Maxillary sinus puncture

Puncture of the maxillary sinus for diagnostic purposes is performed only in cases where it also combines therapeutic purposes, and only when nasal endoscopy raises suspicion of the presence of pathological contents in the sinus. Some authors recommend performing a puncture in catarrhal sinusitis to introduce drugs into the sinus and achieve a faster therapeutic effect. Puncture of the maxillary sinus should be treated with great caution, since failure to comply with a number of technical rules may result in various complications caused by the procedure itself or in the presence of congenital defects in the structure of the facial skeleton. Therefore, any puncture of the paranasal sinuses should be preceded by a thorough X-ray examination to identify the specified defects (two-chamber sinus, absence or thinning of the orbital bone wall, presence of dehiscences, and in traumatic sinusitis - the presence of cracks and bone fragments). The specified phenomena determine the indications and an individual approach to performing a puncture of the maxillary sinus. Sometimes the floor of the maxillary sinus is located significantly higher than the inferior nasal passage - the traditional place for its puncture. In this case, probing of the sinus through the natural opening can be used or a puncture can be performed through the middle nasal passage. In the latter case, special skills are required, since there is a possibility of penetrating the ethmoid labyrinth or the orbit.

Often, during a puncture of the maxillary sinus, patients experience a collapse reaction: a sharp pallor of the face, cyanosis of the lips, relaxation, loss of consciousness. These phenomena are caused by a sharp decrease in arterial pressure due to a drop in vascular tone, a decrease in cardiac output and, as a consequence, cerebral ischemia. In this case, the patient should be sharply tilted forward so as to cause compression of the abdominal aorta and increase arterial pressure in the carotid and vertebral arteries. If the patient's consciousness is not lost, he is asked to inhale ammonia vapors through the nose, causing a sharp irritation of the trigeminal nerve and a reflex increase in arterial pressure. The patient is immediately placed in a horizontal position with slightly raised lower limbs, covered with a blanket, 2 ml of a 10% solution of sodium caffeine benzoate is injected subcutaneously. As a rule, these measures are sufficient to eliminate the signs of a collapse state. In addition to the above-mentioned excess, some "technical" complications are possible, arising from incorrect direction of the puncture needle or its slipping along the lateral wall of the nose in the direction of the orbit. Perforation of the upper (orbital) and posterior wall with penetration of the needle into the orbital nasal cavity, as well as the needle entering the soft tissues of the face, are also possible. In these cases, parasinus injection of lavage fluid or air is possible, causing secondary complications (emphysema, abscess, phlegmon), injury to a large vessel (in case of injury to an artery - hematoma; in case of injury to a vein - embolism), etc. When the maxillary sinus is punctured, a slight crunch of the broken bone septum is always felt.

Anesthesia is performed by 2-3-fold lubrication of the mucous membrane of the lower and middle nasal passages with a 5% solution of dicaine mixed with adrenaline. Infiltration anesthesia is possible with the introduction of 2 ml of a 2% solution of novocaine into the area of the lower nasal passage. Lubrication of the middle nasal passage with an adrenaline solution facilitates the patency of the excretory duct of the maxillary sinus. The puncture is performed with a Kulikovsky needle, the features of which are a sharp beveled end bent at an angle of 20 °. The handle of the needle is presented in the form of a flat thick plate of an asymmetrical shape, the larger shoulder of which is directed towards the bend of the needle, the massiveness and elasticity of the needle itself, allowing significant force to be exerted on it without the risk of bending it. Instead of a Kulikovsky needle, a needle with a trocar for lumbar puncture is sometimes used.

The puncture procedure is performed as follows. Under visual control, the end of the needle is inserted with the concave part downwards into the lower nasal passage to a depth of 2-2.5 cm and the convex part of the end is rested against the arch of the lower nasal passage. Then, focusing on the larger arm of the handle, it is turned so that the curved end and the general direction of the needle are directed toward the outer edge of the orbit. The most critical moment occurs during the puncture. With the left hand the doctor fixes the patient's head, in some cases resting it on the headrest or wall, and with the right hand, holding the needle tightly against the palm, first fixes the end of the needle on the bone with a light drilling motion (prevention of the needle from slipping), then, orienting the end of the needle toward the outer angle of the orbit, with the appropriate force (developed during the experiment) punctures the medial wall of the sinus, while the needle should be firmly fixed in the fingers holding it, so that at the moment of puncture it does not go too far and does not injure the back or upper walls of the maxillary sinus. When inserting the needle, its end should be fixed at the very vault of the inferior nasal passage, where this wall is the thinnest. In some cases, the medial wall of the maxillary sinus is a fairly dense and thick bone, as a result of which the puncture is carried out with great difficulty or is completely impossible. It should be noted that when puncturing the right maxillary sinus, it is more convenient to hold the needle in the right hand, and when puncturing the left sinus, in the left hand.

After the needle is inserted into the sinus, it is pulled out by 2-3 mm to free its lumen from any fragments of the punctured tissue that may have gotten into it. Immediately after the puncture, the fluid contained in the sinus may be released from the needle, especially if it is under pressure. Transudate or the contents of a cyst (cyst-like formation) are released most freely if the needle entered their cavity. Thick pus and jelly-like masses are not released on their own. After the puncture, the doctor performs a number of tests and manipulations. Using an empty syringe, with a light suction movement, an attempt is made to obtain the contents of the sinus. If this is successful, then one should not try to use this technique to completely remove the contents of the sinus, especially if the anastomosis is obstructed, since the vacuum created in the sinus during aspiration can disrupt the integrity of the vascular plexuses of the mucous membrane, even disrupt its connection with the periosteum, which creates conditions for hematogenous spread of infection and the occurrence of serious complications. Checking the functioning of the anastomosis is determined as follows. The patency of the anastomosis is preserved if the syringe piston can be pulled out easily and does not return to its original position, if the liquid injected into the sinus is released into the nasal cavity along with its contents, if when air is injected into the sinus it easily penetrates into the nasal cavity with the corresponding characteristic sounds, but forcing the introduction of air into the sinus should not be done in any case, as this can be complicated by emphysema. The contents of the sinus obtained by careful aspiration, observing the rules of asepsis, are placed in a sterile test tube and subjected to bacteriological examination. However, the contents are often sterile, which can be explained by the presence of anaerobic microbiota.

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