Optical methods for studying the paranasal sinuses have become increasingly widespread in recent years. In combination with other diagnostic methods, they help the doctor make an accurate diagnosis and carry out the necessary treatment. Endoscopy is indispensable in complex diagnostic cases, with discrepancies in the clinical picture of the disease and results.

Despite the fact that the procedure is relatively safe and minimally invasive, it is still traumatic (to insert the endoscope, the sinus wall is punctured, as with a regular puncture), and general anesthesia is often used for its implementation. That is why there are certain indications for endoscopic examination that the doctor takes into account when prescribing this type of examination. Currently, otolaryngologists perform endoscopy of the maxillary and frontal sinuses.

Modern ones are complex technical devices equipped with special optics with a wide viewing angle, video recording devices, digital video signal converters, and various auxiliary tools. Thanks to this device, the doctor can directly examine the sinuses by receiving an image on the monitor screen. In otorhinolaryngology, rigid endoscopes are usually used to examine the paranasal sinuses, which retain their shape during the procedure.

Purposes of endoscopic examination of the sinuses

The paranasal sinuses are located in the human body in such a way that it is impossible to examine them without the help of special devices. It is endoscopy that helps solve this problem. Typically, a specialist performs this procedure to achieve the following goals:

• early detection of the pathological process in the sinuses;
• solving issues of differential diagnosis and taking the contents of the sinus for analysis (to isolate the pathogen and determine its sensitivity to antibacterial drugs);
• biopsy of suspicious areas and morphological examination;
• preparation for surgery or monitoring treatment after it.

Indications for use

Endoscopy of the sinuses allows the doctor to examine the mucous membrane of the paranasal sinuses and timely diagnose the pathological process.

When prescribing an endoscopic examination, the ENT doctor carefully examines the patient and studies the medical history, and then determines the need for the procedure. Indications for diagnostic endoscopy are limited; let’s consider the main ones.

1. Clarification of the diagnosis in cases of damage to the sinuses of unknown origin (when using simpler methods it is not possible to establish the cause of the disease).
2. Sinus injuries.
3. Anomalies in the development of the paranasal sinuses.
4. Polypous.
5. Carrying out various medical procedures.

Methodology

Preparing the patient for endoscopic examination includes toileting the nasal cavity and anesthesia. Penetration into the paranasal sinuses can be carried out under general intubation anesthesia or local anesthesia in combination with tranquilizers or barbiturates in low doses.

For endoscopy of the maxillary sinus, in most cases, access through its anterior wall is used. This is due to the peculiarities of its structure.

• To do this, using a special trocar, a hole is drilled between the third and fourth teeth using rotational movements.
• Then an endoscope with an optical resolution of 0 to 70 degrees is inserted into the resulting hole through the trocar sleeve.
• The specialist examines the walls of the sinus, assesses the color and texture of the mucous membrane, identifies the affected area (if there is one) and performs all the necessary manipulations (sampling tissue for analysis, opening the cyst, etc.).
• At the end of the procedure, the trocar is carefully removed.
• The perforation site is not sutured.

The doctor also receives important information during examination of the sinus anastomosis with the nasal cavity. At the same time, its size, the presence or absence of polypous growths and other pathological changes in the mucous membrane of the anastomosis are determined. The data obtained in this way allows us to determine the tactics of patient management. If during endoscopy it is possible to eliminate a limited pathological process or release and expand the anastomosis, then the procedure ends there. If a specialist detects extensive changes, then this may be an indication for more extensive surgical intervention.

Conclusion

Endoscopic examination of the paranasal sinuses is an original diagnostic method that makes it possible to examine with magnification all the details of a complex configuration. By conducting an examination from different angles, the doctor receives information about all hard-to-reach or anatomically narrow areas of the sinuses and can assess not only their condition, but, if necessary, perform microsurgical intervention.

Endoscopy – from the ancient Greek “looking inside” – is an excellent modern diagnostic method based on examining natural cavities with a special endoscope. The method is based on a fiber optic optical system, which in modern endoscopes is equipped with a miniature camera with a monitor output and a set of various surgical manipulators: wire cutters, scalpels, needles and others.

In fact, the first endoscope was designed back in 1806. The instrument was a rigid metal tube with a system of refracting mirrors, and the light source was a banal candle. Modern endoscopes are flexible tubes with precise optical systems, equipped with computer software and surgical manipulators. Every year, medical technology companies improve endoscopic equipment, opening up new possibilities for endoscopy. One of these relative innovations is endoscopy of the nasal sinuses, including the maxillary sinuses.

Why do endoscopy of the paranasal sinuses?

The main problem of otorhinolaryngology is that the structures of the nose, ear and paranasal sinuses are extremely narrow structures compactly hidden in the bony skeleton of the skull. It is extremely difficult to reach them using a standard set of ENT instruments. With the advent of a new generation of thinnest guides, it has become possible to penetrate the endoscope through the natural anastomosis between the nasal cavity and the sinus to examine the internal contents of the sinuses.

Examination of the nasal cavity using an endoscope

For what purposes can endoscopy be used?

1. First of all, endoscopic examination of the maxillary and other paranasal sinuses is a high diagnostic standard. Compared to computed tomography and, especially, x-rays, the value of endoscopy is colossal. Do you agree that what could be better than, literally, looking into the affected sinus with your eye and assessing the condition of its mucous membrane and the nature of the pathological process? The doctor assesses the condition of the mucous membrane, the plethora of its vessels, the degree of edema, the presence of fluid or pus in the sinus cavity, and notices abnormal tissue growths, polyps, cysts and other “plus tissues”.
2. The endoscope can also be used to take samples of the mucous membrane and its discharge (pus, exudate) for bacteriological examination. It is used to determine the pathogen that caused sinusitis or other sinusitis, as well as the sensitivity of the microbe to antibiotics. This helps to competently and precisely prescribe a course of antibacterial therapy.
3. In addition to diagnostic studies, endoscopic technology is widely used in operations and manipulations of the sinuses. We will talk about the types of such operations in the next section.

Advantages and disadvantages of endoscopic interventions

Previously, before the era of endoscopy, ENT doctors widely used standard surgery methods for sinus pathology: trephine puncture and variants of various operations involving violation of the bone structures of the sinuses. These operations are quite technically complex, fraught with bleeding and disruption of the anatomy of the ENT organs.

Endoscopic surgery on the maxillary sinus is the gold standard of minimally invasive surgery throughout the civilized world. Let's list all its advantages:

1. Safety. Endoscopy rarely causes significant bleeding and does not disrupt the structure and anatomy of the sinuses, since in the vast majority of cases the instrument is inserted into the sinus cavity through its natural anastomosis.
2. Physiological. Precisely because it is possible to insert the thinnest instrument under the control of the eye into the natural anastomosis, there is no need to destroy the bone walls and partitions.
3. Efficiency. Since the endoscopic technique is equipped with a micro-camera, the doctor carries out all manipulations not blindly, as before, but under the control of the eye on a large screen.
4. Fast postoperative recovery. It is logical that the low invasiveness of the operation implies rapid healing and tissue restoration.

Like any, even the most excellent method, endoscopy of the paranasal sinuses has a number of limitations and disadvantages. Disadvantages of the method:

1. Endoscopic technology is very expensive and also requires very gentle processing and sterilization methods. Therefore, not every public clinic has such technologies in its arsenal.
2. The method also requires special training and internship for specialists.
3. Sometimes, in the case of severe tissue swelling or natural narrowness of the anastomosis, it is impossible to insert a conductor into the sinus cavity. It is also impossible to remove a large fragment of a tooth root or a fragment of filling material from the maxillary sinus using an endoscope through the narrow passage of the nasal passage. In such cases, it is necessary to expand the scope of the operation and crush the bone plate, as in a conventional operation. The wide opening is also very convenient to use with an endoscope.

Types of endoscopic interventions for sinusitis

We list the main options for using endoscopic manipulations for pathology of the maxillary sinuses:

1. Removing pus, draining and rinsing the sinuses. This technique is also called. It is indicated for the accumulation and increase in pressure of pus in the sinus cavity when the natural anastomosis is closed by inflamed tissues. As opposed to traditional puncture or puncture, pus is evacuated by expanding the natural anastomosis with a special inflatable balloon. Next, the cavity is washed repeatedly with antiseptics until completely clean.
2. Options for operations. As a rule, a chronic inflammatory process in the sinus is accompanied by the formation of various “plus tissues”: cysts, polyps, growths of the mucous membrane. These abnormal inclusions in the cavity interfere with adequate ventilation and drainage of the cavity and exacerbate inflammation. With the help of surgical attachments for an endoscope, it is possible to quickly and bloodlessly remove these tissues under the supervision of a specialist eye.
3. Options for operations to remove various foreign bodies of the maxillary sinus. Such foreign inclusions are filling material, bone fragments, fragments of teeth, pins and other dental paraphernalia. Unfortunately, most often the natural anastomosis is too narrow for the safe removal of large particles, so in such cases the operation is expanded: a hole is created in the bony septa of the sinus with access from the wall of the nose or upper jaw.

How does endoscopic surgery occur?

I would like to immediately note that each patient may have his own nuances of the operation, its technique and preparation, so we will only briefly outline the main stages of endoscopic manipulations:

1. Maximum preoperative preparation of the patient. Of course, in case of acute purulent sinusitis, drainage must be done as quickly as possible. But with a planned intervention, for example, removal or plastic surgery of the excretory duct, high-quality preparation is the key to success. Such operations are best done during the “cold period”, when swelling and inflammation are minimal.
2. The patient must undergo blood tests, urine tests, and a blood clotting test to prevent possible complications. In the case of general anesthesia, an electrocardiogram and examination by a therapist are also required.
3. Operations are performed both under general anesthesia and local anesthesia. Most often it depends on the extent of the operation and the need for transosseous access.
4. Before the operation, the patient is informed about the potential of surgery, its possible consequences, the course of the operation and the features of the postoperative period are explained. The patient must sign informed consent for medical intervention.
5. Before the operation, the patient is repeatedly washed with antiseptic solutions, then vasoconstrictor drops are instilled to reduce swelling and spasm of blood vessels.
6. Next, depending on the surgical plan, either a window is created in the bone walls of the cavity, or an endoscope is inserted into the natural anastomosis.
7. Once in the sinus cavity, the doctor, looking at the screen, assesses the condition of its mucosa, finds abnormal tissues and begins to remove them with special tweezers and scalpels - a kind of cleaning of the cavity occurs.
8. After removing all excess, the cavity is washed with antiseptics, and sometimes antibiotics are injected into it. The doctor removes the instruments. The operation is over. The rehabilitation period begins.
9. Each patient's rehabilitation features are completely individual. As a rule, recovery programs include: taking antibiotics, constant nasal rinsing, instillation of vasoconstrictor drops, physical therapy and regular monitoring by an ENT doctor.

There are many diseases of the nasal cavity and maxillary sinuses, which are accompanied by the accumulation of purulent exudate and the formation of pathological growths on the mucous membrane. And while they can be removed from the nasal cavity quite easily, in the case of the maxillary sinuses, a complex maxillary sinus procedure will be required. Previously, it was performed using a rather traumatic method, until endoscopic maxillary sinusotomy appeared. This procedure allows you to eliminate pathological contents in the sinuses through small incisions or punctures, which minimizes the risk of complications and shortens the recovery period.

The maxillary sinus is located above the upper jaw and is connected to the nasal cavity by a small anastomosis, the diameter of which does not allow for full drainage and sanitation. If we consider older methods of removing pathological tissue (cysts, polyps, etc.) and exudate from the sinuses, it turns out that they were all quite traumatic procedures. Long-term study of the problem and the creation of endoscopic instruments made it possible to move away from old methods and increase the efficiency of the procedure.

Today, specialists have almost completely switched to endoscopic micromaxillary sinus - a procedure during which all manipulations are performed through small punctures in the walls of the maxillary sinuses. There are alternatives to performing surgical endoscopy of the sinuses, but they are not always as effective or affordable.

Radical maxillary sinusotomy

The method is considered radical and quite traumatic, since access to the maxillary cavity in the wall of the sinus requires a fairly wide (about 10-15 mm in diameter) hole. The most common surgical operation is the Caldwell-Luc method, in which an incision is made in the gum of the upper jaw and a flap of mucous membrane is removed. The exposed bone tissue is pierced with a drill or pierced with a chisel, after which the hole is widened with forceps and penetrated into the sinus for further manipulation.

Compared to endoscopic removal of a maxillary sinus cyst, the radical method has significant disadvantages.

For example, the doctor does not have sufficient visibility to remove all pathological fragments. In addition, the wound after the intervention is quite large, which favors its infection and the occurrence of complications.

Laser method

In terms of the type of access, laser maxillary sinusotomy does not differ from classical radical intervention. The only difference is that to remove a cyst from the sinus, they use not classical instruments (forceps, loops, etc.), but a laser emitter. The method remains the same traumatic, but the risk of relapse is reduced due to better elimination of pathological foci.

Endoscopic maxillary sinusotomy

Access to the sinus cavity during endoscopic maxillary sinusotomy is carried out through small punctures:

• in the anterior wall of the maxillary sinus (in the oral opening);
• through natural anastomosis;
• through oroantral perforations (most often these are fistulas formed during the pathological process);
• through the lower nasal passage.

When making access, not large instruments are used, but small-diameter trocars. The doctor gets maximum visibility thanks to a miniature camera, and removal of pathological ones is carried out mechanically, but laser or wave emitters are more often used.

Puncture

Puncture is considered the most affordable method, which is used if full surgical intervention is impossible due to the abundance of purulent contents in the maxillary sinus or effusion of unknown origin. The method also paid off if the necessary manipulations for sinusitis did not produce results.

The essence of the puncture is the removal of contents from the sinus using a special needle, which is inserted through the nasal septum under local anesthesia. After the needle reaches the sinus, the doctor attaches a syringe to it and pumps out the contents of the cavity. After this, it is washed with antiseptics and antibiotic solutions.

Advantages and disadvantages of maxillary sinus endoscopy

When removing a cyst in the maxillary sinus or eliminating a pathological effusion, the relationship between the effectiveness and safety of the procedure is assessed. In this regard, the classical method is quite significantly inferior to endoscopic sinus surgery.

The main advantages of intervention using an endoscope:

• absence of extensive damage to mucous membranes and bones;
• wide view of the sinus;
• full access to the maxillary cavity;
• low risk of complications and relapses;
• short recovery period;
• The method allows for a variety of manipulations, including removal of a foreign body, cyst, effusion, and polyps from the nasal sinuses.

The operation is performed in a hospital setting and is most suitable for patients for whom classic maxillary sinusotomy is contraindicated.

There are practically no disadvantages to endoscopic maxillary sinusotomy. The only “minus” of such an operation is its higher cost than puncture and radical surgery.

Indications and contraindications for

Maxillary sinus surgery is indicated in the presence of diseases of the upper respiratory tract involving the membranes of the maxillary sinus in the pathological process, especially if, during the development of inflammation, a purulent exudate, effusion or cyst is formed in its cavity.

Doctors call absolute indications for the procedure:

• chronic process with sinusitis;
• chronic sinusitis and nasal congestion, which are characterized by the presence of inflammatory processes;
• the presence of polyps and other neoplasms in the sinuses;
• the addition of a purulent infection during the development of sinusitis;
• ineffectiveness of conservative treatment for sinusitis, sinusitis and other pathologies.

Endoscopic removal of the maxillary sinus cyst, freeing it from purulent accumulations, is not resorted to during exacerbation of the chronic process. If there is a high risk of infection spreading, a puncture is prescribed for drainage and sanitization of the cavities.

In addition, the main contraindications to performing maxillary sinusotomy using endoscopic equipment include systemic diseases:

• poor blood clotting;
• malignant processes in the field of intervention;
• conditions for which general anesthesia cannot be used.

It is not advisable to use this type of intervention to treat breathing problems in children under 3 years of age.

How is endoscopic maxillary sinusotomy performed?

Before removing a cyst in the maxillary sinus with an endoscope, the patient undergoes a full examination. In the presence of acute inflammatory processes, preparation for maxillary sinusotomy includes a course of antibiotics and local anti-inflammatory drugs.

An operation is performed to eliminate pathologies of the maxillary sinuses in a hospital setting. The patient is seated in a chair in a semi-recumbent position. The next stage is the use of vasoconstrictor drops, thanks to which the swelling of the mucous membranes subsides and facilitates manipulation. After this, the doctor applies anesthesia. Its type is discussed before the operation, but in most cases local anesthesia is used for adult patients, and general short-term anesthesia is indicated for children.

After the anesthesia takes effect, surgery begins to remove the cyst and contents of the maxillary sinus. The doctor uses a trocar to make a hole that leads into the sinus and inserts endoscopic equipment through it. First of all, this is a flexible endoscope tube with a camera and a light source and manipulators.

This is interesting! Modern endoscopes are so miniature that they can even be inserted through a canal in a tooth, the root of which extends into the maxillary sinus.

After assessing the condition of the sinus, the doctor, if necessary, rinses the cavity with sterile saline and performs the necessary manipulations: excises cysts or polyps, removes foreign bodies, takes pinches for histology. After this, the doctor re-processes the cavity, if necessary, coagulates the vessels and removes endoscopic instruments from the nasal cavity and places filling materials, if necessary.

On average, the entire procedure takes about 20-30 minutes. Hospitalization takes no more than 3 days after surgery. During this time, the patient's swelling subsides and full breathing through the nose is restored.

How long does recovery and rehabilitation last?

Recovery after endoscopic surgery for the maxillary sinuses takes no more than two weeks. The initial recovery period is the most difficult. At this stage, there is noticeable swelling of the face, and the risk of infection remains high. Therefore, in the first week, the patient is recommended various procedures and methods for restoring the mucous membranes and other structures of the nose:

• sanitization of the nasal cavity with saline solutions up to 10 times a day;
• instillation of drops into the nose with a vasoconstrictor and anti-edematous effect;
• It is recommended to inhale with a nebulizer so that the mucous membrane does not dry out;
• taking antibiotics for a week in dosages determined by the doctor;
• oral hygiene.

If the surgery involved teeth and required filling material to be removed, you may need to visit your dentist to have the filling restored. The temporary “patch” that was installed at the end of the manipulations is recommended to be removed after 3-5 days.

For at least two weeks, the patient is contraindicated from physical activity and stress, including hypothermia and overheating. The diet must include vegetables and fruits. To strengthen the immune system, it is useful to take vitamins in combination with microelements.

Possible complications

Experts say that complications after maxillary sinus surgery are rare. Their appearance is due to non-compliance with doctor’s recommendations during the rehabilitation period. So, a hot bath, sauna, ice cream or too hot tea can cause complications. Therefore, to prevent any problems, you need to follow your doctor’s advice, even if they seem frivolous or unnecessary.

The most common possible complications after this type of intervention:

• the appearance of a tumor on the cheek and pain in the teeth - this type of complication appears if the roots of the teeth are affected during manipulation, but it can also indicate re-infection, which requires repeated intervention;
• headache - most often this is a consequence of the effect of anesthesia;
• facial deformation - may indicate injury to the trigeminal nerve and requires surgical correction and therapy;
• An increase in temperature indicates a resumption of inflammation.

If severe symptoms are present, the doctor may recommend a maxillary sinusoscopy and repeat endoscopic maxillary sinusotomy. However, this happens extremely rarely. In most cases, after a couple of weeks the person returns to a normal lifestyle.

To eliminate inflammation in the nasal cavity and paranasal sinuses, drug therapy, lavage and surgical procedures are used. All these methods are aimed at eliminating swelling of the mucous membranes and improving the outflow of secretions. In our article we will talk about a modern surgical method for treating sinusitis - functional endoscopic surgery.

Intranasal medications, available as sprays, drops, or inhalations, have anti-inflammatory, vasoconstrictor or antibacterial effects. They facilitate nasal breathing, prevent the proliferation of pathogens on the surface of the mucous membranes and relieve inflammation. Preparations with an astringent effect coat the nasal cavity and prevent it from drying out. Saline rinses are a good way to clear accumulated mucus from your sinuses. However, this method is applicable for adults and children over 5 years of age (the younger the child, the greater the likelihood of otitis media).

Nasal rinsing

The most difficult place to rinse is the maxillary sinuses.. Due to the anatomical location, conventional manipulations do not have an effect on the mucus accumulated in the maxillary region. In inpatient and outpatient treatment, three methods are used:

• movement (popular name “cuckoo”);
• use of a sinus catheter;
• puncture of the sinuses (in medical language - puncture).

In most cases, a combination of drug therapy with one or more methods of clearing mucus from the sinuses is sufficient to significantly alleviate the patient’s condition and subsequent complete recovery. However, the hope of many patients that “maybe it will go away on its own” often leads to the fact that ordinary inflammation, which with adequate action and timely medical care would go away in a week, turns into more serious conditions, causing damage to other organs.

Most often, the ears (otitis media), the oral cavity (dental diseases), the lungs (pneumonia, bronchitis) and even the brain (meningitis, encephalitis) are at risk. Missed sinusitis from the acute stage may well turn into a chronic form, providing a person with constant headaches, periodic nasal congestion, snoring and other unpleasant phenomena.

In situations where conservative methods of therapy are powerless, doctors resort to surgical intervention. One of the common methods of the last century, which is successfully used to this day, is open surgery, which allows you to visually examine the sinuses and thoroughly clean them of pus and mucus. But the laboriousness of the process and the need for general anesthesia have led to an increasing number of surgical interventions in the nasal cavity being performed internally. Such manipulations are called - functional endoscopic operations in the nasal cavity. This method was first tested in the 50s of the last century, and since the 60s-70s it has been successfully used in otolaryngology all over the world.

Advantages of endoscopy

In countries with a high level of medicine, endoscopic practice is considered a kind of “gold standard” in the treatment of old forms of sinus inflammation and conditions that are refractory to conservative therapy. One of the clear advantages of such manipulations, especially in comparison with the traditional approach, is no visible postoperative defects, since tissue incisions are not required.

Endoscopic surgery

Another advantage - possibility of detailed diagnostics. An endoscope inserted into the nasal cavity is a light-transmitting device with which you can not only qualitatively examine the affected sinuses, but also assess the extent of inflammation, understand anatomical features and identify “surprises” in advance. And the most important thing is to find and neutralize the source of the disease, thereby speeding up the recovery time, reducing the risk of injury and possible complications. After such an intervention, a scar does not form, pain during the rehabilitation stage is less pronounced, although swelling of the mucous and soft tissues may persist for several days.

The paranasal sinuses are equipped with thin canals of bone that are covered with mucous tissue. With any inflammation, be it allergies or viral rhinitis, these tissues swell and block the passage. Endoscopic surgery on the maxillary sinus (see video in the website gallery) is aimed precisely at expanding the bone canal. Another advantage of such an intervention is that even if the patient again encounters lesions in the nasal cavity in the future, the lumen in the sinuses will not be blocked, which provides an advantage in the treatment of subsequent acute conditions. In addition to the main task of enlarging the bone canal, endoscopic techniques can be used to eliminate various unnecessary tissues in the nasal cavity: cysts, polyps, growths.

Advantages of endoscopic surgery

Since the surgical field during such operations is located quite close to vital organs, safety precautions and precision of manipulation are parameters of paramount importance. In this regard, endoscopic techniques are constantly being improved and studied.

One of the key updates in recent years is the use of visualization control: a computer program that receives data from a CT scan processes the incoming information in a special way and recreates a three-dimensional image of the patient’s nasal cavity.

This layout displays the entire structure of the sinuses and adjacent soft tissues; moreover, through such a program it is easy to track each surgical instrument and calculate further actions. A similar technique involving visual control is more often used in difficult cases: with severe damage to the paranasal sinuses, ineffectiveness of conventional operations, or with a non-standard structure of the patient’s nasal cavity.

Preoperative preparation

The first and one of the most important stages before intervention is diagnosis, which allows us to determine the cause of the disease, the characteristics of the disease, the condition of the air passages and outline a treatment plan. For this purpose, data from radiography, CT, olfactory analysis, cytology and rhinomanometry are used, revealing thickened walls of the mucous membranes, cysts, polyps, localization of blockage of the nasal lumens and other elements of the disease. Accurate knowledge allows you to decide on treatment tactics in general and surgical strategy in particular.

Carrying out endoscopic manipulations

If earlier in the surgical practice of ENT doctors it was believed that in order to completely cure severe and chronic forms of sinusitis, a major removal of the mucous membranes of the nasal sinuses was required, then the modern technique of FES (functional endoscopic sinus surgery) completely refutes this opinion. The technical base and updated instruments used in endoscopic operations provide a gentle intervention mode with the preservation of mucous tissues . At the same time, the outflow of purulent mass and mucus improves, the air passages are restored, and the membranes themselves are able to regenerate and “correct” themselves.

Cleaning the maxillary sinuses

Cleaning the maxillary sinuses is an operation performed under the influence of local anesthesia, which reduces the time of manipulation and speeds up the patient’s rehabilitation. First, an endoscope equipped with microvideo cameras is inserted into the nasal cavity. It allows surgeons to visually assess the amount of work, the structural features of the sinuses and detect the primary focus of the disease. Then, following the endoscope, special micro-instruments are introduced into the affected area, ensuring high precision of each movement of the doctor. As a result, the affected tissue is removed without any harm to healthy cells, which has a beneficial effect on postoperative recovery.

This method minimally injures the mucous membranes and, since most interventions are performed through the nostril openings, does not leave external defects in the form of scars. After endoscopic manipulation, slight swelling, swelling of soft tissues and minor discomfort may be observed.

Foreign body in the nose

Along with pathogenic organisms, inflammation of the maxillary sinuses can cause a foreign body to enter the nasal cavity. If in young children this occurs due to accidental inhalation of small objects or food particles and manually inserting elements of toys into the nostrils, then in conscious adulthood the most common cause is dental procedures. Another way foreign particles can enter the sinuses is through an open wound. A sign of foreign elements in the nasal passages may be copious mucus discharge from one nostril. But there are often cases when, at first, an object that gets into the nasal cavity does not cause any inconvenience, but over time it certainly provokes inflammation.

Removal of a foreign body using endoscopic surgery

With the development of minimally invasive techniques, surgery to remove a foreign body from the maxillary sinus began to be carried out using an endoscope, which allows you to carefully remove the stuck object without harm to healthy tissue. In some cases, particle extraction is performed through an access under the upper lip. The size of the hole does not exceed 4 mm, which ensures the safety of the anastomosis of the maxillary sinus.

Unfortunately, endoscopic equipment is quite expensive, so such operations are not performed in all medical institutions; moreover, flawless intervention requires the knowledge and practical experience of a surgeon.

Rationale. Surgical correction of intranasal structures and sinus surgery with the development of endoscopic technology has reached a new level compared to the work of pre-endoscopic rhinology. The founders of endoscopic rhinosurgery, developing various techniques, based it on the principle of maximum preservation of the healthy mucous membrane of the nasal cavity and paranasal sinuses.

The concept of the pathogenesis of sinusitis from the prechambers into the large sinuses expands the capabilities of the pediatric rhinologist when choosing the type of operation: from the usual displacement of the middle turbinate medially, sufficient in young children, to extended ethmoidectomy, necessary only for total sinus polyposis, severe syndromic diseases (Kartagener syndrome , aspirin triad, cystic fibrosis).

Target.

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

Indications. Acute and chronic diseases of the upper respiratory tract, congenital and acquired anomalies of the nasal cavity, lack of effect of conservative therapy, previous surgical interventions on the nasal cavity and paranasal sinuses.

Contraindications. Contraindications to endoscopic operations in the nasal cavity and paranasal sinuses correspond to the general criteria for preparing a child for surgical interventions (blood clotting indicators, past infectious diseases, hereditary diseases, acute and chronic diseases of internal organs - according to the conclusion of a specialist).

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

Methodology and aftercare. The characteristics of childhood require the rhinosurgeon to comply with four conditions when performing the operation:
surgical interventions should not be performed in areas of active growth of the nasal cavity and development of future sinuses;
only after exhausting all the possibilities of endoscopic functional surgery can surgery be performed through external access with an aesthetic defect;
if classical conservative treatment is insufficient or ineffective for chronic rhinosinusitis, then functional surgery should first remove obstacles to mucociliary transport and air flow in the area of ​​the nasopharynx, turbinates, and then you can resort to gentle surgical interventions in the area of ​​the ostiomeatal complex;
When performing surgical interventions, it is necessary to spare the mucous membrane of the contacting surfaces, especially in the area of ​​the funnel and formations of the ostiomeatal complex.

Due to anatomical changes in the ostiomeatal complex, damage to the cells of the anterior ethmoid group and the maxillary sinus predominates in children over lesions of other sinuses in all age groups. Both the nasal turbinates (inferior and middle) and elements of the lateral wall of the nose (uncinate process, ethmoidal bulla, less commonly Haller’s cell, nasal shaft cells) are involved in stenosis of the ostiomeatal complex; therefore, surgical interventions for recurrent and chronic sinusitis in children are represented by the following operations:
elimination of postnasal occlusion (adenotomy);
intervention in the area of ​​the nasal concha;
correction of elements of the lateral wall of the nose involved in the formation of natural anastomoses of the paranasal sinuses;
elimination of deformations of the nasal septum.

The endonasal approach to the sanitation of the large sinuses due to limited interventions on the intranasal structures of the lateral wall in the area of ​​the antechambers is optimal in childhood, since the age group of the child being operated on dictates the scope of operations. If in adult patients a reasonable and sufficient volume of surgery, even with chronic purulent-polyposis sinusitis, frontal sinusitis, can be infundibulotomy with partial opening of the anterior ethmoid group without maxillary sinus, then in children the volume of operations is dictated by the age capabilities and structure of the ethmoid labyrinth, the level and position of the maxillary sinus .

A number of operations can be performed, from resection of the uncinate process to total ethmoidectomy with fenestration of the sphenoid and maxillary sinuses. However, in the vast majority of cases, even with persistent recurrent processes, opening the anterior chambers in the anterior ethmoidal group is sufficient to obtain positive results in the treatment of chronic sinusitis, sinusitis, and ethmoiditis.

Local anesthesia for endoscopic interventions in the nasal cavity is a mandatory step, even if the operation is performed under general anesthesia. Immediately before the operation, it is recommended to treat the nasal mucosa with oxymetazoline, ensuring a long-lasting anti-edematous effect. In the operating room, under endoscopic control, turundas soaked in oxymetazoline or phenylephrine and a topical anesthetic are introduced. Immediately after achieving superficial anesthesia, an injection of 2% lidocaine with a 1:200,000 epinephrine solution is performed using a special needle for endoscopic sinus surgery, or a dental needle and syringe or insulin syringe is used.

The injection is made in the following areas:
along the attachment of the uncinate process (three injections);
to the place of fixation of the middle turbinate;
into the lateral and medial surface of the middle turbinate;
further depending on the volume of surgical intervention (bottom of the nasal cavity, nasal septum, inferior turbinate).

The purpose of the injection and the process of topical anesthesia is to anesthetize the anterior and posterior ethmoidal nerves, supplying the anterior and posterosuperior parts of the lateral wall of the nose and septum, as well as the branches of the sphenopalatine nerve, passing with the main vessels from the sphenopalatine foramen and supplying the lateral wall of the nose. It is important that the process of administering the anesthetic is carried out slowly, and the operation does not begin until the anesthetic has produced the desired effect. The combined action of the topical anesthetic, the injected local anesthetic and the surface action of the decongestant provides a reliable blood-free field in most cases.