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Shamsiev Djakhangir Fazlitdinovich, Tashkent State Dental Institute Vokhidov Ulugbek Nuridinovich, Tashkent State Dental Institute Karimov Omil Makhmudovich, Tashkent Medical Academy Department of ophthalmology, otorhinolaryngology and gynecology E-mail: dr_ulugbek@list.ru
FUNCTIONAL AND MORPHOLOGICAL FEAUTURES OF WOUND HEALING PROCESS IN THE MUCOSA OF THE NOSE AND MAXILLAR SINUSES IN PATIENTS WITH CHRONIC INFLAMMATORY DISEASES OF PARANASAL SINUSES
Absrtact: the aim of the study was to study the features of the regeneration process occurring in the mucous membrane of the nose and paranasal sinuses against the background of its chronic inflammation. The material for the study was 70 patients with chronic inflammatory diseases of the paranasal sinuses. In the course of the studies, a correlation was found between the mucociliary clearance rates and the regenerative processes of the mucosa in chronic sinusitis. In this regard, it was concluded that functional tests of the evaluation of the mucosal state are the most informative and significant, since they allow us to select an adequate surgical tactic in patients with chronic rhinosinusitis.
Keywords: chronic sinusitis, mucociliary transport, regeneration, mucous membrane.
Regenerative processes of the nasal mucosa and parana- bleeding and antimicrobial protection, carried out by the sal sinuses after surgical treatment against the background of hemostatic system, neutrophilic granulocytes and macro-chronic inflammation and the methods of its rehabilitation phages. These mechanisms initiate and support subsequent
are only being studied. Wound healing is a fairly standard sequence of various physiological processes that begin with any damage to the body's protective covers.
The study of the regenerative characteristics of various tissues of the body is under the close attention of specialists all over the world. With the direct participation of morpholo-gists, histologists, pathophysiologists, biochemists and specialists in other theoretical disciplines, this problem, due to its relevance, increasingly finds a positive and well deserved response from clinicians of different specialties.
The course of the wound process after intra-nasal surgeries is largely determined by the treatment that is performed in the postoperative period. Errors in the introduction of the postoperative period affect the long-term results of surgical intervention. The analysis of literature data shows that there are no generally accepted standards in the management of the postoperative period after endonasal intervention. This applies primarily to questions about tamponade of the operating cavities, as well as to the appointment of antibiotics, corticosteroids, repellents and mucoregulating medications in the postoperative period.
In the first, exudative or inflammatory phase primary protective mechanisms are activated, including stopping
wound healing processes. The second, proliferative phase serves as the basis for the preparation for subsequent reparative processes: proliferation of fibroblasts occurs, granulation tissue is formed, angiogenesis is initiated. In the third, reparative phase, collagen synthesis and restoration of the protective cover takes place.
The standard optimal scheme for maintaining the postoperative period, determining the duration of the tamponade, the principles of care for wound surfaces, and also local or systemic use of drugs, does not exist to the present day. A variety of techniques for conducting the postoperative period are used by otorhinolaryngologists in their daily practice, but their advantages or disadvantages remain highly controversial.
The purpose of this study was to study the characteristics of the regeneration process occurring in the mucous membrane of the nose and maxillary sinus against the background of its chronic inflammation. These features of regeneration ultimately influence the pathogenetic mechanisms of the development of the disease and often determine its clinic.
The material of this study was 70 patients with chronic sinusitis, who entered the ENT department in the period from 2012 to 2016. Among them were 33 women and 37 men aged 18 to 65 years.
All examined patients with chronic sinusitis in the study of the features of the course of the postoperative period were conditionally divided into groups depending on the form of the chronic inflammatory process.
The division into groups was carried out according to the most rational classification for clinical practice, proposed by B. S. Preobrazhensky in 1956. In this classification, the author took as a basis the pathoanatomical principle in combination with the clinical data most characteristic for one form or another. According to this classification, the following forms of chronic inflammation of the maxillary sinus are distinguished:
1. Exudative forms: (catarrhal, serous, purulent);
2. Products: (parieto-hyperplastic, polypoid, cystic);
3. Alternative forms: (cholesteatom, caseous, necrotic, atrophic, fibrous).
In accordance with this classification, all patients were conditionally divided into 3 clinical groups. The first group included 24 patients with exudative forms of chronic sinusitis. The second group included 35 patients with productive forms of chronic sinusitis. The third group included 11 patients with alternative forms of chronic sinusitis. In the case of a mixed form, we considered the patient in a group with more pronounced changes. For example, in the case of purulent-polypoid maxillary sinusitis, we referred the patient to the second clinical group with patients with productive inflammation.
All patients underwent a study of mucociliary transport, for this purpose we used a standard saccharin test. In addition, all patients underwent endoscopic examination of the nasal cavity. This non-invasive method requires a minimum of time and is completely tolerated by the patient. In determining the normal parameters of healing of the nasal mucosa and paranasal sinuses, we took into account the physiological state of the nasal cavity. For example, during breathing, the passage of a stream of air leads to the drying of the wound surfaces and can act as one of the mechanical factors affecting the healing. Often a wounded scab and a withered secret form a significant amount of crust in the nasal cavity, which naturally causes inconvenience to the patient. At the same time, many patients independently remove from the wound surfaces the crusts formed by blowing out or mechanical removal. Thus, not only therapeutic, but also physiological mechanisms influence the process of wound healing of the mucous membrane of the nasal cavity. Exclusion of these influences would be possible with artificial obturation of nasal passages, however this method is not welcomed by many physicians and is poorly tolerated by patients. In addition, it must be remembered that in chronic inflammation the mucosa is already altered by the pathological process and the methods of its rehabilitation are only being studied.
Results of the study. We conducted an endoscopic examination of the process of natural wound healing after maxillary sinus anemia, both through the anterior wall, and the endonasal method performed for their chronic inflammation.
Based on endoscopic and cytological studies, we identified three main phases of wound healing in the nasal cavity. The first phase - healing under the formed blood clot, lasts an average of 7-10 days. The second phase, postoperative lymphatic edema, lasts an average of 17-25 days. The third phase is tissue restructuring and epithelialization.
With endoscopic examination, we could observe that the first 7-10 days postoperative wounds covered the formed blood clots. Their removal occurred as a rule in the self-flagging by the patients themselves, after which the granulation surface, covered with the regenerating mucosa, became visible. The presence of blood clots or crusts does not make it possible to fix exactly the moment of appearance of the first granulations. In addition, approximately at the same time, lymphatic edema of the tissues usually develops. With a significant postoperative edema in the canopy of the nose, the aeration of the operated cavities is severely disrupted. The prolonged contact between the middle nasal concha and the nasal septum arising from the swelling, can cause the formation of synechia. In most patients (67%), edema disappeared by the end of the fourth week, in 14% it disappeared before four weeks, and in 19% the edema was stopped after four weeks.
The normalization of the functional parameters of the operated paranasal sinuses in most patients (71.4%) was recorded by us from the fourth to the seventh week after the operation. On the concave surfaces of the nasal cavity, in the open sinuses of the latticed bone, in the area between the middle nasal cavity and the lateral wall of the nasal cavity, as well as between the nasal conchae and the nasal septum, we noticed an increased formation of crusts. Apparently, in connection with this, frequent formation of synechia and scarring are noted in these areas.
We do not recommend the instrumental removal of crusts, except for cases of excessive formation, accompanied by a sharp violation of nasal breathing.
In our studies, the rate of reparative processes of the nasal cavity and paranasal sinuses has always depended on the severity and prevalence of the pathological process, the features of operative technique and the treatment used in the postoperative period.
The speed of the healing process can vary greatly in different patients and even when comparing the right and left sides of the same patient. In addition, we came to the conclusion that postoperative inflammation, edema and subsequent scarring are directly proportional to the volume of surgical trauma. In this regard, you should try to minimize
the removal of tissue after which the open wound surfaces remain. During intra-nasal operations, crushing and stretching of the left intranasal structures should be avoided. Mechanical and thermal damage to the mucous membrane also leave behind small necrotic particles, which in the future can be a nutrient medium for microorganisms, as well as initiate scar processes. The more fibrin matrix is formed as a result of surgical trauma, the more likely that the deposition of collagen by fibroblasts will lead to the formation of cicatricial synechia.
Regarding postoperative lymphostasis, we believe that, after a surgical trauma, the lymphatic system of the nasal cavity can't fully perform its functions to remove fluid from the focus of inflammation. This leads to a violation of the equilibrium of the oncotic and hydrostatic forces and, as a consequence, the destruction of the cells. Fibers accumulating in the inflammatory focus, lipids and the remains of broken cells maintain an inflammatory response, which increases the proliferation of fibroblasts.
In the postoperative period, patients complained mainly of difficulty in nasal breathing, nasal congestion, mucous discharge from the nose, discomfort and dryness in the nose. When examined in the postoperative period on the 7th day, postoperative wounds are covered with hemorrhagic crusts, an insignificant amount of mucous discharge, in some patients a pronounced edema remains. By the end of the second week, there was a marked improvement in the clinical picture and gradual recovery of functional indicators.
In addition to studying the parameters of mucociliary transport of the nasal mucosa before and during the postoperative period, we conducted a study of mucociliary transport
Thus, our studies allow us to conclude that the wound healing of the nasal mucosa and paranasal sinuses after surgical treatment against a background of chronic inflammation proceeds according to the same laws as the healing of the healthy mucous membrane, although much more slowly.
In this case, we were primarily interested in the timing of healing of postoperative wounds, as well as the timing of recovery of functional parameters of the nasal mucosa and paranasal sinuses.
As is known, after surgery in the nasal cavity and paranasal sinuses, a so-called traumatic inflammation develops, characterized by hyperemia and edema of the mucous membrane, difficulty in nasal breathing, the presence of liquid detachable and the formation of fibrin deposits on the mucous membrane.
The transport function of the mucous membrane of the nasal cavity was controlled by the saccharin test on the 5th day, the 10th day, and one month after the operation (the norm of 5 to 19 minutes). The data are presented in (Table 1).
of the mucosa of the maxillary sinuses in the postoperative period in patients with chronic sinusitis in dynamics.
Analyzing and comparing the results of functional (definition of mucociliary clearance) and morphological studies, we have revealed some distinct patterns. When the mucociliary clearance of the maxillary sinus is less than 90 minutes, the morphological changes in the mucosa were reversible. Irreversible morphological changes in the mucous membrane of the maxillary sinus corresponded to mucociliary clearance for more than 90 minutes or its complete absence. The results of the study are presented in (Table 2).
Time of perform research 1 group 2 group 3 group
Before operation 40-55 min 70-95 min 90-105 min or not
5 days after operation 54-62 min 79-88 min 103-112 min or not
10 days after operation 35-48 min 52-67 min 78-92 min
Month after operation 31-45 min 44-51min 61-86 min
Table 1.- Characteristics of indicators of mucociliary transport of the nasal mucosa prior to surgery and in the postoperative period, depending on the form of the disease
Time of perform research 1 group 2 group 3 group
Before operation 17-35 min 24-45 min 26-52 min
5 days after operation 35-54 min 42-61min 46-65 min
10 days after operation 25-30 min 29-37 min 27-41min
Month after operation 14-23 min 20-31min 23-38 min
Table 2.- Characteristics of indicators of mucociliary transport of the mucosa of the maxillary sinuses in the postoperative period in patients with chronic sinusitis and maxillofacial dysfunction depending on the form of the disease
As is known, the indicator of mucociliary transport of the mucosa of the maxillary sinus of a healthy person is on the average 30-35 minutes.
Thus, analyzing the data given in the (table 2), it can be noted that by the end of the third week after the operation, the functional parameters of the mucosa are almost completely restored. However, it should be noted that healing processes in some patients can last up to 3-6 months, which, apparently, is due to the individual characteristics of the organism. In our studies, the normalization of the morphological and functional parameters of the operated paranasal sinuses in most patients (71.4%) was recorded by us from the fourth to the seventh week after the operation.
Thus, we can draw the following conclusions:
1. The rate of reparative processes of the mucous membrane of the nasal cavity and paranasal sinuses always depends on the severity and prevalence of the pathological process. In addition, the speed of wound healing is affected by the technique used and, of course, the treatment used in the postoperative period.
2. Given the correlation between mucociliary clearance rates and morphological changes in the mucous membrane in chronic inflammatory diseases of the paranasal sinuses, we consider the functional tests of the evaluation of the mucosa as the most informative and significant, since they allow us to select an adequate surgical tactic in patients with chronic rhinosinusitis.
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