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Surgery for chronic maxillary sinusitis
Medical expert of the article
Last reviewed: 04.07.2025
Non-surgical treatment does not always provide a radical effect, and then the question arises about the use of surgical treatment for the following indications:
- lack of effect from non-surgical treatment, which included the use of antibiotics, proteolytic enzymes, vaccine therapy, release of the ostium, punctures and drainage, anti-allergic treatment, physical therapy methods, etc.;
- the presence of proliferative processes in the sinus cavity, established by puncture and radiation diagnostic methods;
- closed forms of chronic sinusitis caused by obliteration of the natural anastomosis and the impossibility of non-surgical and puncture treatment;
- the presence of purulent fistulas, osteomyelitic sequesters, gunshot foreign bodies, the presence of teeth that have fallen into the sinus during their extraction;
- the presence of infected cysts and various parasinus, intraorbital and intracranial complications;
- the presence of secondary complications from internal organs caused by a chronic purulent process in the paranasal sinuses.
The above indications for surgical intervention on the maxillary sinus are also valid for other paranasal sinuses, taking into account the clinical course of their diseases and their topographic and anatomical position.
Contraindications are determined by the general condition of the body, its ability to endure surgical intervention, the presence of systemic diseases of the blood, endocrine system, general inflammatory and infectious diseases, etc. These contraindications can be temporary or permanent. In some cases, a number of contraindications can be ignored (with appropriate protective support), if surgical intervention on a particular paranasal sinus must be carried out for vital indications.
Surgery on the maxillary sinus, as with any other operation on the upper respiratory tract rich in reflexogenic zones, is preceded by preoperative preparation of the patient, which, depending on the state of his health, the chosen method of anesthesia (local or general) can take from several hours to 1-2 weeks. Patients who are to undergo surgery under anesthesia (correction of blood pressure in hypertensive syndrome, blood glucose levels in diabetes mellitus, elimination of hypovolemia and metabolic disorders by infusion therapy, etc.) require especially thorough examination. An important place in the preoperative preparation of the patient is occupied by premedication, aimed at eliminating psychoemotional stress, reducing reflex excitability, pain sensitivity, secretion of the salivary and bronchial glands (in surgical interventions on the organs of the pharynx, larynx, etc.), potentiating the action of general and local anesthetics. To ensure adequate sleep before the operation, a tranquilizer (seduxen or phenazepam) and a sleeping pill from the barbiturate group (phenobarbital) are prescribed per os at night. In the morning, 30-40 minutes before anesthesia or before local infiltration anesthesia, seduxen, promedol and atropine are administered intramuscularly. In particularly excitable patients, droperidol is added to these drugs. For patients prone to allergic or anaphylactoid reactions, antihistamines (pipolfen, diphenhydramine, suprastin) are included in the premedication. After the onset of the premedication effect, the patient is taken to the operating room on a gurney. On the day of the operation, both before and after, food and drink are excluded.
Operation Caldwell-Luke
Local infiltration anesthesia: trunk, local-regional and application, or epimucosal. All three types of anesthesia are performed sequentially in the designated order.
Trunk anesthesia: anesthesia of the trunk of the maxillary nerve in the retromaxillary region in close proximity to the maxillary tubercle. The intraoral method of infiltration trunk anesthesia is used: for this, it is convenient to use a long Arteni needle, which is bent at an angle of 110 ° at a distance of 2.5 cm from the end of the needle. This shape of the needle facilitates the accurate introduction of the anesthetic solution into the paratuberal region. The needle is injected into the alveolar-buccal fossa behind the third molar (8th tooth) with the concavity inward and upward by 45 °, advanced along the bony wall of the upper jaw, all the time contacting its tubercle until the concave part of the needle (2.5 cm) completely enters the tissue. In this position, the end of the needle is at the entrance to the pterygomaxillary fossa; tilting the needle downwards and advancing it another 2-3 mm corresponds to the position of its end near the trunk of the first branch of the trigeminal nerve. Having reached the specified position, an anesthetic substance is administered (4-5 ml of 1-2% novocaine solution). Novocaine can be replaced by new anesthetic solutions that have more pronounced anesthetic and some specific pharmacological properties.
Very effective in this regard are the "dental" combined anesthetics Ultracaine D-S and Ultracaine D-S Forte. The action of the drug begins quickly - in 1-3 minutes and lasts for 45 minutes for the first, and 75 minutes for the second. The drug provides reliable and deep anesthesia, wound healing occurs without complications, due to good tissue tolerance to minimal vasoconstriction. To achieve the specified effect, it is enough to administer 1.7 ml of solution. Ultracaine cannot be administered intravenously. In some patients, the drug can cause an acute attack of suffocation, impaired consciousness, shock. In patients with bronchial asthma, the risk of developing this complication is extremely high.
The new anesthetic substance scandonest, used in many countries under the name of carbocaine, along with a powerful anesthetic property, has a weak vasoconstrictor effect, which allows it to be widely used in local-regional surgeries. It is produced in three modifications with different indications: 3% scandonest without vasoconstrictor effect, 2% scandonest norepinephrine and 2% scandonest special. The first is used in surgeries for hypertensive patients, it is also an ideal means for trunk anesthesia, its pH is close to neutral, which ensures painless injections. The second is used in all types of surgical interventions, even long and complex ones. The third contains a small dose of synthesized adrenaline, which makes its effect more localized (vasoconstriction and local concentration of the drug) and deep. It is important to emphasize the special importance of scandoneste in operations on the upper respiratory tract: it does not contain the paramine group, which completely eliminates the risk of allergies in patients who are hypersensitive to this group.
Indications for use of scandonest:
- 3% scandonest without vasoconstrictive effect is used for stem injections, in hypertensive patients, diabetics and patients with coronary insufficiency;
- 2% scandonex norepinephrine can be used in any operations, as well as in patients with rheumatic heart defects;
- for particularly difficult and lengthy operations, as well as in routine practice.
Dosage: 1 ampoule or 1 vial for a normal operation; this dose can be increased to 3 ampoules for mixed anesthesia (trunk and local). This anesthetic substance can be used for all surgical interventions on the upper respiratory tract.
Trunk anesthesia of the maxillary nerve can also be achieved by injecting an anesthetic solution into the area of the posterior palatine canal; the injection point is 1 cm above the edge of the gum, i.e. above the point of intersection of the line connecting the third molars with the line continuing the dental arcade. 4 ml of 1-2% novocaine solution or the above anesthetics in the appropriate dose are injected into this point.
Local-regional anesthesia is performed by infiltration of soft tissues in the area of the canine fossa and infraorbital foramen - the exit site of the infraorbital nerve. Preliminary infiltration with a 1% solution of novocaine of the mucous membrane of the vestibule of the oral cavity of the corresponding side, going 1 cm beyond the frenulum to the opposite side, and up to the second-third molar of the "causal" side.
Application anesthesia is performed by 2-3-fold lubrication or insertion of turundas soaked in a 5% solution of dicaine or a 5-10% solution of cocaine into the lower and middle nasal passages for 5 minutes.
The operation takes place in five stages:
- A single-stage horizontal incision of the mucous membrane and periosteum along the transitional fold of the oral vestibule, starting from the 2nd incisor, 3-4 mm from the frenulum of the upper lip and ending at the level of the second molar. The mucous membrane together with the periosteum is separated as a whole flap, exposing the anterior bone wall of the maxillary sinus along the entire canine fossa, trying not to damage the infraorbital nerve emerging from the infraorbital fossa. Some authors suggested making a vertical incision in the projection of the center of the canine fossa to prevent damage to the alveolar nerve branches, but this type of incision has not found widespread use.
- The sinus is opened in the thinnest bone part of the anterior wall, identified by its bluish tint and percussion sound. Sometimes this part of the anterior wall is so thin that it breaks under slight pressure or is completely absent, eaten away by the pathological process. In this case, purulent masses may be released through the fistula or granulations or polyps may prolapse under pressure. Pus is immediately removed by suction, and tissues that obstruct the view of the sinus are partially (preliminarily) removed, trying not to cause profuse bleeding.
The sinus can be opened with a spear-shaped bur according to A.I. Evdokimov or with a grooved chisel or gouge, which make rounded cuts around the bone plate to be removed. The released bone plate is lifted from the edge with a thin raspatory and removed. The size of the opening in the anterior wall of the maxillary sinus can vary depending on the nature of the pathological process and its localization in the sinus.
- Surgical treatment of the cavity is the most important stage, and the technique of its implementation remains controversial to this day. In the classic version of Caldwell-Luc, the operation was called "radical" due to the fact that, according to the authors' proposal, total curettage of the mucous membrane was performed regardless of its condition, which was motivated by the assumption of preventing relapses. However, this method did not justify itself for many reasons:
- total scraping of the mucous membrane does not lead to a cure for the chronic inflammatory process, but prolongs it for months and years by going through various pathomorphological stages from the lush growth of granulation and repeated surgical interventions to the cicatricial process and obliteration of the sinus and its outlet;
- removal of islets of the mucous membrane, albeit pathologically altered, but capable of regeneration and reparative restoration, deprives the body of the ability to use its adaptive-trophic functions aimed at restoring the normal mucous membrane of the sinus, which plays an important physiological role for the entire PNS;
- Total scraping of the mucous membrane of the maxillary sinus leads to the destruction of the remaining, albeit only in the area of viable, islets of vegetative fibers - a connecting link with vegetative trophic centers, which also hinders reparative processes in the sinus.
There are examples from practice, when only the formation of an effectively and long-term functioning artificial sinus-nasal anastomosis and the removal of only obviously non-viable tissues, polyps and lush granulations without curettage of the mucous membrane leads to complete sanitation of the maxillary sinus, therefore the vast majority of modern rhinosurgeons are gentle with the mucous membrane of the paranasal sinuses. Total removal of the mucous membrane is indicated only in extremely rare cases, mainly as a palliative method of treating "profuse" recurrent polyposis of the entire PNS, deep destructive damage to the entire mucous membrane and periosteum, the presence of osteomyelitic changes in the sinus walls. After removing all pathological contents from the sinus, its final revision is performed, paying attention to the bays, the posterior and orbital walls, especially the supero-medial angle bordering the posterior cells of the ethmoid labyrinth. Many authors suggest conducting a revision of this area by opening several cells. If there is an inflammatory process in them (chronic purulent sinus ethmoiditis), pus is released immediately after opening the cells, which is a reason for revising all accessible cells with their removal and forming a single cavity with the maxillary sinus.
- Formation of an artificial drainage opening ("window") in the medial wall of the sinus to communicate with the inferior nasal passage and perform drainage and ventilation functions. In the classic version of the Caldwell-Luc operation, this opening was literally cut into the nasal cavity, and the resulting flap was removed together with the mucous membrane of the lateral wall of the inferior nasal passage. This method is not used today. First, the thin bone medial wall of the sinus is carefully broken and, by penetrating the space between the bone and the mucous membrane of the lateral wall of the inferior nasal passage with a thin nasal raspatory, the bone part of the septum is fragmentarily removed until an opening the size of a modern 2-ruble coin is formed. In this case, they try to extend the opening as high as possible, but not further than the place of attachment of the bone of the inferior nasal concha. This is necessary for the subsequent formation of a mucous flap of sufficient length. Then the remaining mucous membrane of the lateral wall of the nose is separated in the direction of the bottom of the nasal cavity, going onto it by 4-5 mm. Thus, the "threshold" between the bottom of the sinus and the bottom of the nasal cavity is exposed, which is an obstacle to subsequent plastic surgery of the nasal mucous membrane of the bottom of the sinus. This threshold is smoothed either with a narrow chisel, or a sharp spoon, or a burr, thereby insuring the mucous membrane of the nose (the future flap) from damage. After smoothing the threshold and preparing a site on the bottom of the sinus in the immediate vicinity of the threshold for the flap, plastic surgery of the bottom of the sinus begins. To do this, with the support of the mucous membrane (the future flap) from the lower nasal passage by some suitable instrument, such as a nasal raspatory, a sharp spear-shaped eye scalpel, a rectangular flap is cut out of this mucous membrane with a special U-shaped incision in the following sequence: the first vertical incision is made from top to bottom at the level of the posterior edge of the bony opening of the "window", the second vertical incision is made at the level of the anterior edge of the "window", the third horizontal incision is made at the upper edge of the "window", helping yourself with a raspatory inserted into the lower nasal passage. The resulting rectangular flap (which has a tendency to contract) is placed through the smoothed threshold on the bottom of the sinus. Some rhinosurgeons neglect this part of the operation, believing that the epithelialization of the sinus still occurs from the source of the nasal cavity. However, experience shows the opposite. The remaining uncovered bone tissue of the scraped threshold is prone to lush granulation with subsequent metaplasia into scar tissue, completely or partially obliterating the newly formed “window” with all the ensuing consequences. In addition, the plastic flap is a powerful source of reparative physiological processes, accelerating the normalization of the cavity, since the secretory elements present in it release trophically active and bactericidal substances,promoting healing and morphological and functional rehabilitation of the sinus.
- Tamponade of the maxillary sinus. Many practitioners attach a purely formal significance to this stage, and even in reputable textbooks and manuals its significance is reduced to the prevention of postoperative bleeding, the formation of hemosinus, its infection, etc. Without diminishing the significance of this position, we note, however, that a fundamentally different significance of sinus tamponade is completely ignored, or rather, the significance of those substances with which the tampon is impregnated, introduced into the postoperative cavity both in a mixture with Vaseline oil and antibiotics immediately after the completion of the operation on a particular sinus, and in the postoperative period.
We are talking about regenerants and reparants - preparations that have the ability to stimulate reparative regeneration. This process promotes the restoration of tissue and organ areas damaged as a result of trauma, surgery, inflammation or dystrophy. As a result of reparation, either tissues and organs in the parabiosis stage are restored to normal, or the foci of necrosis are replaced by specific and/or connective tissue, which has the highest regeneration potential. It is easy to see that these provisions are directly related to the pathological condition under consideration; after all, for an organ, which we consider the maxillary sinus as an element of the system, it is not indifferent whether it becomes empty and obliterated by connective tissue, or at least 50-60 percent of its internal surface is covered as a result of forced regeneration with multilayered cylindrical ciliated epithelium and those elements of the mucous membrane that ensure homeostasis of the sinus.
The general mechanism of regenerative action includes the enhancement of biosynthesis of purine and pyrimidine bases, RNA, functional and enzymatic cellular elements, including membrane phospholipids, as well as stimulation of DNA replication and cell division. It should be noted that the biosynthesis process during both physiological and reparative (post-traumatic) regeneration requires substrate provision (essential amino and fatty acids, microelements, vitamins). In addition, the process of protein and phospholipid biosynthesis is highly energy intensive, and its stimulation requires appropriate energy supply, i.e. appropriate energy materials. Such agents that provide energy and substrate for the reparation processes include actovegin, solcoseryl, etc. The effect of these drugs is often difficult to differentiate from the body's "own" regenerative action.
In accordance with the localization of action, regeneration and reparation stimulants are conventionally divided into general cellular (universal) and tissue-specific. General cellular stimulants that act on any regenerating tissue include anabolic steroids, non-steroidal anabolics - sodium deoxyribonucleate (derinat), methyluracil, inosine, etc. - and vitamins of plastic metabolism. There should be no doubt that after removing the tampon from the wound cavity of any origin, along with infection prevention, the above reparants should be used locally and in the general therapeutic plan. There is no extensive experience of such use, and the method of using these drugs in otolaryngology awaits its scientific research, but even now it is possible to recommend the use of some anabolic steroids, non-steroidal anabolics and vitamins of plastic metabolism for the harmonization of reparative and regenerative processes in the postoperative period during operations not only on the paranasal sinuses, but also on other ENT organs. For example, sodium deoxyribonucleate in a ratio of 1:20 or derinat (5:10) can be added to vaseline oil, which is used to soak “sinusitis” tampons for sinus tamponade after surgery - drugs with pronounced reparative and regenerative properties.
Thus, sodium deoxyribonucleate has immunomodulatory, anti-inflammatory, reparative and regenerative properties. It activates antiviral, antifungal and antimicrobial immunity at the cellular and humoral levels. Regulates hematopoiesis, normalizes the number of leukocytes, granulocytes, phagocytes, lymphocytes and platelets. Stimulates reparative processes in wounds, restores the structure of the mucous membrane of the upper respiratory tract and gastrointestinal tract, facilitates the engraftment of autotransplants (in particular, a flap of the mucous membrane of the nose, placed on the bottom of the maxillary sinus, eardrum, etc.). After removing the tampons from the maxillary sinus (or from the nasal cavity after septum surgery), this preparation can be introduced into the sinus after it has been washed and emptied of the washing liquid, mixed with carotolin in a ratio of 5 drops of the preparation to 5 ml of carotolin, daily for 7 days. Instead of carotolin, rosehip or sea buckthorn oil with corn oil can be used in a ratio of 1 ml of sea buckthorn oil to 5 ml of corn oil.
Another drug - Derinat - is available in solutions for external and internal use, it is very convenient to use it in a mixture with Vaseline or other vitaminized oil for soaking tampons or use in pure form or in a mixture with carotolin, rosehip oil, sea buckthorn in the postoperative period.
Tissue-specific stimulators of the regeneration process are drugs with different mechanisms of action, combined into subgroups according to their selective action on a particular tissue or organ system.
Of great importance for stimulating reparative processes in the wound are vitamins with plastic action (alfacalcidol, ascorbic acid, benfotiamine, beta-carotene, vitamin E, retinol, etc.). Their use (local and general) significantly affects reparative processes and must be carried out without fail in the postoperative period for 10-14 days.
Returning to the tamponade of the maxillary sinus, we will note some of its features. Before the tamponade, final hemostasis must be achieved by any existing methods (sealing of the bone vessel, scraping of bleeding pathological tissues, laser coagulation of the vessel). The application of adrenaline gives only a temporary effect of vasoconstriction, after which the opposite effect occurs - the phase of vessel dilation. Before the tamponade, it is advisable to pour an appropriate antibiotic into the sinus, let in 5-10 drops of hydrocortisone emulsion, 1 ml of carotolin mixed with a solution of deoxyribonucleate, and under visual control, disperse the mass formed in the cavity over the bays of the sinus. After this, several small pieces of hemostatic sponge or 2-3 sponges (1x1 cm) "Alvostaz", used in dentistry for the treatment of alveolitis, are placed in the sinus. "Alvostaz" is a composite sponge containing eugenol, thymol, calcium phosphate butyl para-aminobenzoate, iodoform, lidocaine, propolis; the basis is a hemostatic absorbable sponge. "Alvostat", introduced into the inflammatory cavity, quickly relieves pain and promotes healing in the shortest possible time. After the introduction of the sponge, the sinus begins to be tamponed. The tampon, soaked in the appropriate solutions (as discussed above), is held by an assistant, and the surgeon gradually places it in the form of an accordion, starting from the farthest corners of the sinus so that when it is removed, the part of the tampon that is to be removed last is not in front of the part being removed. With good hemostasis, tight tamponade is excluded, the tampon is placed loosely, but so that it fills the entire volume of the sinus. The end of the tampon is brought out through the artificial "window" into the lower nasal passage, then into the common nasal passage and outward, fixing it at the nostril with a cotton-gauze anchor and a sling-like bandage. An important stage in bringing the tampon out of the sinus into the nasal cavity is the insurance of the flap lying on the smoothed threshold. In order not to displace the flap, it is pressed with a nasal raspatory to the underlying bone and the tampon is carefully and slowly pulled into the nasal cavity and outward. After removing the fixation of the flap, no traction of the tampon should be performed. At the end of the tamponade, the position of the flap is verified and, if necessary, it is straightened and fixed by pressing the tampon from above. The tampon is removed after 48 hours. In order for it to slide easily, during the formation of the artificial drainage hole, ensure that its edges are smooth, without burrs, which the gauze tampon easily clings to when removing it. 6. Suturing the wound in the vestibule of the mouth is an optional procedure and depends on the surgeon's preference. After 3-4 hours, the correctly aligned edges of the wound stick together tightly. Some authors recommend placing a small gauze roll on the wound in the vestibule of the mouth to fix the edges of the wound, which is removed after 2-3 hours.The previously practiced pressure bandage on the canine fossa area, supposedly to prevent swelling of the cheek, is now used less and less often due to its ineffectiveness.
Postoperative patient management. No food intake until the next day. Drinking a small amount (0.2-0.3 l until the next morning) of cold tea sweetened and acidified with lemon is allowed. Injectable analgesics are prescribed for pain. In addition, the patient is prescribed an appropriate antibiotic, diphenhydramine, sedatives as indicated. Bed rest until the next morning. After removing the tampon, the sinus is washed with a warm sterile isotonic solution or furacilin, and depending on its condition, composite preparations containing reparants, antibiotics, and fat-soluble vitamins are administered for several days. Usually, with such intensive treatment, recovery occurs in 2 weeks, and the patient can be discharged from the hospital for outpatient observation 3-5 days after the operation.
Kretschmann-Denker operation
The operation was first proposed by A. Denker in 1903, and was then improved by G. Kretschmann in 1919 by extending the incision beyond the frenulum of the upper lip.
Indications, contraindications, preoperative preparation, anesthesia are identical to those for the Caldwell-Luc operation. This surgical intervention allows access to the nasopharynx, for example, to remove a fibroma of the base of the skull. According to V.V. Shapurov (1946), this surgical approach has another purpose: a wide opening of the maxillary sinus with resection of the edge of the pyriform sinus creates conditions for the soft tissues of the cheek to sink into the sinus and, consequently, for its partial or complete obliteration, which leads to a radical cure, of course, at the cost of the remaining cosmetic defect of the face. Of the instruments, there is a great need for bone forceps. This operation, like the previous one, consists of a number of stages:
- the incision is extended by 1 cm beyond the frenulum of the upper lip;
- the pyriform opening is exposed and the soft tissues with the periosteum are separated from the anterior sections of the lateral wall of the nose and from the anterior wall of the maxillary sinus;
- The edge of the pyriform opening, part of the anterior wall of the maxillary sinus and part of the lateral wall of the nose located behind the inferior turbinate are removed with a chisel or bone forceps; after sufficient opening of the maxillary sinus through its anteromedial angle, all other stages are performed as in the Caldwell-Luc operation.
With this method, direct visibility of all the bays of the maxillary sinus using a frontal reflector is difficult; for this purpose, video fiber optics can be used with the image output to a monitor screen; using this technique, it is also possible to conduct an endoscopic revision of the sinus.
The Kanfeld-Shturman operation involves an intranasal method of opening the maxillary sinus. This method was developed by many other authors, but in previous years it was not widely used due to the limited view of the maxillary sinus, high bleeding, and the need in most cases to resect the anterior part of the inferior nasal concha.
Anesthesia - application in the area of the lateral wall of the nose and in the area of the lower nasal passage, infiltration anesthesia in the same area. The opening of the sinus is carried out through the lateral wall of the nose at the level of the lower nasal passage. With the availability of modern means, this operation can be performed by video surgery with a minimal opening and the condition of small pathological changes in the maxillary sinus.