Method for diagnosing maxillary sinus granulomas in children with rheumatic diseases

Abstract

FIELD: pediatric rheumatology; otolaryngology.SUBSTANCE: with combined endotracheal anesthesia in an operating room, an incision is made in the mucous membrane under the inferior nasal concha using a monopolar knife. The mucoperiosteal flap is separated and turned upward. Using a chisel or piezo-device, infraturbinal access is created. A biopsy of the mucous membrane of the maxillary sinus is performed through the formed access. The mucoperiosteal flap is returned to its place. The edges of the incision are sutured with suture material – Vicryl 5.0.EFFECT: method allows for safe and minimally invasive collection of histological material in the absence of signs of inflammation in the sinuses, which allows for safe and effective verification of granulomatous changes in children with systemic vasculitis, as indicated by a rheumatologist.1 cl, 5 dwg, 3 ex

Description

[0001] The invention relates to the field of medicine, namely to pediatric rheumatology and otolaryngology, and can be used for invasive diagnostics of granulomatous processes in the maxillary sinuses in children, most often with granulomatosis with polyangiitis (GPA), against the background of systemic rheumatic diseases.

[0002] A known method for diagnosing granulomas of the paranasal sinuses in granulomatosis with polyangiitis in children consists of performing a biopsy of the mucous membrane of the affected sinus in order to verify the diagnosis. The authors emphasize that in pediatric patients, the clinical manifestations of the disease are often nonspecific, which necessitates obtaining histological material for differential diagnosis with infectious and neoplastic processes. Moreover, traditional approaches include the use of endoscopic access to the affected areas, but do not regulate the algorithm of actions in the absence of clinical signs of sinusitis [Handal M, Sharma A, Ernst M, Khalil K, Weiss E. Pediatric Presentations of Granulomatosis With Polyangiitis: A Double Case Study. Case Rep Dermatol Med. 2025 Mar 14; 2025:6052518. doi: 10.1155 / crdm / 6052518. PMID: 40123739; PMCID: PMC11928219].

[0003] A clinical case is known in which a biopsy of the maxillary sinus mucosa was performed in granulomatosis with polyangiitis complicated by silent sinus syndrome. The work describes the morphological signs of necrotizing granulomatous inflammation with the presence of vasculitis and giant cells. The disadvantage of the method is the lack of standardization of access choice for localized forms of the disease in children and the possibility of using the method only with radiologically confirmed changes in the sinus [Kramer N, Manthei B, Speier L, et al. (May 31, 2024) Granulomatosis With Polyangiitis as an Etiology of Silent Sinus Syndrome: A Case Report. Cureus 16(5): e61442. doi: 10.7759 / cureus.61442].

[0004] There are generalized data on the tactics of obtaining biopsy material for granulomatosis with polyangiitis, according to which open and endoscopic approaches to the tissues of the lungs, kidneys, skin, and less often to the mucous membrane of the paranasal sinuses are most often used. The disadvantage of this approach is the lack of regulations and an algorithm of actions for pediatric patients, in whom the disease often occurs in a localized form, and systemic manifestations are minimal [Klionsky Yael "Ellie", Diamond Herbert S. Granulomatosis with polyangiitis (GPA, formerly Wegener granulomatosis): Guidelines [Electronic resource] / / Medscape. - Updated: 08 / 21 / 2024. - Access mode: https: / / emedicine.medscape.com / article / 332622-guidelines (accessed: 08 / 13 / 2025)].

[0005] There are data on the morphological picture of granulomatous lesions of the nasal mucosa, including the analysis of biopsies in granulomatosis with polyangiitis, sarcoidosis, tuberculosis and fungal infections. The authors indicate that in case of localized granulomatous lesions of the nose and paranasal sinuses, biopsy is the main diagnostic criterion. The disadvantage of the method is its descriptive nature without reference to minimally invasive approaches in children [Coup AJ, Hopper IP. Granulomatous lesions in nasal biopsies. Histopathology. 1980 May; 4(3):293-308. doi: 10.1111 / j.1365-2559.1980.tb02923.x. PMID: 7390412].

[0006] A known method for obtaining material from the maxillary sinus for microbiological examination in patients involves inserting a sterile cannula into the postoperative defect. A sterile probe with a viscose mini-tip and applicator is inserted into the cannula until it contacts the walls of the maxillary sinus. Rotating movements are performed. The applicator and tip are then removed from the cannula and placed in a container with a transport medium for delivery of the sample to a microbiology laboratory. The cannula is then removed from the maxillary sinus and nasal cavity. This method is not intended for pediatric use, does not take into account the characteristics of rheumatological diseases, and does not regulate the diagnostic algorithm for suspected granulomatous lesions of the mucosa (Russian Federation Patent No. 2794083).

[0007] Scientific publications by Russian authors emphasize the relevance of systemic vasculitis in children and the need to develop minimally invasive diagnostic methods. For example, the publication "Modern Aspects of Head and Neck Surgery" cites a study by T.V. Beketova, which systematizes data on ANCA-associated vasculitis, including granulomatosis with polyangiitis. The author notes that morphological confirmation is necessary for diagnosis, but specific surgical algorithms for obtaining material from the paranasal sinuses in childhood are not presented (Scientific Guidelines for Rheumatology. Collection "Modern Aspects of Head and Neck Surgery", Tyumen, 2019).

[0008] Data on the condition of children with rheumatic diseases receiving glucocorticoid and biological therapy are also available. A study by K. A. Kovygina demonstrated that patients in this group have an increased risk of complications and limited compensatory capabilities. This confirms the need for minimally invasive approaches and minimizing surgical aggression during diagnostic procedures, including those with suspected granulomatous lesions of the maxillary sinuses (K. A. Kovygina, “Comprehensive assessment of the nutritional status of children with rheumatic diseases receiving glucocorticosteroid therapy.” Russian Pediatric Journal, 2024).

[0009] Advantages of access to the maxillary sinus through the inferior nasal passage: simplicity of surgical technique, good visibility of the surgical field, minor blood loss, minimal impairment of nasal function in the postoperative period ([Bana-shek-Meshcheryakova T.V., Semenov F.V. Comparative analysis of surgical approaches in the removal of maxillary sinus cysts. Russian Rhinology. 2017; 25 (4): 9-12. https: / / doi.org / 10.17116 / rosrino20172549-12).

[0010] Thus, the analyzed sources demonstrate that in Russian practice, methods for obtaining material from the maxillary sinus and surgical interventions using infraturbinal access are used, but there is no unified algorithm that takes into account the specifics of childhood, the presence of rheumatic diseases and the need for morphological verification of granulomas.

[0011] A review of granulomatous diseases of the head and neck is available, examining the clinical and morphological characteristics of vasculitis, sarcoidosis, and fungal and mycobacterial infections. It is emphasized that granulomatous lesions of the paranasal sinuses are significantly less common in children than in adults, but verification of the diagnosis requires mandatory morphological confirmation. A drawback is the lack of a detailed description of the optimal surgical approach for obtaining material in pediatric patients (Klionsky Yael "Ellie", Diamond Herbert S. Granulomatosis with polyangiitis (GPA, formerly Wegener granulomatosis): Guidelines. Electronic resource / / Medscape. Updated: 08 / 21 / 2024).

[0012] The method was chosen by the authors as a prototype.

[0013] The objective of the claimed invention is to develop an algorithm for diagnosing granulomas of the maxillary sinuses in children with rheumatic diseases, including granulomatosis with polyangiitis.

[0014] The technical result aimed at solving the stated problem consists in reducing the invasiveness of the intervention, decreasing the risk of infection and trauma to the sinus mucosa, as well as the possibility of conducting morphological diagnostics without the development of complications in patients undergoing immunosuppressive therapy.

[0015] The invention involves collecting material from the maxillary sinus for histological examination in a child with rheumatic disease, if clinical and laboratory data indicate the possibility of granulomatous lesions of the paranasal sinuses, but in the absence of symptoms of acute or chronic sinusitis, as directed by a rheumatologist. This is accomplished by performing a subturbinal mucosal incision under general anesthesia, creating a minimal opening in the medial wall of the maxillary sinus, and performing a biopsy of the pathological tissue. After obtaining the material, the surgical site is closed using plastic surgery principles.

[0016] The proposed method combines the stage of preliminary assessment of the clinical picture with the mandatory exclusion of an infectious process, subsequent decision-making on biopsy in the presence of rheumatological indications and the use of a low-traumatic modified infraturbinal approach, which allows for safe and effective verification of granulomatous changes in children with systemic vasculitis.

[0017] The method is carried out as follows.

[0018] In a child with a rheumatic disease, most often juvenile idiopathic arthritis or granulomatosis with polyangiitis, undergoing immunosuppressive therapy, a preliminary clinical, laboratory, and instrumental examination is performed, including nasal endoscopy and computed tomography of the paranasal sinuses. In the absence of signs of acute or chronic sinusitis and in the presence of rheumatological indications for morphological verification, a diagnostic biopsy is performed. If there is no inflammatory process in the maxillary sinuses, and the anatomy of the osteomeatal complex is intact, a modified infraturbinal approach is performed. Under combined endotracheal anesthesia in the operating room, an incision is made in the mucous membrane under the inferior turbinate using a monopolar knife (Colorado needle) (Fig. 1). Next, the mucoperiosteal flap is separated and turned upward (Fig. 2).The next step involves creating a bone window in the inferior nasal meatus using a chisel or piezoelectric device (Fig. 3). A sample of pathological tissue is then removed for histological examination through the created infraturbinal access. The mucoperiosteal flap is then replaced, and the incision edges are sutured using 5.0 Vicryl suture material (Fig. 4). This technique preserves the physiology of the sinus, making the procedure as gentle as possible. In cases of chronic sinusitis, standard functional endoscopic maxillary sinus surgery is performed through the middle meatus.

[0019] The novelty of the invention lies in the first proposed method for diagnosing maxillary sinus granulomas in children with rheumatic diseases. This method combines the exclusion of signs of sinusitis with performing a biopsy for rheumatological indications using a modified infraturbinal approach. Unlike known methods for obtaining sinus material, which primarily focus on infectious processes or odontogenic sinusitis in adults, the proposed method takes into account the specific characteristics of childhood, the course of systemic vasculitis, and the high risk of complications associated with immunosuppression. A novel feature is the use of a minimally invasive infraturbinal approach specifically for diagnostic purposes in granulomatous diseases in children, which reduces invasiveness, ensures procedure safety, and increases the diagnostic value of the biopsy.

[0020] Clinical examples of the method implementation

[0021] Example 1. Patient M., 11 years old. During examination, complaints of intermittent nasal congestion and nosebleeds were revealed. MRI of the paranasal sinuses revealed no signs of acute or chronic sinusitis; a slight decrease in pneumatization was observed in the left maxillary sinus (Fig. 5). A differential diagnosis is required between a cyst, polyp, and granuloma of the maxillary sinus. Based on the results of serological tests, granulomatosis with polyangiitis was suspected; a rheumatologist referred the patient for biopsy. For morphological verification of the diagnosis, a biopsy of the maxillary sinus mucosa was performed using an infraturbinal approach. No complications were noted in the postoperative period. Histological examination confirmed the presence of granulomatous inflammation with necrotizing vasculitis.

[0022] Example 2. Patient K., 9 years old, diagnosed with granulomatosis with polyangiitis, receiving canakinumab therapy. While the underlying disease was stable, the child began complaining of cheek pain and nosebleeds. Endoscopy and CT scan of the sinuses revealed no signs of sinusitis. Due to suspected new localized granulomatosis foci, a diagnostic biopsy of the maxillary sinus mucosa was performed through an infraturbinal approach on the recommendation of a rheumatologist. Sufficient material was obtained for morphological examination, and no complications were reported. Histological findings: productive granulomatous inflammation with necrotic elements.

[0023] Example 3. Patient S., 13, has been receiving long-term therapy for ANCA-associated vasculitis. A routine examination revealed changes in the nasal mucosa, as revealed by a CT scan of the paranasal sinuses: a total decrease in pneumatization of the left maxillary sinus with a blocked sinus ostium. To exclude the progression of the granulomatous process, a biopsy of the maxillary sinus mucosa was performed through the middle nasal meatus. Purulent discharge from the sinus was removed, a mucosal fragment was taken for histological examination, and the sinus ostium was dilated. The postoperative period was uneventful, the obtained material allowed for clarification of the vasculitis activity and adjustment of the immunosuppressive therapy regimen. The surgical intervention relieved the chronic sinusitis.

[0024] The proposed method allows for safe and minimally invasive collection of histological material in the absence of signs of inflammation in the sinuses, allowing for safe and effective verification of granulomatous changes in children with systemic vasculitis, as recommended by a rheumatologist.

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