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ENGLISH VERSION: PREVENTING THE OBLITERATION OF ARTIFICIAL
ANASTOMOSIS AFTER INTRANASAL FRONTOTOMY IN PATIENTS WITH
_ _ *
CHRONIC FRONTAL SINUSITIS*
A.V. Loburets, S.B. Bezshapochnyi
Higher State Educational Establishment of Ukraine "Ukrainian Medical Stomatological Academy" Department of Otorhinolaryngology with Ophthalmology
In most cases, chronic forms of sinusitis require the use of surgical treatments. The analysis of data in the world literature shows that the recurrence after endoscopic sinusitis functional sinusotomy is about 20%, and in almost half of cases it is required to conduct reintervention. The aim of the research: To study the effectiveness of plastic reconstruction of frontal-nasal anastomosis using muco-periosteal flap on the leg during intranasal frontotomy in patients with chronic frontal sinusitis. Materials and methods. In the period from January 2014 to January 2017 at the ENT department of Poltava M. V. Skiifosovskii Regional Ciinica i Hospital, surgical treatment of 248 patients with chronic inflammation of the frontal sinus was conducted. The study included 67 patients with uncomplicated course of chronic sinusitis. These patients were divided into 2 groups: Group 1 - 31 patients that were operated using the classical method of intranasal frontotomy, by extended drainage type (Draf II), Group 2 - 36 patients operated using the modified method. In order to prevent fusion of the formed artificial frontonasal anastomosis in endonasal access and to obtain stable functional results, we have used the modified method of intranasal frontotomy. Research results. Indicators of rhinomanometry before surgery and in 1 month display a statistically significant difference in patients of Group 2, who underwent nasal frontotomy with correction of INS (p <0.05). Conclusions: 1. In all patients of ENT Department, isolated or combined chronic inflammation of frontal sinus in general structure of sinusitis was observed in 21.64% of cases. 2. Chronic Inflammation of frontal sinus requires the use of surgical management in 95%% of cases. 3. The application of plastic reconstruction of frontal-nasal anastomosis during intranasal frontotomy promotes earlier clinical convalescence of patients, reduces the number of relapses of frontal sinusitis. 4. The application of rhinomanometry allows us to give qualitative and quantitative characteristics of the status of nasal ventHation, which is an important criterion for the effectiveness of the correction of INS structures and prognostic indicator of PNS ventilation. Keywords: chronic sinusitis, nasal sinus-surgery, plastic reconstruction of the frontal-nasal anastomosis.
Introduction
Inflammatory diseases of the paranasal sinuses are most common in the structure of ENT pathologies and constitute about 25% of the adult population. The number of identified cases of sinusitis demonstrates a constant tendency to increase [1, 2, 4, 6, 10]. Frontal sinuses are affected less frequently than the maxillary and ethmoid ones, but the acute inflammatory process in them often becomes chronic. Great variability in the structure of frontal sinuses leads to a wide variety of clinical manifestations of sinusitis.
In most cases, chronic forms of sinusitis require the application of surgical treatment. At present, open extranasal radical approaches are quite rarely used for surgical treatment of sinusitis, but endoscopic endonasal access, which has become widely implemented in recent years, often does not have the sufficient clinical effectiveness. The analysis of data in the world literature shows that the recurrence after endoscopic sinusitis functional sinusotomy is about 20%, and in almost half of cases it is required to conduct reintervention [2, 3, 5, 7, 8, 9]. Given the fairly high level of chronic sinusitis relapse after intranasal frontotomy caused by cicatri-cial obliteration of artificial anastomosis, we set out the aim to develop effective methods of prevention, which would satisfy patients by their functional results.
Among the methods of surgical treatment of sinusitis aimed at restoring anastomosis of the affected sinus with the nasal cavity, the most physiological are variants in which mucosa in the area of artificial anastomosis is minimally injured. Mucosa with preserved function of ciliated epithelium, on the one hand, ensures the normal
biomechanics of mucus, and on the other - prevents the formation of excess connective tissue and cicatricial anastomosis, one of the main reasons for relapse. One of the priorities for minimally invasive surgery is to preserve the mucous membrane of the nose and paranasal sinuses (PNS). At the stage of early postoperative period, it is important to achieve rapid and complete epithelializa-tion of the mucous membrane with the recovery of mucociliary transport system, drainage and ventilation of the sinuses, nasal breathing and as a result, timely clinical convalescence of a patient.
The aim of the research is to study the effectiveness of plastic reconstruction of frontal-nasal anastomosis using muco-periosteal flap on the leg during intranasal frontotomy in patients with chronic frontal sinusitis.
Materials and methods
In the period from January 2014 to January 2017 at the ENT department of Poltava M.V. Sklifosovskii Regional Clinical Hospital, surgical treatment of 248 patients with chronic inflammation of the frontal sinus was conducted.
Depending on the nature of changes in the frontal sinus, involvement of PNS in the pathological process and presence of morphological disorders of intranasal structures (INS) the following types of surgery were performed: endonasal frontotomy (20.9%); endonasal frontotomy with correction of INS (6.5%); frontotomy as part of polysinusotomy (40.3%); polysinusotomy that included frontotomy and correction of INS (22.6%); extranasal frontotomy (9.7%). In all cases, frontal ethmoidotomy was carried out in frontotomy. In all cases, extranasal frontotomy was combined with intranasal approach.
* To cite this English version: A. V. Loburets, S.B. Bezshapochnyi Preventing the obliteration of artificial anastomosis after intranasal frontotomy in patients with chronic frontal sinusitis //Problemy ekologii ta medytsyny. - 2016. - Vol 20, № 3-4. - P. 20-24.
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patients that were operated using the classical method of intranasal frontotomy, by extended drainage type (Draf II), Group 2 - 36 patients operated using the modified method.
Table 1 demonstrates the distribution of patients by volume of surgery and Table 2 - by age, gender and group affiliation.
Table 1.
Ratio of surgical intervention in patients 1 and 2 groups.
Study group Total Endonasal frontotomy Endonasal frontotomy with correction of INS Polysinusotomy Polysinusotomy with correction of INS
Group 1 Amount 31 9 4 11 7
% 46.3 13.45 6 16.4 10.45
Group 2 Amount 36 12 5 9 10
% 53.7 17.9 7.45 13.45 14.9
Table 2.
The distribution of patients by age and sex, group affiliation.
Age Total Men Women Total in groups:
abs. % abs. % abs. % Group 1 Group 2
m f m f
15-25 18 26.9 12 17.9 6 9 6 3 6 3
26-35 21 31.3 13 19.4 8 11.9 10 4 3 4
36-45 13 19.4 4 5.95 9 13.4 1 4 3 5
46-55 7 10.4 4 5.95 3 4.5 - 1 4 2
56-66 8 12 5 7.5 3 4.5 2 - 3 3
Total 67 100% 38 56.7 29 43.3 19 12 19 17
periosteal flap is displaced upwards toward the frontal sinus, the bone that forms the processus uncinatus is partially removed. Further, artificial fronto-nasal canal is formed to the size required for proper drainage and ventilation of the frontal sinus. The final step in operation is laying the selected flap on the leg in the frontal pocket and shaped fronto-nasal channel. The flap is fixed by means of a special silicone drainage tube.
In the postoperative period, patients in both groups were treated according to modern protocols, including the nasal irrigation of mucosa with saline solutions starting from the 3rd day after surgery, short course of local decongestants (xylometazoline), intranasal corticosteroids (mometasone furoate) at a dose of 50 mg in nostril 2 g / d starting from day 10. Duration of corticosteroids application ranged from 2 weeks to 1 month.
All patients underwent rhinomanometry study before and after surgery, endoscopic examination while staying at the hospital and in the remote postoperative period.
Results and discussion
By 2008, the predominant types of operations on the frontal sinus were the extranasal surgical approaches performed in 84% of cases, bypass frontotomy was often carried out. Most of operations were carried out on an emergency basis, for health reasons, and the average patient's stay at the hospital was 13.2 days (with 7.1 days in 2016). Since 2009, 54% of the surgeries were routine in nature.
The rates of growth of surgical activity for frontal sinus in 16 last years are presented graphically in the diagram (Figure 1).
Indications for frontotomy were the presence of persistent morphological changes in the mucosa of frontal sinus, as confirmed by radiographic diagnostics methods, and ineffective conservative treatment.
Of all operated patients, for this study we selected 67 cases with chronic sinusitis of uncomplicated course. These patients were divided into 2 groups: Group 1 - 31
The average age of patients was 34.7 years.
In order to prevent fusion of the formed artificial fronto-nasal anastomosis in endonasal access and to obtain stable functional results, we have used the modified method of intranasal frontotomy, which is based on the methodology of advanced frontal sinus drainage. This technique was performed in all patients from clinical group 2.
The method is conducted as follows. The operation is usually performed under intravenous anesthesia with intubation. The surgery technique is similar to classical frontotomy of extended drainage type - Draf II. The difference is that during surgery the ankyroid process is not removed, but modeled into the muco-periosteal flap which partially offsets the mucosal defect that occurs during surgery when forming frontal pocket and fronto-nasal canal.
Under endoscopic control, medial luxation of the middle nasal concha is performed, hydroseparation of the area of ankyroid process is conducted and, if possible, -agger nasi and areas bulla ethmoidalis. Partial uncinec-tomy between the middle and lower thirds of ankyroid process is conducted, while ankyroid process is not completely removed, its bottom third is preserved along with mucoperiosteum. Further, U-shaped muco-periosteal flap on the leg is formed, separated from the upper two-thirds ankyroid process with transition to the lateral wall of the nasal cavity in the area of agger nasi. At the same time, the foundation of the flap is the selected area of mucosa in the rear surface of ankyroid process (rear leg) and mucus taken from the bottom third of agger nasi, continuing to lower third of ankyroid process (front leg). Muco-
g ■
— Ш
■ 1 1 ■ I I I I I I
200(1 2001 2002 2003 2004 200? 2006 200" 200S 2009 2010 2011 2012 2013 2014 2015 2016
Figure 1. Frequency of frontoti
Analyzing the data obtained by statistical analysis of archival data, we concluded that the increase in surgical activity is directly related to the introduction of modern endoscopic techniques and surgeons' gradual mastering the skills of rhino- and sinus-surgery. Moreover, the growing number of these surgeries could be affected by significantly improving diagnostic methods, including the dominant role of CT with the possibility of 3D modeling.
Over the past 3 years (from 2014 to 2016) in the ENT Department of Poltava Regional Clinical Hospital 1206 patients with acute exacerbation of chronic rhinosinusitis were treated, including 261 (21.64%) patients with chronic inflammation of the frontal sinus that is observed as an isolated disease or as part of polysinusitis. Among them, surgery on the paranasal sinuses with chronic rhinosinusitis was performed in 1093 patients (90.63%). The share of performed frontotomies was 22.68% (248 patients). Frontotomy is 68 patients was conducted in relation to isolated chronic
in the period from 2000 to 2016 sinusitis, in 156 patients frontotomy was performed as a part of polysinusotomy. In 24 patients, frontotomy had combined endo- and extranasal access. In 13 patients with chronic sinusitis, frontotomy was not performed due to patient's waiver. Thus, almost every 4th surgical treatment of patients with pathology of paranasal sinuses was conducted by frontal sinus drainage.
The main complaint of patients in groups 1 and 2 with isolated sinusitis was headache of different intensity. Endoscopic symptoms often were rather insignificant. In cases of polysinusitis, complaints of abnormal discharge from the nose and shortness of nasal breathing were dominant. In the majority of patients in both groups, disorders of the emotional sphere were determined, disrupted attention and sleep, irritability. Semiotics of the disease in patients with chronic sinusitis in groups 1 and 2 is presented in Table 3.
Table 3.
Complaints of patients of groups 1 and 2
Complaints1 Grou p 1 Grou p 2
Isolated frontal sinusitis, n=13 Polysinusitis, n=18 Isolated frontal sinusitis, n=17 Polysinusitis, n=19
Headache 13 7 17 11
Discharge from the nose 2 16 4 15
Difficulty in nasal breathing 4 16 5 14
Disorders of the emotional sphere 10 12 13 11
1each patient may have several complaints at the same time
According to the modified way we have operated on 36 patients with chronic sinusitis. Stages of plastic reconstruction of fronto-nasal anastomosis according to endoscopy are shown in Figures 2-5. Complications during the surgery were not observed.
Fig. 2. Stage of endoscopic frontotomy 1 - selected fragment of muco-periosteal flap; 2 - middle nasal concha; 3 - nasal septum.
Fig. 3. Stage of endoscopic frontotomy 1 - formed anastomosis of the frontal sinus; 2 - muco-periosteal flap is made in the front surface of the frontal-nasal canal.
Fig. 4. CT of PNS 1 month after surgery (a - coronary projection, b - sagittal projection).
Results of clinical studies in patients of Groups 1 and 2 after surgery
Results of rhinomanometry study are presented in Table 4. Indicators of rhinomanometry before surgery and in 1 month display a statistically significant difference in patients of Group 2, who underwent nasal fron-totomy with correction of INS (p <0.05, value of Student t-test 2.306). Indicators of rhinomanometry in patients of both groups who underwent frontotomy without correction of INS had no statistically significant difference. Correction of INS changes the aerodynamic resistance in a large area, and in a wide range of values, whereas without correction - only in the area immediately adjacent to the site of anastomosis and by overall reduction of mucosal swelling.
The reason that led to complications in the postoperative period in most cases was failure to follow the recommendations as to the visits to the doctor, to perform care for the nasal cavity after discharge of the patient from the hospital. Fig. 5. Endorhinoscopy of frontal pocket 1 month after frontotomy: 1- artificial anastomosis of the right frontal sinus.
Table 4.
Rhinomanometry study in of patients Groups 1 and 2.
Study group Volume of surgical intervention Posterior active rhinomanometry
Before surgery, A*± standard deviation 1 month after surgery A**± standard deviation A*/A**
Group 1 Endonasal frontotomy (n=9) 1.46±0.13 1.31 ±0.12 1.11
Endonasal frontotomy with correction of INS (n=4) 2.04±0.33 1.30±0.14 1.56
Polysinusotomy (n=11) 1.84±0.29 1.47±0.24 1.25
Polysinusotomy with correction of INS (n=7) 2.44±0.48 1.60±0.23 1.52
Group 2 Endonasal frontotomy (n=12) 1.44±0.19 1.14±0.28 1.26
Endonasal frontotomy with correction of INS (n=5) 2.29±0.23 1.39±0.17 1.65
Polysinusotomy (n=9) 1.78±0.17 1.38±0.13 1.28
Polysinusotomy with correction of INS (n=10) 2.07±0.33 1.35±0.18 15(3)
The coefficient of aerodynamic nasal resistance - A; * - at the stage of planning the surgery; ** - 1 month after surgery
The most frequent types of complications related to endonasal polysinusotomy were synechiae of the nasal
Thus, due to a number of factors, in Group 1 within a year of observation, 7 cases of sinusitis relapse were detected, which is 19.35%. In Group 2, there were 5 cases of exacerbation of frontal sinusitis (13.88%). All patients underwent revision of the operated sinus, after which we have concluded that in 8 patients of Group 1 and 4 patients in Group 2 there was cicatricial obliteration of artificial anastomosis. It was of partial (10 patients) or complete nature (2 patients). In these patients for the duration of observation recurrent exacerbation of frontal sinusitis was noted. The exception was an isolated case, when in the satisfactory size of anastomosis occurrence of moderate swelling of the mucous membrane was observed in the frontal sinus, leading to severe pain symptoms. Exacerbation of sinusitis was usually caused by acute respiratory viral infection. In patients of both groups, no cases of complicated forms of sinusitis were observed.
Conclusions
1. In all patients of ENT Department, isolated or combined chronic inflammation of frontal sinus in general structure of sinusitis was observed in 21.64% of cases.
2. Chronic inflammation of frontal sinus requires the use of surgical management in 95% of cases.
3. The application of plastic reconstruction of frontalnasal anastomosis during intranasal frontotomy promotes earlier clinical convalescence of patients, reduces the number of relapses of frontal sinusitis.
4. The application of rhinomanometry allows us to give qualitative and quantitative characteristics of the status of nasal ventilation, which is an important criterion for the effectiveness of the correction of INS structures and prognostic indicator of PNS ventilation.
References
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Marepia/ HagiMWOB go pegaKLLii' 09.02.2017
Table 5.
Complications after frontotomy in patients of Groups 1 and 2
Complications of surgery (number of cases)
Study group Volume of surgical intervention Synechiae of the nasal cavity Narrowing of the formed anastomosis of the frontal sinus Relapse of frontal sinusitis within 1 year Relapse of sinusitis (along with frontal sinusitis) within 1 year
Endonasal frontotomy (n=9) - 2 1 -
Group 1 Endonasal frontotomy with correction of INS (n=4) 1 1 1 -
Polysinusotomy (n=11 ) 3 3 2 3
Polysinusotomy with correction of INS (n=7) 2 2 2 4
Endonasal frontotomy (n=12) - 1 1 -
Group 2 Endonasal frontotomy with correction of INS (n=5) 1 - - -
Polysinusotomy (n=9) 1 2 3 2
Polysinusotomy with correction of INS (n=10) 2 1 1 3
