Sciences, St. PETERSBURG, 2005. 23 C.).

According to our observations made in the clinic of otorhinolaryngology state budgetary educational institution of higher professional education "Rostov state medical University" of Ministry of health of Russia (Growth (MCM) was found in 3 patients operated previously, according to the present method, with a second opening through HFI 12, 13, and 18 days after the first intervention, under the grafts made of ePTFE, established on the area after operation the th bone defect in the anterior wall of HFI, formed fibrous skeleton of coarse-fibered connective tissue that covers the postoperative bone defect in the anterior wall of the HFI, insulating bosom against the ingress of scar tissue cheeks.

The proposed method is as follows.

In a patient with the disease HFI non-inflammatory type, such as a cyst, perform extranasal the opening of the sinuses. HFI sanitize and remove the cyst. Then from the plate of ePTFE with a thickness of 1 mm and an open porosity of 70% model transplant, adequate in form and 5% more square postoperative bone defect in the anterior wall of the HFI. Put a graft on bone remains of the front wall HFI, the soft tissue is sutured tightly, rigidly fixing the graft to the bone.

In the postoperative period antibacterial drugs the patient is not appointed, the sutures will dissolve on their own within 5-6 days after surgery. Patient discharged within 1-2 days after surgery to outpatient care physician at the place of residence.

Practical feasibility of the proposed method is illustrated by an example from clinical practice.

Example: the patient M, 38 years old, medical history, No. 297/792, was treated at the ENT clinic of the Rostov state medical University, diagnosed with retention cyst of the right HFI - education by size 12×22 mm, filled with a homogeneous liquid content, the outcome is the future of alveolar Bay, it was clearly foreseeable at HFI on computerized tomography of the paranasal sinuses. The next day after hospitalization was carried out surgical treatment according to the claimed method.

It was made extranasal opening right HFI and subsequent sanitation - removing retention cysts of the alveolar Bay sinus. Then from the plate of synthetic polymer - porous polytetrafluoroethylene (ePTFE) with a thickness of 1 mm and an open porosity of 70% of the simulated graft in the form of bone postoperative bone defect in the anterior wall of the HFI and 5% more of its area. The remnants of the anterior bony wall of the HFI laid the prepared graft of a porous tetrafluoroethylene (ePTFE). Then the graft is laid in the soft tissue of the cheeks, which are rigidly fixed it, after which the soft tissue is sutured with catgut tightly. Through the day the patient is examined: the seams are good, the clearance between them is detachable from the wound no.

In the postoperative period antibacterial drugs the patient was not prescribed. Strands of catgut resolved independently. After 1 day after surgery the patient M in a satisfactory condition and was discharged for outpatient care physician at the place of residence. The time of stay of the patient M patient was 3.4 bed-day.

Control examination of a patient in 1.5 months. not found the OS is ogneni in the early postoperative period, related ingrowth into the lumen of the HFI scar tissue.

The proposed method was tested in the ENT clinic of Rostov state medical University in 15 patients and showed positive results. Recurrence of disease or development processes in HFI associated with ingrowth into the lumen of the sinus of scar tissue, in the near and long-term postoperative periods a single patient were noted. The average time of hospital stay was 3.6 bed-days. The postoperative period in all patients was uneventful, cosmetic defects of the face was not.

The average time of hospital stay of 15 patients with diseases of the HFI-cysts HFI operated according to the prototype, was 6, 12 bed-days, which is 1.7 times more than the average time of hospitalization of patients operated using the proposed method.

Thus, compared with the prototype of the proposed method has the following advantages: prevents the development of complications in the early postoperative period associated with ingrowth into the lumen of the sinus of scar tissue, and almost 1.7 times reduces the treatment time.

The method of surgical treatment of diseases of the maxillary sinus (HFI), including extranasal opening HFI, its reorganization and plasticity postoperative bone defect its anterior wall of the graft, characterized in that after Sana the AI HFI of the plates of synthetic polymer porous polytetrafluoroethylene (ePTFE) with a thickness of 1 mm and an open porosity of 70% model transplant, adequate in form and 5% more square postoperative bone defect in the anterior wall of HFI, put a graft on the remnants of the anterior bony wall of the HFI, the soft tissue is sutured tightly, rigidly fixing the graft to the bone.



 

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