Puncture and irrigation of maxillary sinus
Maxillary sinus puncture and irrigation can be used for diagnosis and treatment. It was created by Mikulic as early as 1887.
1. Indications ① In patients with a history of purulent nasal discharge, X-ray films of paranasal sinuses showed turbidity in maxillary sinus area. ② For subacute and chronic maxillary sinusitis, we can irrigate and expel pus, promote the recovery of mucociliary function, and inject drugs into sinus cavity through puncture needle; ③ Puncture a hole, insert the maxillary sinus endoscope from all angles, and perform biopsy and video recording.
2. contraindications 1 contraindications for children under 7 years old, because the sinus cavity is not mature, children do not cooperate. ② Patients with hemophilia, leukemia and other hematological diseases should be contraindicated.
3. Business methods
(1) Anesthesia of mucosal surface flushed through natural orifice. Insert the curved maxillary sinus irrigation tube into the middle nasal passage, reaching about half the depth from front to back. The tip goes outward and downward, then slowly pulls forward, and then enters the natural mouth through the uncinate sinus. The hole is 5 ~ 7 cm in diameter and 8 ~ 10 mm in length. After insertion, rinse with salt water. It is difficult to wash the nasal septum with this method for patients with deviated height, middle turbinate hypertrophy, enlarged ethmoid vesicle and enlarged uncinate process.
(2) Puncture through the middle nasal meatus to flush the inner membrane of maxillary sinus. According to the previous method, aim the tip of the maxillary sinus irrigation tube at the outer side wall of the upper edge of the inferior turbinate, feel soft, and then pierce the sinus cavity for irrigation. The advantage of this method is that it does not damage the branches of nasolacrimal duct and palatal artery, so it will not cause bleeding. The hole dug here is not easy to close.
(3) Submucous anesthesia in front of the inferior nasal meatus can be performed by puncture and irrigation of the inferior nasal meatus, or by submucosal infiltration anesthesia with 1% procaine. The patient had better take a sitting position. The surgeon holds the patient's head with one hand and the puncture needle with the other hand, and places the needle near the attachment of the inferior turbinate, about 1cm behind the front end of the inferior turbinate, and punctures at a 45-degree angle toward the outer corner of the eye. When I pierced the sinus cavity, I suddenly felt a sense of no resistance. If it does not penetrate the bone wall, the puncture point can be moved backward or rotated. After penetrating into the sinus cavity, pull out the needle core, make the patient bow his head, hold the bending plate with both hands, and raise the elbow to prevent the irrigation fluid from flowing into the cannula. Connect the syringe and try to extract. If air or pus can be pumped out, it means that it has penetrated into the sinus cavity, and normal saline can be injected for washing. At this time, the patient needs to open his mouth to breathe. At this point, the patient needs to open his mouth and breathe until the eluate is clear. Then according to the condition, remove the residual liquid and inject appropriate antibiotic solution or metronidazole solution. After washing, pull out the puncture needle, insert 1% ephedrine cotton pad into the lower nasal passage to stop bleeding, and take it out after 10 minutes. The advantage of this method is high success rate, which can ensure that the needle tip is in the maxillary sinus cavity. The disadvantage is that it can't be completely painless, which may damage the nasolacrimal duct and cause complications. It is not suitable for children.
(4) The patient was supine and punctured through canine fossa, and the upper part of labial gingival sulcus was disinfected, and 5ml of 1% lidocaine containing adrenaline was injected into the deep periosteum. Then insert the maxillary sinus puncture needle into the maxillary sinus at the lower edge of orbit 1cm. After successful puncture, let the patient sit up and wash. The advantage of this method is that it is easy for patients to accept and suitable for children, and patients will not faint because of mental stress. The disadvantage is that the bone in the anterior wall of maxillary sinus is thicker than the bone in the lateral wall of inferior nasal meatus, so puncture requires a lot of force, and sometimes a bone chisel is needed.
(5) indwelling and flushing the plastic tube in the sinus, using a thick puncture needle to penetrate into the sinus cavity, using a suitable thin polyethylene tube or silicone tube with the length of 10 ~ 15 cm, inserting it into the sinus cavity through a pinhole, and fixing its outer end to the upper lip or alar with adhesive tape. The advantages are that it avoids the pain of repeated puncture, can be washed many times a day, shortens the treatment time, and can take nasal sinus secretions for cytological and bacteriological research at any time as needed.
4. Washing liquid In order to improve the curative effect, the following drugs can be added to physiological saline according to the situation:
(1) vasoconstrictor can make mucosal blood vessels contract and reduce swelling, which is beneficial to ventilation and drainage. Among them, 0.5% alamin (m- hydroxylamine) has the best effect, and the secondary vasodilation is mild, which has no inhibitory effect on mucocilia.
(2) Antibiotics All kinds of antibiotics can be used. Because of the different resistance of bacteria to various antibiotics, it is necessary to carry out secretion bacterial culture and drug sensitivity test before use. If the drug sensitivity test is unconditional, high-efficiency broad-spectrum antibiotics can be added. Because chronic maxillary sinusitis, especially odontogenic sinusitis, is mostly infected by anaerobic bacteria, metronidazole and chloramphenicol must be added to the irrigation solution to achieve the therapeutic purpose.
(3) Adrenal cortical hormone should choose aqueous solution, such as hydrocortisone acetate, instead of alcohol solution, so as not to stimulate mucosa. These drugs can reduce mucosal swelling and help antibiotics play an anti-inflammatory role.
(4) The enzyme can liquefy the viscous pus in the sinus, which is beneficial to discharge it out of the sinus. Experience has proved that the combined use of antibiotics and enzyme drugs is not taboo. Commonly used enzymes are streptococcal liquid enzyme 500 ~ 5000 u/ml, streptococcal catalase 1000U/ml and deoxyribonuclease 50000 ~ 100000 u/ml.
5. Maxillary sinus puncture error According to domestic data, the puncture error rate of 32 1 case is 4. 1%. ① Puncture to the outside of maxillary sinus, such as orbit, buccal soft tissue, pterygopalatine fossa and submucosa of inferior nasal meatus. ② Puncture into the submucosa of the medial or lateral wall of maxillary sinus. It's all caused by unskilled skills or excessive force. After puncture, an empty needle should be used for aspiration. If air can't be pumped out, puncture error should be considered, and water injection can't be forced to wash, so as not to cause complications.
6. Common complications
(1) Syncope is a temporary loss of consciousness caused by reflex vascular motor center dysfunction caused by neuropsychiatric factors, which leads to cerebral anemia. Mental stress, pain, weakness, hunger, fatigue, excessive indoor steam, poor air circulation, etc. It is easy to happen. The author believes that the rude language behavior of medical staff makes patients lose trust, which is also related to some extent. Therefore, patients should be explained in detail before puncture, and their feelings should be asked from time to time. The early symptoms of syncope are fatigue, chest tightness, nausea, tinnitus, blackness at the moment, dizziness, and unstable sitting position, but they fainted and lost consciousness before telling the doctor. The examination found that the patient was pale, sweaty, shallow breathing, slow pulse and slightly lower blood pressure. In severe cases, he did not respond to stimulation and his pupils dilated. This process is very short, about a few seconds to a few minutes, and the patient's consciousness gradually recovers. Let the patient lie down or keep his head down, keep breathing unobstructed, acupuncture Renzhong point, inhale oxygen and drink a cup of hot water. It is not advisable to puncture again.
(2) Collapse is the manifestation of acute systemic vascular hypotonia and heart failure. It is easy to occur in chronic consumptive diseases, insufficient stress response and low secretion of renal epithelial quality, and pain and mental tension are its inducement. Symptoms are more serious than fainting, such as pale skin, cyanosis, weak and frequent pulse, shallow breathing, low blood pressure, hypothermia, confusion and inability to recover quickly. Collapse is generally reversible, but if it is not rescued in time, it may be life-threatening. It is necessary to make full preparations for maxillary sinus puncture for long-term bedridden patients, such as infusion, correction of electrolyte disorder, and hormone administration. When performing puncture, you should take a lying position. For those who have collapsed, attention should be paid to blood pressure, pulse and breathing, and 40 ~ 60 ml 10% glucose solution can be injected intravenously immediately.
(3) Air embolism is a rare complication, but it is fatal. It is caused by the needle piercing the mucosal vein of maxillary sinus during puncture, forcibly injecting air into the sinus after flushing, and queuing the liquid remaining in the sinus. Air passes through facial vein, internal jugular vein to the right heart, or air bubbles enter the medulla oblongata upward, which causes respiratory center embolism and death. During gas injection, the patient can feel the sound of bubbles in the neck of the operation side, and then his face turns purple and falls down, losing consciousness, and his breathing and heartbeat quickly stop and die. During the rescue, the patient should bow his head quickly and lie on his left side to avoid more bubbles entering the brain, left heart system and coronary artery, and carry out artificial respiration and oxygen inhalation. If it doesn't work, it is necessary to carry out heart massage and puncture to suck out the gas in the heart.
(4) The incidence of allergic reaction to local anesthetics is not high, but it can be fatal. The central nervous system is excited first and then paralyzed from top to bottom. Such as convulsions, irregular breathing to stop, blood pressure drop, consciousness from excitement to loss, pupil from small to large. Spasmodic agents, artificial respiration and pacemakers should be used in rescue.
Internal rhinostomy
(Intranasal-maxillary sinus ostomy) This method is also called maxillary sinus fenestration, which was invented by Mikulitz in 1886. The operation method is similar to that of puncture and irrigation through maxillary sinus through inferior nasal meatus, but the difference is that a window hole is opened in inferior nasal meatus for catheter insertion and irrigation at any time, which has the advantages of ventilation in sinus and restoration of ciliary transport function. The purpose of colostomy is not to drain. Through this window, an endoscope can be inserted into the maxillary sinus to observe the lesions.
1. operation method: anesthetize with 1% dicaine (containing adrenaline) in the inferior nasal meatus first, then infiltrate anesthesia with 1% procaine at the lateral wall of the inferior nasal meatus 2cm away from the inferior turbinate, and then chisel out a mucosal bone flap there with a bone chisel, and transfer the mucosal bone flap to the sinus with the pedicle at the back to prevent window opening. If necessary, the upper, lower and front fenestration can be enlarged with a bone file, and the part of the inferior turbinate covering the fenestration can also be removed to prevent the fenestration from being blocked.
2. The cause of treatment failure is the same as that of maxillary sinus puncture and irrigation.
Translabial subgingival rhinostomy of maxillary sinus
This method was newly invented by Wei Xu and used in 1965. Anesthetize the inferior nasal meatus and inferior turbinate first, then anesthetize the labial gingival fossa, soft tissue near the nose and canine fossa with 1% procaine, and pack gauze between the teeth and cheeks to absorb the oozing blood. Make a horizontal incision from the first canine to the midline 5 ~ 6 mm above the gingival margin, cut the mucosa and periosteum, and be careful not to damage the gingival ligament of the upper lip. Separate the tissue, expose the piriform ridge, and pull the incision up to the mucoperiosteum above the attachment point of the inferior turbinate. The inferior nasal meatus can be fenestrated about 1.5cm above the nasal floor. Use a stripper to peel the mucosa of the bone wall of the inferior nasal meatus to a distance of about 3cm from the piriform ridge, and slowly advance from the attachment point of the inferior turbinate to the nasal floor. Pull the mucoperiosteum of the inferior nasal meatus inward with a stripper, chisel a bone under the inferior turbinate into the maxillary sinus, and bite off the pear-shaped ridge together if necessary until the anterior and internal angle of the maxillary sinus is clearly seen. There is no need to destroy the anterior wall of maxillary sinus. The window should be as large as possible to reduce the possibility of closing. Through the window, we can see the situation in the sinus and treat the mucosa in the sinus. Separate the mucosa of maxillary sinus, reach the bottom of maxillary sinus along the lower edge of window, and remove the bone wall to the bottom of nasal cavity. It is 5mm higher than the maxillary sinus floor on average. The bone ridges of maxillary sinus and nasal cavity must be completely chiseled to facilitate smooth drainage. The mucosal flap of maxillary sinus was turned over to the nasal cavity to cover the bone surface. The pedicle was placed at the edge of the window, pressed and fixed, and the maxillary sinus was filled with iodoform gauze for 5 days. The incision was sutured with silk thread, and the stitches were removed on the 6 th day.
Caldwell Luxom
The operation was first performed by Weorge Galter Caldwell and Henry Paul Luc in 1893, so it was named Caldwell-Luc operation.
1. adapt
(1) chronic suppurative maxillary sinusitis, with purulent secretion after continuous puncture and irrigation for one month or sinus injection for half a month.
(2) Pathologically, there is tuberculous inflammation or fungal infection in maxillary sinus.
(3) Imaging examination confirmed that there were polyps, cysts or benign tumors in maxillary sinus.
(4) Foreign body in maxillary sinus.
(5) Odontogenic maxillary sinusitis and maxillary sinus leakage.
(6) Other operations were performed through maxillary sinus, such as posterior nostril exploration, sphenoid sinus and sella turcica exploration, pterygoid canal nerve transection, ligation of internal maxillary artery, orbital decompression, orbital blowout fracture reduction, parotid gland transplantation for atrophic rhinitis, drainage of maxillary sinus cancer before radiotherapy, removal of foreign bodies in pterygopalatine fossa, inward movement of nasal side wall and opening of ethmoid sinus.
2. Surgery
(1) Local infiltration anesthesia combined with nasal and paranasal mucosa anesthesia. The suborbital nerve, alveolar nerve and sphenopalatine ganglion are mainly anesthetized locally.
(2) At the junction of the upper lip and labial gingival mucosa, from the cusp crest to the second cusp, cut to the bone wall, peel off the periosteum, and expose the bone surface of canine fossa.
(3) Cutting the front wall. Cut the inside of canine fossa, that is, the front wall of maxillary sinus, with a round chisel or electric drill, and then enlarge it into a bone hole with a diameter of 1 ~ 1.5 cm with a rongeur. If bleeding occurs, bone wax can be used to stop bleeding, or bone chisel can be used to stop bleeding on both sides of the bleeding place.
(4) Take out the diseased tissue. The classic Kirsch-Luc operation is to completely peel off the mucosa in the sinus in order to be completely cured. But in fact, the sinus cavity is often filled with new fibrous tissue after operation, which is still easy to be infected and inflamed, and the curative effect is not ideal. With the further understanding of mucosa physiology and pathology, people have adopted the method of preserving mucosa. For example, for odontogenic maxillary sinusitis, only the mucosa near the root of the tooth is removed, and other mucosa is retained. In recent years, it is advocated that only the irreversible mucosa damaged by infection should be removed, and the reversible mucosa should be preserved as much as possible. As for the differentiation between reversible and irreversible lesions, it is difficult to observe with naked eyes, and the diagnosis can only be made by pathological examination of mucosa taken by maxillary sinus endoscope before operation. Irreversible lesions include mucosal necrosis, abscess, granulation, cyst and polyp.
(5) Cut a pair of holes in the inferior nasal meatus at the front lower part of the inner side wall of the maxillary sinus, cut the bone wall into a pair of holes with a round chisel, and expand it forward and downward with a rongeur, so that its front-back diameter is not less than 65438±0.5cm, and its up-and-down diameter is not less than 65438±0.0cm, and the lower edges of a pair of holes are in the same plane as the bottom of the nasal cavity. Use a sharp knife to cut the mucosa of the internal and external nasal passages of the paranasal sinuses up and down along the opposite edge, make a facial mucosa flap, and turn it to the bottom of the paranasal sinuses to make the regenerated mucosa cover the sinus cavity. If the anterior end of the inferior turbinate is hypertrophy, which hinders this operation, or blocks the patency of the hole, the anterior end of the inferior turbinate can be removed.
(6) Check whether the nasal cavity and maxillary sinus meet the surgical requirements by stuffing and suturing. If there is no bleeding, there is no need to stuff it. If there is bleeding, the sinus cavity should be filled with iodoform gauze, and the other end should be led from the opposite hole to the inferior nasal meatus for removal the next day. Incision of labial gingival sulcus mucosa can be sutured with silk thread and pressed on cheek to reduce swelling and remove blood stasis.
3. The key to the success of radical maxillary sinus surgery is whether the hole can be kept unobstructed for a long time. Domestic data show that about 60% can achieve this goal, and the other 40% failed because of reinfection caused by hole sealing. Therefore, the improvement of operation is mainly to prevent the hiatus from closing again and promote the regeneration of mucosa in sinus. The specific method is as follows:
(1) Before the sinus cavity is surgically filled, the plastic ring is stuck at the opposite hole to prevent narrowing or sealing during the healing process. In order to prevent the plastic ring from slipping off, its edge can be made into two grooves, which can be used for a long time without affecting postoperative washing.
(2) Maxillary sinus and nasal cavity anastomosis was completed by Zhang Yu 1964. The method is that when the mucosa in the sinus is removed during the operation, the inner wall mucosa is preserved, and the mucosa in the nasal cavity of the lower nasal passage is divided into three parts: the upper part, the lower part and the rear part, which are transferred into the sinus respectively and sutured with the mucosa in the sinus. If the longitudinal and transverse diameters of the anastomosis can be kept above 65438±0cm, the purpose of keeping the orifice unobstructed for a long time can be achieved.
(3) The mouth self-pulling hook 1953 is made by the author. The purpose of this instrument is to replace the assistant who specializes in retractor and save manpower in busy work. In addition, it can also avoid excessive tension and prevent postoperative cheek swelling. The strength of the masseter is 45kg, and the strength required by the retractor is less than 4.5kg, so the patient will not feel tired when using the self-pulling hook with mouth. The instrument is suitable for patients with mandibular joint dysfunction and the following teeth falling off or loosening.
(4) Radical Maxillary Sinus Surgery with Enlarged Natural Sinus Orifice 1993 When Xiao Bijun and others performed radical maxillary sinus surgery, they adopted the method of enlarging natural sinus ostium to promote sinus drainage and achieved better results than traditional surgery.
I hope my answer can help you ~