ANTRITIS (highmoritis; a gaymor [an ova a bosom] + - itis; synonym: antritis maxillaris, sinusitis maxillaris, maxillitis) — an inflammation of a mucous membrane of a genyantrum, sometimes with involvement in process of her periosteum and a bone wall. The disease can be acute and chronic. Acute forms are more characteristic of G. at children.
The etiology and a pathogeny
Acute G. develops after the postponed flu, acute Qatar of upper respiratory tracts, rhinitis, measles, scarlet fever and nek-ry other diseases more often, and also at inflammatory diseases of teeth. Less often acute G. develops at injuries of an upper jaw, operations on an alveolar shoot or in nasal cavities. Overcooling against the background of decrease in reactivity of an organism can be a provocative factor. Hron, an inflammation of genyantrums usually is a consequence of an acute inflammation, especially under unfavorable conditions for the outflow which collected in them patol of a secret. It can be promoted by thickenings of a mucous membrane of a nose, a hypertrophy of sinks, curvatures of a nasal partition closing or narrowing output openings of genyantrums.
At bacterial, a research in contents of a bosom or rinsing waters streptococci, staphylococcus, diplococcuses and other microorganisms are found. In nek-ry cases at a bacterioscopy yeast-like fungi come to light.
During the outbreak of flu viruses are found, antibodies to them are more rare.
Considering ways of penetration of an infection, distinguish rhinogenic (more often at adults), hematogenous (generally at children), dontogenous and traumatic G. Vydelyayut also special forms G. — vasculomotor and allergic. Vasculomotor G. develops at people with an unstable nervous system when under the influence of negative emotions there is a vasodilatation causing hypostasis of mucous membranes of a nose and adnexal bosoms. Allergic reaction in fabrics of a genyantrum is the cornerstone of allergic G.
The pathological anatomy
Acute G. proceeds in the form of a catarral (serous) and purulent inflammation. Sometimes it is stages of the same process. Microscopically the phenomena of alteration, proliferation and exudation are found. Depending on dominance of this or that process the gross appearance can be extremely various. At a serous inflammation the mucous membrane is thickened, the infiltrirovana, can fill all gleam of a bosom. Its surface becomes hilly. The cylindrical ciliary epithelium covering a bosom is often kept, its partial rejection is sometimes observed. Infiltration of a mucous membrane cellular elements, generally lymphocytes and polinukleara is characteristic. Often in its thickness are formed various sizes of a cavity, filled with exudate, to-ry can fill also remained gleam of a bosom. Vessels are sharply expanded, around their gleam cellular infiltration is noted. Upon transition of process to purulent the mucous membrane becomes covered by purulent plaques, exudate becomes purulent. Often hemorrhages are found, to-rye at flu can be numerous, exudate in this case accepts hemorrhagic character.
At hron. Pathoanatomical changes are even more various. Usually allocate catarral, purulent, polypostural, it is purulent - polypostural forms. Changes at hron, catarral and purulent G. are similar to those at acute, but are more expressed. At a catarral form process in a mucous membrane reaches deep layers more often, cysts, diffusion hypertrophies are sometimes observed. At a purulent inflammation the mucous membrane is edematous and thickened, cavities (pseudocyst) due to expansion limf, cracks an exudate are found. Formation of true cysts owing to a prelum of channels of mucous glands is noted.
The hyperplasia and serous treatment conduct to diffusion hypertrophies and formation of polyps. Fabric of a polyp is edematous; plazmotsellyulyarny or lymphoid infiltration is noted; existence of an eosinophilia testifies to the allergic nature of a polyp. Depending on dominance of ferruterous or granulyatsionny fabric can meet adenomatous or granulation polyps. G.'s sign of an allergic origin is increase in number mast cells (see), to-rye concentrate generally around vessels and glands. Mast cells are found also in polypostural liquid, and the quantity reflects them sharpness of allergic process.
At hron. The gleam of a bosom is often carried out by exudate, to-ry can be serous, purulent, contain the holesteatomny masses (a false cholesteatoma). The thickening of a mucous membrane is followed by infiltration of all its layers, fibrosis. The razvolokneniye, a loosening and fragmentation of a subepithelial basal membrane is noted. Content of neutral and acid mucopolysaccharides, especially hyaluronic to - you with the phenomena of its depolymerization changes, the framework of argyrophil fibers and membranes of blood vessels is broken. During the involvement in process of a periosteum and bone walls in the last destructive and hyperplastic processes are found. At dominance of destruction thinning, disintegration and sequestration of bone walls is observed.
A clinical picture
the fever, fervescence, bad overall health, the headache of various intensity which is often irradiating to the area of a forehead, a root of a nose and teeth are characteristic Of acute G. Pain in the field of the struck genyantrum amplifies during the pressing on its front wall. On character pain sharp, intensive and constant, is followed by feeling of a raspiraniye, amplifies at a ducking, cough and sneezing. Sometimes the photophobia and dacryagogue join. The nose is bunged up, cold (often unilateral) with plentiful separated mucous (catarral G.), mucopurulent, purulent character (purulent G.). On side of the wounded bosom sense of smell decreases. During the involvement in process of a periosteum the swelling of a cheek and hypostasis lower, and sometimes and an upper eyelid is observed.
At rinoskopiya (see) hypostasis is noted, a hyperemia of a mucous membrane of a nasal cavity, the average nasal course is narrowed, in it the characteristic strip of slime or pus is visible. If to incline the head of the patient down and sideways, the affected bosom up, then the expiration separated from a bosom — Zablotsky's symptom — Desyatovsky is observed.
For hron. The general weakness, an indisposition, bystry fatigue, a headache (is more often in the evening), a congestion of a nose is characteristic. The discharge from a nose can be mucous, serous, purulent. Sense of smell decreases, quite often comes anosmia (see). At a rinoskopiya, in addition to inflammatory changes of a mucous membrane, to-rye are shown by puffiness, a thickening, cyanosis, the hypertrophy of the lower and average nasal sinks is often noted. The strip separated on average the nasal course is observed. At polypostural forms polyps can carry out all nasal cavity and go down in a nasopharynx (a choanal polyp). The wavy current with periodic remissions is characteristic of vasculomotor and allergic G. The clinic of an aggravation is characterized by the same symptoms, as at acute G.
Sometimes at acute, but is more often at hron. Both at adults, and intracranial complications in the form of hypostasis of a meninx, serous or purulent occur at children meningitis (see), an encephalomeningitis, phlebitis of sine of a firm meninx with development of rhinogenic sepsis (see), pachymeningitis (see), rhinogenic abscess of a brain (see. Brain , abscess), rhinogenic arachnoiditis (see). They are most frequent in the period of a flu epidemic. There can be orbital complications: reactive hypostasis of cellulose of an eye-socket and century, retrobulbar abscess, wasps those to the opera of an awn you eye-sockets, phlegmon, vein thrombosis of an eye-socket, etc. Also the periostitis of an upper jaw meets.
the Diagnosis is specified at diafanoskopiya (see), X-ray analysis (see Gaymorografiya, Paranasal sinuses, radiodiagnosis of diseases), ekhografiya (see. Ultrasonic diagnosis ). The diagnostic puncture of a bosom allowing to specify availability of exudate and its character is widely applied. It is at the same time possible to make washing of a bosom, a biopsy, to take prints. A number of authors offered optical devices for endoscopy of genyantrums (see. Antroskopiya ).
At acute G. and an aggravation hron. Appoint the febrifuges, sulfanamide drugs, antibiotics hyposensibilizing means, vitamins. Locally apply vasoconstrictors (3% solution of ephedrine, Naphthyzinum, etc.), to-rye it is possible to use in the form of drops, for spraying, greasing, introduction to a nasal cavity on cotton plugs. From physiotherapeutic means appoint sollyuks, a diathermy, currents of ultrahigh frequency; upon transition of process in chronic it is possible to use microwave therapy, an electrophoresis of various medicinal substances (antibiotics, hormones, etc.), diadynamic currents, diadinamoforez, mud cure, paraffin applications, inhalations and aerosols. For treatment hron. Of an allergic origin use means of nonspecific desensitization (drugs of calcium chloride, antihistaminic drugs, Prednisolonum, a cortisone, AKTG, gistoglobin, etc.) and specific desensitization (small doses of allergens, vaccines and autovaktsnna). At fungal G. anti-fungal drugs (nystatin, levorinum, etc.) are shown to per os, and also for introduction to a bosom.
The puncture of a genyantrum is made as with diagnostic, and to lay down. purpose special needle or various troakara. It is possible to use a spinal needle. After local anesthesia (greasing of a mucous membrane of 1 — 2% solution of Dicainum or 5 — 10% solution of cocaine with addition of adrenaline) make a puncture through the closing nasal stroke (fig. 1), otstupya 1,5 — 2 cm from the front end of the lower nasal sink, at the place of its attachment. Patol, contents delete from a bosom with suction and washing. For washing use warm solutions boric to - you, potassium permanganate, Furacilin, Rivanolum, Romasulonum and other desinfectants. After removal of wash liquid enter antibiotics into a bosom (depending on sensitivity of microflora to them), hormonal drugs, proteolytic enzymes (it is possible to combine). For constant drainage of a genyantrum use catheters, polyethylene and metal tubes that is especially convenient in children's practice since helps to avoid repeated punctures. If the effect of conservative treatment does not occur or there is a threat of an intracranial or orbital complication, resort to surgical intervention (maxillary sinusotomy), the purpose to-rogo — removal patol. contents of a bosom. Ways of surgical interventions share on intranasal — a resection of a nasal wall of a bosom on average and lower the nasal courses, front — opening of a bosom through a front wall; combined or radical — a resection of a front wall with a simultaneous resection of a nasal wall.
Radical operations of Caldwell — Luke and A. F. Ivanov are most widespread. The section is made on a transitional fold of an entrance of the mouth. Otseparovyvat soft tissues together with a periosteum, bare a front wall of a bosom and open (fig. 2). The bosom is opened with a chisel, a chisel or. delete with trepan and an acute spoon patol, contents. Caldwell and Luke (G. W. Caldwell, H. P. Luc) suggest to delete all mucous membrane, A. F. Ivanov — only the changed its sites. Create the message with a nasal cavity through the closing nasal stroke. On a wound put catgut stitches, are sometimes limited to a compressing bandage.
the Forecast at acute G. usually favorable. Recovery in most cases occurs in terms of several days to 2 — 3 weeks. At the persons exhausted with the lowered reactivity or at just had serious infectious diseases acute G. can drag on and accept hron, a current. At hron., proceeding without complications, the forecast usually favorable also depends from morfol, changes and duration of a course of process. In the presence of complications the forecast acute and hron. Is defined by character of a complication.
Prevention comes down to increase in protective forces of an organism, its hardening. Exercises and sport, walks in the fresh air, hydrotherapeutic procedures, treatment of the diseases of a nose leading to disturbance of nasal breath are for this purpose recommended (a curvature, thorns, crests of a nasal partition, hron, cold). At acute cold the strong smorkaniye promoting hit of slime in genyantrums is forbidden.
According to V. M. Uvarov (1951), G. V. Starenkova (1956), Dontogenous G. make G. Sravnitelno apprx. 20 — 25% of all the high percent of dontogenous G. can be explained with anatomic proximity of a bottom of a genyantrum to tops of fangs of an upper jaw (fig. 3). So, a root of the second small radical and roots of the first and second big molars are separated from a bottom of a genyantrum by a thin coat of a bone tissue. Sometimes the bottom of a genyantrum borders on roots of the third big radical, and in front — on roots of the first small molar and even a canine; in these cases roots of the specified teeth can stand in a bosom, they are separated from only the last periosteum and a layer of a mucous membrane. Inflammatory processes in the field of tops of roots of these teeth can easily extend also to a mucous membrane of a genyantrum. The break of pus in a genyantrum can be also at suppuration of an odontocele of an upper jaw (see. Odontocele ). Inflammatory processes around the impacted teeth (see), and also the remains of fangs can be a source to an infection. Is one of complications of osteomyelitis of an upper jaw. Quite often G. develop as a result of perforation of a bottom of a genyantrum during an odontectomy. Perforation can sometimes be followed by pushing through of tooth or its root in a genyantrum. Thus, Dontogenous G. can arise without disturbance of an integrity of a bottom of a genyantrum and at its disturbance — so-called perforative G.
Clinical picture dontogenous G. without message of a genyantrum with an oral cavity a little in what differs from rhinogenic G. Dontogenous G. quite often can be followed by a twinge of toothache, is more often in the second small and the first big molars of an upper jaw that leads to the wrong diagnosis and unjustified interventions, up to an odontectomy.
At perforative G. the message between oral cavities and a nose is formed. Usually complaints of patients are that liquid food at normal position of the head pours out from a nose. The effluence of liquid from a nose amplifies at a ducking forward and stops at a zaprokidyvaniye of the head back. In the subsequent symptoms of an acute inflammation of a genyantrum join (temperature increase, loss of appetite, plentiful releases of pus from fistula).
Diagnosis dontogenous G. put on the basis of anamnestic data, survey, a rinoskopiya, sounding, a X-ray analysis.
Treatment acute and hron, dontogenous G. without disturbance of an integrity of a bottom of a genyantrum do not differ from treatment of rhinogenic G.
At perforative dontogenous G. do operation on Caldwell — to Luke; after it make plastic closing of an opening by movement of local fabrics from a vestibular surface of an alveolar shoot or from the sky (fig. 4). After operation the bandage is fixed a protective plate. The first bandaging is made in 6 — 7 days. With 5 — the 6th day within a week daily wash out a genyantrum through an educated anastomosis.
Prevention dontogenous G. comes down to sanitation of an oral cavity (see). At detection of the dontogenous inflammatory centers at the patient with G. careful sanitation of an oral cavity shall precede treatment (conservative or surgical). The teeth which are not giving in to conservative treatment are subject to removal.
Bibliography: Vernadsky Yu. I. and Zaslavsky N. I. Dontogenous antritises, M., 1968, bibliogr.; B about to-shtey F. S N. Intranasal surgery, M., 1956; Korneev S. T. The sparing method of drainage of a genyantrum, Vestn, otorynolar., 6, page 82, 1972; To at N of e of l with to and I am V. Ya. Klinika, diagnosis and treatment of fungal antritises, in the same place, No. 4, page 49, 1970; Likhachev A. G. and about l d m and I. I N. Chronic allergic rinosinuita, M., 1967; The Multivolume guide to otorhinolaryngology, under the editorship of A. G. Likhachev, t. 4, page 7, M., 1963; Potapov I. I., P about about with about in V. S. and Sh e in r y and B. V N. Treatment of rhinitis and a rinosnnuit at adults and children, M., 1968; P p e about 0 r and - female B. S., etc. Allergic diseases of upper respiratory tracts, M., 1969; The Guide to surgical stomatology, under the editorship of. And. II. Evdokimova, page 192, M., 1972; At a pitch about V. I. Dontogenous antritises, L., 1962, bibliogr.; Griinberg H. Die prima-chronische Sinusitis maxillaris irn endor-skopischen Bild, Z. Laryng. Rhinol., Bd 50, S. 813, 1971; Hellmich S. u. H e r-b e r h about 1 d C. Technische Verbesserungen-der Kieferhohlen-Endoskopie, Arcli. klin. exp. Ohr. - Nas. - u. Kehlk. — Heiln. Bd 199, S. 678, 1971; K an i s e r-M e i k., h a r d t I. Atlas der Ohren, Nasen-und Halskrankheiten sowie deren Grenzgebiete, Lpz., 1965; Schwab W. Die Operati o-nen an Nase, Mund und Hals, Lpz., 1964.
I. B. Soldatov; P.V. Naumov (ostomies.).