Method for surgical removal of pathological contents of maxillary sinuses before sinus lifting

Abstract

FIELD: otorhinolaryngology.SUBSTANCE: under endotracheal anesthesia, an endoscope equipped with optics and an instrument for removing pathological contents of the maxillary sinus are inserted into the nasal passage. The inferior nasal concha is displaced medially using a raspatory. Then, stepping back from the edge of the piriform opening by 1.5–2.0 cm in the caudal direction, a mucoperiosteal flap of the lateral wall is separated in the lower nasal passage. The mucoperiosteal flap is displaced posteriorly, exposing the bone skeleton in the projection of the inferomedial angle of the maxillary sinus. Next, using a cold plasma coblator, in ablation mode, the mucous surface of the bone skeleton is evaporated for 2–3 seconds, followed by coagulation of small vessels. Then, a bone valve measuring 10–15 mm is formed from the exposed bone skeleton. The bony valve is retracted in the caudal direction, forming an antrostomy. A 70-degree endoscope is inserted through the formed antrostomy and the pathological contents of the sinus are visualized. In this case, if the cyst is visualized with a coblator in ablation mode, the cyst is evaporated along with its contents, and the remaining cyst is captured and removed. If a polyp is visualized, the polyp stalk is first evaporated, and then the remaining part of the polyp is removed. If a foreign body is visualized, it is removed with forceps. In this case, if the foreign body is encapsulated or located in the thickness of the mucosa, a coblator in ablation mode evaporates part of the mucosa until the foreign body is exposed, and then removed. Next, the sinus cavity is washed with saline solution. The antrostomy is closed with a bone flap. The formed mucoperiosteal flap is placed back in its original place.EFFECT: method allows for endoscopic endonasal removal of pathological contents from the maxillary sinuses with a minimal risk of cyst / polyp recurrence and postoperative complications, reduced blood loss during surgery, shortened surgical time, postoperative rehabilitation periods, and temporary disability.3 cl, 3 ex

Description

[0001] The invention relates to the field of medicine, namely to otolaryngology and maxillofacial surgery, and can be used in the surgical removal of pathological contents of the maxillary sinuses.

[0002] Sinus lift is a surgical procedure aimed at increasing bone volume in the lateral maxilla for subsequent dental implantation. One of the main risk factors for postoperative complications with sinus lift is the presence of pathological contents or chronic inflammation of the maxillary sinus, which impede access and increase the risk of damage to the Schneiderian membrane.

[0003] Endoscopic micromaxillary sinusotomy is a minimally invasive technique that allows for the revision, debridement, and correction of pathological changes within the sinus with minimal tissue trauma. Its use before sinus lift reduces the risk of infectious complications and improves the success of implant osseointegration.

[0004] The most common pathological contents of the maxillary sinuses include cysts, polyps and foreign bodies.

[0005] Maxillary sinus cysts can be divided into 2 types: non-secretory (pseudocysts) and secretory (retention) cysts. The first type is characterized by a very thin membrane with an inner layer of tightly packed connective tissue cells and is thought to arise in the submucosa due to fluid retention. Retention cysts are epithelial-lined formations that arise due to obstruction of the mucosal glands. They are less common than pseudocysts. There are many hypotheses regarding the mechanisms of maxillary sinus cyst formation. Various etiologic factors have been proposed (allergy, barotrauma, chronic rhinosinusitis); their occurrence has been associated with an inflammatory process due to high levels of immunoglobulins, complement, and antiproteases found in cyst aspirates; with a disruption of water balance mechanisms caused by infection; with obstruction of the osteomeatal complex, etc.The end point in the pathogenesis of the cyst in all cases is either the formation of a mucous plug of the serous-mucinous gland of the sinus, leading to the expansion of the gland duct to a cystic structure, or fluid retention in the submucosal layer. (Giotakis, Evangelos I., Weber Rainer K. (2013). Cysts of the maxillary sinus: a literature review).

[0006] An antrochoanal sinus polyp develops from a cyst when a pressure differential arises between the sinus cavity and the nasal cavity. This is facilitated by individual nasal anatomy and, for example, frequent, forceful sneezing with the mouth and nose closed.

[0007] The main clinical manifestations of a maxillary sinus cyst or polyp include pain over the sinus, toothache, and possibly lip numbness. These symptoms are often combined with general nasal symptoms, such as nasal congestion, nasal discharge, and postnasal drip.

[0008] The most common cause of foreign bodies in the maxillary sinus are iatrogenic complications of dental procedures, such as the extraction of upper molars and premolars, implant placement, root canal filling, and other maxillary procedures. These procedures can result in fragments of teeth, filling material, implants, and foreign bodies of unknown origin becoming lodged in the sinus.

[0009] The presence of a foreign body in the sinus may remain asymptomatic for a long time or lead to the development of a number of pathological processes: chronic odontogenic sinusitis, oroantral fistula, cystic formations, and, in some cases, the spread of infection to adjacent anatomical structures (orbit, nasal cavity). The clinical picture varies from moderate nasal congestion and discomfort to severe pain, purulent discharge, and general signs of intoxication.

[0010] The main method for diagnosing pathological contents of the maxillary sinus is radiation (MSCT, CBCT, radiography).

[0011] A sinus cyst is defined on radiographs as a rounded, dome-shaped shadow emanating from the wall or floor of the sinus. CT scans reveal the following characteristic features: dome-shaped appearance, absence of surrounding bone destruction, and a smooth, spherical contour along the free border of the cyst. A sinus polyp appears as a well-defined, low-density lesion; it is possible for the polyp to extend through a widened ostium, including an accessory ostium, into the nasal cavity. There is mild bone remodeling around the sinus ostium without signs of destruction. Increased density in the center may occur with chronicity and / or fungal contamination.

[0012] The only effective way to remove pathological contents of the maxillary sinuses is surgical. Several surgical approaches exist, but endoscopic approaches are the least traumatic.

[0013] A method of micro-maxillary sinusotomy through the middle or lower nasal passage and antrostomy with removal of the cyst is known (Methods for removing a cyst of the maxillary sinus. G.Z. Piskunov / / Russian Rhinology, 1, 2016).

[0014] However, some patients experience trigeminal nerve dysfunction after microantrotomy. If the cyst is small and located in the anteromedial angle of the maxillary sinus, it is necessary to widen the anastomosis, which increases the risk of orbital injury.

[0015] A known method of endoscopic endonasal rhinoantrostomy for the surgical treatment of chronic maxillary sinusitis consists of the following: Under the guidance of a 45° endoscope, after medialization of the middle turbinate, the edge of the uncinate process is identified. A button probe is used to mobilize it. The fiber of a holmium Ho-YAG laser is passed through a guide instrument, the working end of which is oriented toward its longitudinal axis and bent at a 100° angle, allowing the guide instrument to be inserted behind the uncinate process. Under the control of 45° endoscopic optics, tissue vaporization is performed along the edge of the natural ostium of the maxillary sinus in the posteroinferior direction to a rhinoantrostomy size of 1x2 cm. Further sanitation of the maxillary sinus is performed instrumentally through the formed rhinoantrostomy (patent RU 2732692 C1, published 09.21.2020).

[0016] The disadvantages of this method are the high trauma to the mucosa and the risk of postoperative complications, such as stenosis of the sinus ostium, cicatricial changes inside the sinus, and atelectasis of the sinus.

[0017] A known method of endoscopic puncture laser removal of a maxillary sinus cyst involves the following: Two punctures of the sinus are performed through the inferior nasal passage. One puncture is performed using a Kulikovsky needle, and the other using a trocar. The trocar and Kulikovsky needle are then inserted into the maxillary sinus parallel to each other, with the latter positioned under the trocar. A Ho-YAG laser fiber is then inserted into the Kulikovsky needle, and an endoscope is inserted into the trocar. Then, under endoscopic control, the Ho-YAG laser fiber is advanced into the cyst cavity, and the laser beam is applied until explosive rupture of the cyst membrane occurs. Next, the maxillary sinus is sanitized, for which it is washed with an antiseptic through a trocar and the contents are aspirated using an electric suction device (patent RU 2693449 C1, published 02 / 07 / 2019).

[0018] The disadvantages of this method are the lack of the possibility of rapid coagulation when bleeding occurs, as well as traumatic access to the sinus due to the use of a trocar, without the possibility of reconstructing the sinus wall.

[0019] In recent years, cold plasma surgery, a gentler method than laser surgery, has become increasingly popular. This device (a cold plasma coblator) allows tissue dissection and destruction at temperatures up to 55°C using a highly focused (50-100 µm) sodium plasma cloud formed on the working surface of an electrode in a NaCl (isotonic saline) solution. The plasma cloud's intensity is sufficient to instantly disintegrate various types of soft tissue and cartilage. At the same time, the temperature outside the active zone does not exceed normal. Moreover, the depth at which this plasma impacts tissue is less than a millimeter, so underlying tissues are unaffected. This "cold" plasma, generated from the liquid surrounding the instrument, ensures bloodless incision and coagulation.

[0020] The available literature does not contain any description of methods for using cold plasma ablation to remove pathological contents of the maxillary sinuses.

[0021] The closest to the claimed method - the prototype is the method of cold-plasma evaporation of soft tissues in endonasal dacryocystorhinostomy, during the use of which the universal electrode of the coblator (EIC5874-01) is touched to the lateral wall of the nose in the projection area of ​​the lacrimal sac, after which the mucous membrane in the touch zone is evaporated (exposure ≤5 sec), a bone window is milled in the area of ​​the lacrimal fossa with a shaver burr attachment, followed by expansion; the mucous membrane of the medial wall of the lacrimal sac is removed by evaporation in the same mode as when removing the nasal mucosa; the formed anastomosis is tamponed or drained (patent RU 2729714 C1, published 08 / 11 / 2020).

[0022] However, this method is not intended for removing the contents of the maxillary sinuses, but is used only in ophthalmological practice.

[0023] The objective of the invention is to develop an endoscopic endonasal method for removing pathological contents from the maxillary sinuses, with a minimal risk of cyst / polyp recurrence and postoperative complications.

[0024] Technical result: increasing the efficiency of the method by reducing blood loss during surgery, shortening the time of surgery, reducing the period of postoperative rehabilitation and temporary disability.

[0025] The proposed method is as follows.

[0026] Under endotracheal anesthesia, an endoscope equipped with a 70-degree optical camera is inserted into the nasal passage, and the inferior nasal meatus and its lateral wall are anemized. A raspatory is used to medialize (displace) the inferior turbinate. Then, 1.5-2.0 cm caudally from the edge of the pyriform orifice, a mucoperiosteal flap of the lateral wall is separated in the inferior nasal meatus. This flap is then displaced posteriorly, exposing the bony framework in the projection of the inferomedial angle of the maxillary sinus, without affecting the nasolacrimal duct. Next, using a coblation electrode (coblation), in ablation mode, vaporize the access surface of the maxillary sinus for 2-3 seconds, followed by coagulation of small vessels on the bony surface of the lateral nasal wall (the entry point to the maxillary sinus). A septal raspatory is used to create a 10-15 mm bony flap from the exposed bone skeleton and retract it caudally, opening access to the sinus.The sinus cavity is examined with an endoscope. If a cyst is visualized, the coblator in ablation mode, using the set parameters, is used to vaporize the cyst and its contents. The remaining cyst is grasped and removed with antral forceps for histological examination. If a polyp is visualized, the coblator is used to vaporize the base (pedicle) of the polyp, and the remaining portion of the polyp is removed with antral forceps. If a foreign body is visualized that is encapsulated or located within the mucosa, the coblator is used to first vaporize a portion of the mucosa until the foreign body is exposed, followed by its removal. If the foreign body is not fixed by the mucosa or adhesions, it is removed with antral forceps. The sinus cavity is then irrigated with saline, the antrostomy is closed with a bone flap, and the formed mucoperiosteal flap is returned to its original location.

[0027] The preferred embodiment is the EIC8875-01 coblator from the Arthrocare model Coblator II electrosurgical device with a saline solution supply system connected to it after setting the following exposure parameters: ablation power 230 W, coagulation power 20 V, output voltage 265 V and 75 V, respectively.

[0028] More than 300 patients have been operated on using the proposed method. All surgeries were successful and yielded good functional results.

[0029] The proposed method minimizes trauma to the maxillary sinus both during access and during removal of the pathological lesion and its contents, reducing the likelihood of scarring and the development of sinus hypoplasia. It provides a complete view of the sinus and allows for the removal of cysts, polyps, or foreign bodies, regardless of their location. Furthermore, access to the sinus eliminates trauma to the nasolacrimal duct.

[0030] The invention is illustrated by the following examples of specific application of the claimed method.

[0031] Example 1

[0032] Patient N., 29, was admitted to the otolaryngology department for preparation before sinus lift surgery. He presented with ENT complaints of intermittent difficulty breathing through the nose, pain, and discomfort in the left maxillary region for three years. A high-resolution MSCT scan of the paranasal sinuses was performed, followed by analysis of MIP, MPR, VRT, and SSD reformations. Description of the study: a dome-shaped cystic formation measuring 2 x 3 cm was detected on the left inferior wall of the maxillary sinus; the cyst wall was thinned.

[0033] The patient underwent cold plasma removal of a cyst of the left maxillary sinus using the stated method.

[0034] Under endotracheal anesthesia and under 70-degree endoscopy, the inferior nasal meatus was anesthetized. A mucoperiosteal flap was created on the lateral wall of the inferior nasal meatus using a raspatory, 1.5 cm caudally from the edge of the pyriform orifice. Cold plasma coagulation of small vessels in the bony wall was performed, and a 10-mm antrostomy flap was formed. A cyst was visualized in the maxillary sinus cavity. A coblator was used to evaporate the cyst and its contents in ablation mode. The remaining cyst was removed with antral forceps, and the material was sent for histological examination. The sinus cavity was irrigated with saline, the antrostomy flap was closed with a bone flap, and the formed mucoperiosteal flap was returned to its original location.

[0035] The EIC5 874-01 coblator for electrosurgical operations of the Arthrocare model Coblator II electrosurgical apparatus with a saline solution supply system connected to it was used after setting the following exposure parameters: ablation power 230 W, coagulation power 20 W, output voltage 265 V and 75 V, respectively.

[0036] Pain and discomfort disappeared within 24 hours after surgery, and nasal breathing was satisfactory. The patient was discharged for further observation and treatment. A follow-up examination was performed on the 3rd and 7th days after surgery. Nasal breathing was normal, and there was no pain or discomfort in the upper jaw.

[0037] Example 2

[0038] Patient E., 42, was admitted to the otolaryngology department for removal of pathological contents of the maxillary sinus for sinus lift. The patient complained of difficulty breathing through the nose and a feeling of fullness in the projection of the maxillary sinus on the left. CT scan data showed decreased pneumatization of the left maxillary sinus due to a formation completely filling the sinus. The ostium of the maxillary sinus on the left is dilated. Ground glass opacity and swelling of the alveolar arch of the maxilla with a lack of corticomedullary differentiation are present. There are signs of an oroantral fistula at the level of tooth 26. The patient was examined by a maxillofacial surgeon. A step-by-step treatment was proposed: removal of the maxillary sinus contents followed by sinus lift.

[0039] The patient underwent cold plasma removal of a left maxillary sinus polyp using the claimed method.

[0040] Under endotracheal anesthesia, under 70-degree endoscopy, the inferior nasal meatus was anesthetized. A mucoperiosteal flap was created on the lateral wall of the inferior nasal meatus, 2.0 cm caudally from the edge of the pyriform orifice, using a raspatory. Cold plasma coagulation of small vessels in the bony wall was performed, and a 15-mm antrostomy flap was formed. A polyp was visualized in the maxillary sinus. Visible polypous tissue was removed from the sinus cavity. The polyp stalk was vaporized with a coblator in ablation mode, and the remaining portion of the polyp was then removed with antral forceps. The sinus cavity was then irrigated with saline, the antrostomy was closed with a bone flap, and the formed mucoperiosteal flap was replaced. Nasal breathing was restored, the discomfort in the sinus area subsided, and the patient was discharged 24 hours later for further observation and treatment.

[0041] Postoperative examination was carried out on the 3rd day, 7 days and 3 months after the operation - there were no recurrences of the polyp, nasal breathing was free, there was no feeling of distension in the upper jaw area.

[0042] Example 3

[0043] Patient K., 37, was admitted to the otolaryngology department for removal of pathological contents from the maxillary sinus for a sinus lift. The patient complained of intermittent pain and a feeling of heaviness in the right maxillary sinus, discharge from the right side of the nose, and bad breath. Her medical history included the extraction of tooth 16 approximately 6 months ago, after which a short-term communication between the oral cavity and the sinus was noted.

[0044] According to CT data, a hyperdense linear lesion up to 10 mm in size is visible in the lumen of the right maxillary sinus, surrounded by thickened mucosa, with signs of chronic odontogenic sinusitis. The sinus ostium is dilated, with a partial decrease in pneumatization. The bone walls show no signs of destruction. A step-by-step treatment is recommended: removal of the maxillary sinus contents followed by sinus lift.

[0045] The patient underwent endoscopic micro-maxillary antrotomy under endotracheal anesthesia, similar to cases 1 and 2. After exploring the sinus cavity and visualizing the foreign body with a coblation device, a portion of the mucosa was vaporized in ablation mode until the foreign body was exposed. It was then removed with antral forceps under endoscopic control. The sinus cavity was thoroughly irrigated with saline, and the mucosal membrane was debrided. The bony flap was replaced, and the formed mucoperiosteal flap was repositioned.

[0046] The postoperative period was uneventful, with no significant pain. The patient was discharged for outpatient observation on the third day. Follow-up examinations at 7 days and 3 months revealed clear nasal breathing, no complaints, and no radiographic signs of recurrence or inflammation.

[0047] The proposed method allows to minimize tissue trauma, ensure complete removal of pathological contents of the maxillary sinus and reduce the time of postoperative rehabilitation.

[0048] The developed method will reduce bleeding, shorten the period of postoperative rehabilitation and temporary disability, accelerate reparative processes and eliminate the process of formation of cicatricial changes in the postoperative area.

Claims

1. A method for surgical removal of pathological contents of the maxillary sinuses before sinus lifting, including the introduction through the nasal passage and the formed antrostomy of an endoscope equipped with optics and an instrument for removing pathological contents of the maxillary sinus, characterized in that the inferior turbinate is displaced medially with a raspatory, then, retreating from the edge of the piriform opening by 1.5-2.0 cm in the caudal direction, a mucoperiosteal flap of the lateral wall is separated in the inferior nasal passage, which is displaced posteriorly, exposing the bone skeleton in the projection of the inferomedial angle of the maxillary sinus, then with a cold plasma coblator, in ablation mode, evaporation of the mucous surface of the bone skeleton is carried out for 2-3 seconds, followed by coagulation of small vessels, then a bone skeleton is formed from the exposed bone skeleton a valve measuring 10-15 mm, which is retracted in the caudal direction, forming an antrostomy,through which a 70-degree endoscope is inserted and the pathological contents of the sinus are visualized, while in the case of visualization of a cyst, the coblator in the ablation mode evaporates the latter with the contents, and the remains of the cyst are captured and removed, in the case of visualization of a polyp, the stalk of the polyp is first evaporated, and then the remaining part of the polyp is removed, in the case of visualization of a foreign body, it is removed with forceps, while if the foreign body is encapsulated or is in the thickness of the mucosa, the coblator in the ablation mode evaporates part of the mucosa until the foreign body is exposed, and then removed, then the sinus cavity is washed with a saline solution, the antrostomy is closed with a bone valve, the formed mucoperiosteal flap is placed in its original place.

2. The method according to paragraph 1, characterized in that the coblator of the EIC8875-01 brand is used as part of the Arthrocare Coblator II electrosurgical apparatus, pulsating, with a system for supplying saline solution connected to it after setting the following exposure parameters: ablation power of 230 W, coagulation power of 20 V, output voltage of 265 V and 75 V, respectively.

3. The method according to paragraph 1, characterized in that antral forceps are used as an instrument for removing the pathological formation of the maxillary sinus.