PARANASAL SINUSES

From Big Medical Encyclopedia
Fig. 1. The diagrammatic representation lateralno the IV walls of the right half of a nasal cavity (nasal sinks are removed): 1 — the probe in a trellised funnel; 2 - - semi-lunar crevice; 3 — an opening of a Highmore's bosom; 4 — openings of average cells of a sievebone; 5 — openings of back cells of a sievebone; 6 — klinovidnoreshetchaty deepening; 7 — the probe entered into an apertura sinus sphenoidalis; 8 — the upper nasal course; 9 — the average nasal course; 10 — the closing nasal stroke; 11 — a big trellised bubble; 12 — a frontal sinus.
Fig. 2. Diagrammatic representation of a nasal cavity and adnexal bosoms (frontal cuts): 1 — a front cell of a sievebone; 2 — a frontal sinus; 3 — an average cell of a sievebone; 4 — an opening of a Highmore's bosom in a semi-lunar crevice; 5 — an ankyroid shoot of a sievebone; 6 and 8 — a Highmore's bosom; 7 — the lower nasal sink; 9 — an additional opening of a Highmore's bosom; 10 — an average nasal sink; 11 — a back cell of a sievebone; 12 — an upper nasal sink; 13 — a cock crest (crista galli).

PARANASAL SINUSES [sinus paranasales (PNA, BNA); sinus nasales (JNA); synonym okolonosovy bosoms] — pneumatic cavities in bones front and a neurocranium, the voices covered by a mucous membrane, reported with a nasal cavity and being resonators. Distinguish the following Pct of N (fig. 1 and 2): the largest Highmore's bosom (maxillary, T.; sinus maxillaris, PNA, JNA, BNA; antrum Highmori), frontal (sinus frontalis, PNA, JNA, BNA), wedge-shaped (sinus sphenoidalis, PNA, BNA; sinus sphenoideus, JNA) and bosoms (cell) of a trellised labyrinth or sievebone (sinus ethmoidalis, s. cellulae ethmoidales, PNA; sinus ethmoidei ant., post., JNA; cellulae ethmoidales, BNA).

Embryology

Adnexal bosoms begin to develop on 8 — the 10th week of embryonic development from three main grooves of a sidewall of a nose. From the ascending branch of the first main groove the frontal sinus, and from the descending branch — a Highmore's bosom develops. From the second main groove average and back cells of a sievebone develop. Front cells form from adnexal frontal grooves. The wedge-shaped bosom is formed in the course of growing of a mucous membrane of a nasal cavity into a wedge-shaped bone. At newborns all Pct of N are put, but the Highmore's bosom is the most developed. Final development of Pct of N is reached at the age of 15 — 20 years.

Anatomy

Highmore's bosom the steam room, is located in a body of upper jaws (see), in a form reminds a pyramid. Left and right bosoms not always identical size. Depending on degree of a pnevmatization of a Highmore's bosom there is a protrusion of its walls with formation of bays (alveolar, infraorbital, palatal and malar) which can change a shape of a bosom and its topographical ratios. Distinguish medial, anterolateral, posterolateral, top and bottom walls of a bosom. The medial wall is at the same time lateral wall of a cavity nose (see), usually has the form of a quadrangle, in lower parts she is more fat, than in upper. Opening of a bosom (maxillary crevice, T.), connecting it to a nasal cavity, is above a bottom and has the oval form. Sometimes, except a constant opening, is available additional, located kzad and from top to bottom from the basic. The anterolateral wall in a form reminds a triangle. On average its department there is impression — a klykovy pole; in this place a wall the thinnest. Anterolateral and medial walls connect, creating a bone ledge — the cape.

The posterolateral wall of a bosom has the form of the wrong quadrangle. The posterosuperior corner of a wall close approaches back group of cells of the trellised labyrinth which is a part of a sievebone and a wedge-shaped bosom. The upper wall of a bosom the thinnest, has the form of a triangle and is the lower wall eye-sockets (see). On an upper wall of a bosom the infraorbital furrow passing kpered into the infraorbital canal is located; in them there passes the infraorbital sosudistonervny bunch. The form and the sizes of the lower wall depend on a form hard palate (see) and conditions of an alveolar shoot. The bosom Krovosnabzhatsya by branches of maxillary, facial and orbital arteries. Venous outflow — in the veins, of the same name with arteries. Outflow of a lymph comes from a Highmore's bosom in retropharyngeal and deep cervical limf. nodes. The innervation is carried out maxillary and orbital by nerves.

Frontal sinus it is put in scales of a frontal bone, has the form of the trihedral pyramid turned by the basis from top to bottom, and a top up. In a bosom distinguish front, back, internal and lower walls. The thickest is the front wall, a back wall, on the contrary, very thin. The lower wall consists of nasal and orbital departments. If the bosom a big, then lower wall can last throughout an upper wall of an eye-socket, reaching small wings of a wedge-shaped bone, a wedge-shaped bosom and an average cranial pole. The internal wall passes vertically, deviating only in an upper part. With a nasal cavity the frontal sinus is reported via the frontonasal channel which opens a semi-lunar crevice in the forefront of the average nasal course (a threshold of a half-speed, T.). Blood supply of a bosom is carried out by branches orbital (eye, T.) and maxillary arteries; venous outflow — in frontal and orbital (eye, T.) veins, and also in an upper sagittal sine. The lymph flows in vessels of a nasal cavity. The bosom is innervated by branches of front trellised and supraorbital nerves.

Wedge-shaped bosom it is located in a body of the bone of the same name. The upper wall of a bosom thin, is a bottom of the Turkish saddle. The lower wall — thicker — takes part in formation of the arch of a nasopharynx (a nasal part of a throat, T.). Back wall of a bosom very thick; it is connected with an occipital bone and is limited to a slope. Thickness of sidewalls is most changeable. In close proximity to them pass an internal carotid artery, III, IV, V and the VI craniocereberal (cranial, T.) nerves. The internal wall divides a wedge-shaped bosom into two parts, most often asymmetric Blood supply is carried out by branches of the maxillary and ascending pharyngeal arteries. A venous blood flows in veins of a nasal cavity, a throat; a lymph — in vessels of a nasal cavity and a throat. The bosom is innervated by a back trellised nerve and branches of a pterygopalatine node.

Bosoms of a sievebone are presented by numerous cells (on average 7 — 12 cells). Allocate front, average and back cells of a sievebone. Front cells open in the average nasal course, averages — in the upper or average nasal course and back — in the upper nasal course. Their blood supply is carried out by front and back trellised arteries, and also branches of an infraorbital artery; venous outflow — in veins of a nasal cavity and an eye-socket. The lymph flows in vessels of a nasal cavity and a century. The innervation is carried out front and back by trellised nerves.

See also Skull .

Methods of inspection

In diagnosis of diseases of Pct of N use external examination, a palpation and percussion in the field of a projection of bosoms, rinoskopiya (see), sounding of bosoms, their puncture, diafanoskopiya (see), nondestructive testing (see), rentgenol. research and some other.

Front walls frontal, Highmore's and partly bosoms of a sievebone are a part of bones of a facial skull therefore patol. processes in bosoms can extend to facial tissues. In the field of projections of Items of N, a threshold of an oral cavity and a hard palate the swelling, infiltration of soft tissues, a hyperemia, fistulas can be visible. By means of a palpation estimate a consistence of fabrics, reveal morbidity what also make percussion of area of projections of Pct of N for.

Rinoskopiya gives the chance to examine the nasal courses and nasal sinks, to reveal a condition of a mucous membrane, growth of fabrics, character separated from bosoms. In certain cases make diagnostic suction by means of Polittser's cylinder. The olive of a cylinder is entered into a threshold of one half of a nasal cavity, the wing of the second half is pressed, the head of the patient is inclined aside, opposite to the studied bosom, and at the time of breath holding make suction. Then by means of a rinoskopiya emergence (or absence) separated from under an average nasal sink and in a nasal cavity is defined.

Sounding bosoms make for definition of passability of an anastomosis; washing of bosoms — for the purpose of release from patol. contents, introduction in need of pharmaceuticals or a contrast agent for a X-ray analysis. Probe frontal sinuses more often, is more rare — wedge-shaped. Sounding of Highmore's bosoms is usually not made. Before sounding of bosoms a mucous membrane of a nose it is triple grease mestnoanesteziruyushchy and vasoconstrictors (1 — 2% with solution of Dicainum or 5% solution of cocaine, 3% solution of ephedrine or 0,1% solution of adrenaline). For sounding of a frontal sinus by the most convenient Lansberg's probe cannula is. Thanks to relative softness of metal it is easy to change a form of a cannula according to features of an entrance to an anastomosis of a bosom (an aperture of a frontal sinus, T.) or to pick up a cannula of a necessary form. Under control of sight the cannula is entered under the front end of an average nasal sink, softly grope an opening in a front third of the arch of the average nasal course and by easy effort advance up and slightly knaruzh. The forced carrying out a cannula is inadmissible since it can lead to making of the false course. If the probe meets an obstacle, it is necessary to try to carry out it closer or farther from the place of a typical arrangement of an anastomosis of a frontal sinus in a semi-lunar crevice of the average nasal course. Sometimes sounding is complicated owing to a curvature of a nasal partition, a hypertrophy of an average nasal sink, etc. In such cases or eliminate this pathology, or make a trepanopunktion of a frontal sinus.

It is always difficult to probe a wedge-shaped bosom in connection with its deep arrangement and impossibility of visual control over the implementation of manipulation. In rare instances after expansion of the general nasal course by means of vasoconstrictors there is visible a natural foramen of a wedge-shaped bosom (an aperture of a wedge-shaped bosom, T.) or its front wall. At usual localization of a natural foramen of a wedge-shaped bosom are guided in the area of Tsukkerkandl, edges is determined by a front nasal awn and the middle of free edge of an average nasal sink. The second point is defined is inexact in this connection Tsukkerkandl's line serves only as an approximate reference point and search of an anastomosis is supplemented with palpation of a front wall of a bosom the probe. During the sounding of a wedge-shaped bosom the metal cannula which is slightly bent on the end is entered into the general nasal course in the area of Tsukkerkandl against the stop in a front wall of a wedge-shaped bosom. This wall is felt otstupya on 3 mm lateralno from a nasal partition in search of an opening in a bosom. Sounding of a frontal and wedge-shaped sinus is facilitated during the carrying out rentgenol, control by means of the electron-optical converter (EOC).

Puncture Pct of N make both with diagnostic, and with the medical purpose. The puncture of a Highmore's bosom is most widespread, the trepanopunktion of a frontal sinus, in rare instances — punctures wedge-shaped and trellised bosoms is rather often made. Before a puncture of a Highmore's bosom grease a mucous membrane under the lower nasal sink anesthetizing and vasoconstrictors twice. The puncture is made aspirating needles (Kulikovsky, a long needle of Dyufo, etc.) through the closing nasal stroke at distance of 2,5 cm from the front end of the lower nasal sink, in the highest point of its attachment. Puncture all three layers of a wall (a mucous membrane of a nose, a bone plate and a mucous membrane of a bosom) so that the end of a needle entered a gleam of a bosom approximately on 1 cm. Sometimes anatomic options of norm at which the front wall of a Highmore's bosom in its medial department considerably acts in a gleam of a bosom and is located close to a medial wall meet. At deep immersion of a needle in a bosom it is possible to puncture also a front wall therefore during washing liquid is forced in soft tissues of a cheek. The puncture of an upper wall of a bosom is in rare instances possible that it constitutes considerable danger of development of intra orbital complications. At antritis the puncture of a bosom quite often is followed by the expiration of pus, at a cyst — yellowish, opalescent liquid. The received contents are directed to a research of microflora and its sensitivity to antibiotics. At suspicion of a tumor make tsitol. research of contents. It is possible as well a puncture biopsy. After suction of contents washing of a bosom is made by antiseptic solution, is more often solution of Furacilin 1:5000; it is possible to wash out solution of Peloidinum, etc. Washing is made by means of a Janet's syringe or the rubber pear connected to a needle a rubber tube, using usually 150 — 200 ml of liquid.

The method of a puncture of bosoms of a sievebone consists that by the needle bent on an arch having several openings on each side do a puncture in a big trellised bubble, suck away contents of a bosom and wash out. The method was not widely adopted.

The numerous options of a puncture or a trepanopunktion of a frontal sinus differing from each other in the place and way of imposing of an opening are offered. At adults entered a trepanopunktion of a frontal sinus through a front wall by a technique broad practice Antonyuk. Before a puncture determine a form and depth of a bosom by roentgenograms (i.e. distance between front and back walls of a frontal sinus), and also thickness of a front wall according to what length of the drill entered into a bosom is established. For definition of the place of a trepanepunktion apply with spirit solution of tetraethyl-diamino-triphenyl-carbohydride sulfate a midline on a forehead and a nose bridge, then on a superciliary arch — the line, perpendicular to the first; the educated right angle opened towards the studied bosom is halved bisectrix. On bisectrix otstupya 1 — 1,5 cm from vertex of angle taking into account data of a X-ray analysis put a point for a trepanopunktion.

Puncturation of a wedge-shaped bosom is made by the same rules, as its sounding. Not to damage a trellised plate, the cavernous sine, an optic nerve, make a puncture in the field of a natural foramen of a bosom, considering that height of a front wall of a bosom of 9 — 30 mm, width of 6 — 22 mm, and the natural foramen is located on 2 — 3 mm lateralny from a partition of a nose 5 — 10 mm below than an upper wall of a nasal cavity.

Antroskopiya — introduction to cavities of Pct of N of optical devices — is applied seldom because of narrowness of bone soustiya of bosoms with a nasal cavity. Antroskopiya of a Highmore's bosom is usually made through the opening in the closing nasal stroke made at radical bosom operation; an antroskopiya of a frontal sinus — through the opening made in front or lower its walls. It is reasonable to use a method when there is a suspicion on a X-ray negative foreign body or discrepancy clinical and rentgenol, the tumors given about results of treatment, processes of healing after operation, etc. At an antroskopiya the mucous membrane of a bosom looks thin, brilliant, with a yellowish shade, small vascular network.

Apply immunological, biochemical, morphological and other methods of a research to diagnosis of allergic diseases of Pct of N (see. Allergic diseases ).

X-ray inspection. At the same time on one roentgenogram it is impossible to receive a sharp image of all Pct of N because of imposing of bones of a skull therefore for their comprehensive investigation resort to a multiprojective X-ray analysis. The main projections are noso-mental, frontonasal, side and axial (see. Skull , X-ray inspection). Considerably expands possibilities of diagnosis tomography (see), to-ruyu most often apply in a direct frontonasal projection, and a computer tomography (see. Tomography computer ). A series of tomograms provides good visibility of all Pct of the N unavailable to a polyposition X-ray analysis. It is necessary to resort to artificial contrasting of Pct of N (sinusografiya) less often, a cut carry out when survey pictures and tomograms do not supply with the sufficient information on character and prevalence patol. process. The technique of administration of contrast medium is chosen taking into account anatomic features contrasted by Pct of N. Most often make gaymorografiya (see).

of Fig. 3. The roentgenogram of a skull and adnexal bosoms of a nose is normal (a nosopodborodochny projection): 1 — a frontal sinus; 2 — an eye-socket; 3 — cells of a trellised labyrinth; 4 — a Highmore's bosom.

On roentgenograms and tomograms not changed pneumatic Pct of N form the sites of the increased transparency limited to bone walls (fig. 3). At a disease of Pct of N the picture in a nosopodborodochny projection which is well reflecting a form, size and the sizes of frontal sinuses is initial. Bosoms of a sievebone occupy an interval between a medial contour of eye-sockets and a nasal cavity, in an upper part lobbies, and in lower — back bosoms are projected. Wedge-shaped bosoms in this projection are not visible. The Highmore's bosoms varying in a form and size clearly are visible in a picture, except for area of an alveolar bay, edges is better traced in a picture with an inclination of the cartridge on 10 — 12 °.

Pathology

Malformations. Carry their excessive pnevmatization or total absence of some of them to malformations of Pct of N that meets much less often. Besides, degistsention — inborn defect of a bone can meet.

Existence of the full bone partition dividing a bosom into two cavities — front and back belongs to seldom found malformations of a Highmore's bosom, is more rare — lower and upper. Sometimes there are degistsention in the field of an upper wall, and also in podglaznich number the channel. It is possible to refer their absence, various deviations of the course of the frontonasal channel, existence of degistsention of bone walls to malformations of frontal sinuses, a thicket orbital. Degistsention in various departments of bosoms of a sievebone cause the message them with an eye-socket, frontal and wedge-shaped bosoms, with front and average cranial poles. Degistsention can meet also on sidewalls of a wedge-shaped bosom. At the same time her mucous membrane can adjoin to a firm cover of a brain in an average cranial pole, to area of a cavernous sine, an optic nerve, an internal carotid artery and upper orbital crack. Clinically anomalies are not shown. However at an inflammation of Pct of N development of intra orbital and intracranial complications is possible that demands the corresponding treatment.

Damages walls of Pct of N arise at wounds or the closed injuries of a skull and person.

Distinguish the isolated, multiple isolated, combined and combined damages of Pct of N. At the isolated injuries one bosom is injured, at multiple isolated — several bosoms, but without penetration into the next bodies. The combined damages include the changes of walls of bosoms which are combined with injury of a skull, eye-socket. The combined injury is an injury of bosoms as a result of influence of different types of weapon.

The symptomatology of injuries of bosoms depends on the volume, prevalence and the nature of damage. Disturbance of the general state can be shown by development shock (see), long loss of consciousness. Almost constant symptom is the headache.

First of all it is necessary to estimate the general and neurologic condition of the patient, then register local changes. At a palpation of area of the person sometimes is defined patol. mobility and smeshchayemost of bone fragments, existence of interstitial emphysemas (see); at a rinoskopiya and faringoskopiya (see) note possible damages, reveal bleeding (see), liquorrhea (see). At open changes by means of sounding specify the nature of a fracture, reveal damage of a meninx and a brain. In the subsequent investigate sense of smell (see), sharpness sight (see).

Rentgenol. signs of damages of Pct of N divide on direct and indirect. Refer existence in a shadow of a bone of the line to straight lines change (see), disturbance of a continuity and shift of linear shadows of walls of bosoms; they are most expressed at show chaty and depressed fractures. At damage of frontal sinuses transition of the line of a change of frontal scales to a wall of a bosom is usually noted. The change of a front wall of a bosom as pressed or splintered is best of all distinguished in pictures in a side projection. On changes of walls of Highmore's bosoms, most often anterolateral, specifies disturbance of a continuity and shift of linear shadows of their walls on roentgenograms and tomograms.

It is often impossible to reveal in pictures of a crack of walls of a Highmore's bosom because of difficult mutually imposing of bone elements of this area. A direct sign of injury of bosoms of a sievebone — interruption of a contour of a medial wall of an eye-socket. An indirect sign of damage of Pct of N — the blackout of a bosom caused by hemorrhage in her cavity. In process of a rassasyvaniye of blood the pnevmatization of a bosom is gradually recovered. If after an injury traumatic sinusitis develops, then in Pct of N quite often further owing to hyperplastic process there are massive pristenochny imposings.

At treatment of injuries of Pct of N with damage of soft tissues it is reasonable to carry out an operative measure to early terms for the purpose of removal of impractical fabrics, repositions of bone fragments and operational closing of defect against the background of antibacterial therapy. Active early surgical tactics is in most cases shown at the combined damages. The purpose of operation is audit of a bosom and damages of the next bodies, if necessary — sewing up of defects and formation of soustiya of bosoms with a nasal cavity for sufficient drainage of the injured bosoms for the purpose of the prevention of spread of an infection to bordering limits (a head cavity, an eye-socket).

Purulent inflammations of bosoms, osteomyelitis of bone walls of bosoms occur among complications of damages of Pct of N (see. Osteomyelitis ), meningitis (see), abscess of a brain.

Diseases. Inflammatory diseases of Pct of N (sinusitis) subdivide generally on acute and chronic, exudative and productive (see. Antritis , Sphenoiditis , Frontal sinusitis , Etmoidit ). In some cases the pansinusitis develops, at Krom inflammatory process strikes all Pct of N. Flowing purulent separated from one bosom in another, e.g. from frontal in a Highmore's bosom with development of a piosinus is in rare instances possible.

Fig. 4. The roentgenogram of a skull and adnexal bosoms of a nose at a right-hand frontal sinusitis, an etmoidita and antritis (a nosopodborodochny projection): blackout of a frontal sinus (1), cells of a sievebone (2) and Highmore's bosom (3) on the right.

The general rentgenol. a symptom of sinusitis is blackout of Pct of N owing to decrease in their lightness. At assessment of a pnevmatization of bosoms it is necessary to consider extent of their anatomic development since Pct of N, underdeveloped, small on volume, have the lowered transparency on roentgenograms that can be mistakenly regarded as patol. blackout. If all bosom is filled with an edematous mucous membrane, serous or purulent exudate, granulations or polyps, continuous, homogeneous blackout of a bosom (fig. 4) is found. To establish character of this blackout, without resorting to a puncture of Pct of N or its contrast research, in such cases it is impossible.

Fig. 5. The roentgenogram of a skull and adnexal bosoms of a nose at a cyst of a Highmore's bosom (a nosopodborodochny projection): in a lower part of the left Highmore's bosom the shadow of a cyst with the semicircular upper bound is visible (it is specified by an arrow).

Cystic stretching of Pct of N arises rather seldom, usually at long closing of an output opening of a bosom and accumulation of contents in it: serous (gidrops bosoms), mucous (see. Mucocele ), purulent (pyocele or empyema of a bosom). Also the cyst, a polyp or a tumor of Pct of N can be the cause of such stretching. Cysts of Pct of N, as a rule, meet in Highmore's bosoms and give the semicircular well outlined homogeneous shadow (fig. 5) in pictures. Increasing in sizes, the cyst can occupy all bosom, edges in these cases becomes intensively and evenly darkened. The persistent headaches which are localized in a forehead, a temple, a darkness are characteristic of a cyst of Highmore's bosoms. At a puncture of a Highmore's bosom receive a transparent serous viscous liquid of amber color. Treatment operational.

Sometimes the pneumosinus — stretching of a bosom (usually frontal) air, arising when, e.g., a polyp meets, the giperplazirovanny mucous membrane and other educations in the field of soustiya play a role of the valve passing air in a bosom. In some cases the pneumosinus can be caused atypically proceeding pnevmatizatsiy frontal sinus at children. Clinically the pneumosinus is shown by local morbidity in the field of a frontal sinus. Unlike a pneumosinus at the pnevmatotsel air gets into soft tissues (usually in a forehead) or into a head cavity from a frontal sinus through the defects in its front or back walls which resulted from an injury or inflammatory process. Treatment operational.

Tumors

Distinguish benign and malignant tumors of Pct of N.

Benign tumors can have an epithelial, mezenkhimny and neuroectodermal origin.

Transitional cell papilloma meets seldom and develops usually at men at advanced age against the background of is long the existing recurrent allergic polyps of a nose (see. Papilloma , papillomatosis). Macroscopically has an appearance of melkobugristy growths of bright red color. Can burgeon in an eye-socket and a head cavity, destroying a bone. After an oncotomy a recurrence is celebrated. At a malignancy of a tumor planocellular cancer develops more often.

Adenoma — a rare tumor, is localized in a Highmore's bosom and bosoms of a sievebone. Has an appearance of the node on the wide basis of a dense or myagkoelastichesky consistence covered with not changed mucous membrane. Can destroy a bone and extend in a nasal cavity; recurs during not radical removal (see. Adenoma ).

Chondroma (see) meets seldom, preferential at youthful age. It is localized originally in walls of Highmore's and frontal bosoms. The dense tumoral node has the wide basis, is covered with the connective tissue capsule and a mucous membrane. The tumor can reach the big sizes, destroy bones and burgeon in a head cavity.

Osteoma (see) meets more often other benign tumors of Pct of N, it is usually localized in a frontal sinus, is more rare — in bosoms of a sievebone. Are considered casuistic an osteoma of Highmore's and especially wedge-shaped bosoms. Wedge, symptoms are defined by localization of a tumor. The osteoma growing on a back wall of a frontal sinus can cause increase in intracranial pressure and a headache; at localization of an osteoma on the lower wall of a frontal sinus or bosoms of a sievebone protrusion of an eyeglobe can appear. Less often the tumor burgeons in a nasal cavity, causing difficulty of nasal breath. The osteoma on roentgenograms gives accurately outlined shadow of high intensity, adjacent to one of walls of a bosom (see fig. 2 K of St. Osteoma ).

The angioma, fibroma, a gemangioperitsitoma, a myxoma, a neurofibroma, an enclavoma are observed extremely seldom (see. Angioma ; Gemangioperitsitoma ; Myxoma ; Neurofibroma ; Enclavomas ; Fibroma ).

Treatment of benign tumors operational. Depending on localization and the sizes of a new growth make operation on Moore or Denkera (see. Moura operation , Denkera operation ), Caldwell's operation — Luke (see. Antritis ) or Killian's operation (see. Frontal sinusitis ).

Malignant tumors of Pct of N most often develop in a Highmore's bosom, bosoms of a sievebone. Approximately apprx. 80% of malignant tumors of Pct of N have a structure of planocellular cancer (see), meet Less often fibrosarcoma (see), rhabdomyosarcoma (see), chondrosarcoma (see), osteogene sarcoma (see), malignant lymphoma (see. Lymphoma ), etc.

Klien. the picture depends on a look, localization and prevalence of a new growth. In early stages malignant tumors often proceed asymptomatically or are followed by signs of inertly current inflammatory process what late negotiability of patients is connected with. Emergence of explicit symptoms which depend on initial localization and the direction of growth of a tumor, demonstrates widespread defeat. Unilateral difficulty of nasal breath develops after protrusion of an internal wall of a Highmore's bosom, its germination and performance by the tumoral mass of the nasal courses. At the same time there is mucopurulent, sometimes a sanious discharge from a nose. The prematurity of difficulty of nasal breath is characteristic at malignant tumors of bosoms of a sievebone. The tumor which is localized on an anterolateral wall of a Highmore's bosom causes a swelling of a cheek. At the tumor located in an upper part of an anterolateral wall, the swelling is defined below an outside corner of an eye, the eyeglobe is displaced up. Spread of a tumor to area of a hard palate, pathological mobility of teeth demonstrate localization of process on the lower wall of a bosom. At defeat of a medial and upper part of a Highmore's bosom a swelling of fabrics at an internal corner of an eye, a lower eyelid, dacryagogue and shift of an eyeglobe are defined. The same symptoms are observed also during the involvement in tumoral process of bosoms of a sievebone and an eye-socket. A swelling in the field of a temporal pole, the lockjaw and protrusion of an eyeglobe are observed forward at defeat of a posterolateral wall of a Highmore's bosom.

The headache of various character can be the first, but not precursory symptom of a disease. Quite often in such cases diagnose neuralgia. At damage of bosoms of a sievebone the headache usually develops earlier. Neuralgia arises at spread of a tumor to a pterygopalatine pole and at sarcomas of a posterolateral wall of a Highmore's bosom. The dull aching aches in a bosom with irradiation in teeth, temporal area, an ear, an eye are more often observed in late stages of development of a tumor. Repeated nasal bleedings (see), exophthalmos (see), dacryagogue, germination of a tumor in soft tissues of the face, an oral cavity, increase cervical limf. nodes — signs of widespread tumoral process.

Prevalence of cancer of Highmore's bosom can be estimated on the following stages.

Stage of I. The tumor limited to one wall of a bosom without transition to related anatomic departments and without destruction of bone walls; metastasises are not defined.

Stage of II: a) the tumor which is affecting one or two walls of a bosom, causing focal destruction of bone walls, but not going beyond a cavity; regional metastasises are not defined;

b) a tumor of the same or smaller local distribution, but with a single, movable metastasis on the party of defeat.

Stage of III: a) the tumor extending to adjacent anatomic areas — an eye-socket, a nasal cavity, bosoms of a sievebone, a hard palate, an alveolar shoot, etc., with destruction of bone walls; the regional and remote metastasises are not defined;

b) a tumor of the same or smaller local distribution, but with multiple metastasises on the party of a tumor or bilateral metastasises.

Stage of IV: a) the tumor sprouting face skin, either the second Highmore's bosom, or a nasopharynx, or a pterygopalatine pole and a base of skull with extensive bone destruction; there are no regional and remote metastasises;

b) a tumor of any stage with the motionless regional or remote metastasises.

Regional innidiation of cancer of adnexal bosoms in comparison with similar new growths of other departments of upper respiratory tracts is observed much less often. Are regional retropharyngeal and deep cervical limf. nodes.

Diagnosis of malignant tumors of Pct of N in an initial stage of development of a disease presents great difficulties. The complex diagnostic method allows to estimate character and degree of prevalence of tumoral process. It includes detailed studying of the anamnesis, a palpation, a rinoskopiya (front and back), a faringoskopiya by means of a fiber optics, a survey and aim X-ray analysis with use of contrast agents, a tomography, tsitol. research of punctate, biopsy.

The malignant tumors of the small sizes which are localized pristenochno in a Highmore's bosom can be diagnosed by means of an antroskopiya. Through the closing nasal stroke make opening of a bosom by means of a direct chisel. Rinoantroskop enter through an educated opening, estimate a condition of a Highmore's bosom, make a biopsy.

Fig. 6. The roentgenogram of a skull and adnexal bosoms of a nose at cancer of the left Highmore's bosom (a nosopodborodochny projection): the bosom is darkened, its nizhnenaruzhny bone wall (it is specified by an arrow) is destroyed.

Malignant tumors of Pct of N at early stages of development cause osteoporosis of bone walls of a bosom, and is later than them destruction, edges extends in process of growth of a tumor to the next bone structures (fig. 6). Tumoral masses in large Pct of N, for example Highmore's, can cause emergence against the background of air of an additional shadow, however it is almost impossible distinguish it radiological from a shadow of a mucous membrane, giperplazirovanny as a result of an inflammation.

Malignant tumors of Pct of N need to be differentiated with serous and hyperplastic and polypostural sinusitis, chronic purulent sinusitis, is more rare from secondary cholesteatoma (see), fibrous osteodysplasia of jaws (see).

The standard method of treatment of malignant tumors of Pct of N is combined. It includes knife or electrosurgical methods of operation and before - or postoperative radiation therapy.

The tumor of bosoms of a sievebone at limited defeat can be removed by excision of all trellised cells together with a mucous membrane of upper parts of a nasal cavity. For the purpose of reduction of number of a recurrence, is more often along with removal of all trellised cells, make ekzenteration of an eye-socket (see).

At cancer or sarcoma of Pct of N the electrosurgical resection of an upper jaw with removal of all walls p nasal sinks is shown. The tumor is deleted within healthy fabrics (see. Electrosurgery ). The wound surface is subjected to superficial coagulation. Gauze tampons and napkins hold in a wound by means of prostheses obturators. At metastasises in regional limf. nodes make one - or bilateral fascial futlyarnoye excision of cervical cellulose. If metastasises are soldered to an internal jugular vein or grudino - a clavicular and mastoidal muscle, carry out operation on Krayl (see. Krayla operation ).

The technique of difficult maxillofacial prosthetics is developed. During operation establish the protective plate differentiating an operational wound and an oral cavity; in 2 — 3 weeks put the creating prosthesis, in 2 — 3 months — a final prosthesis. Step-by-step prosthetics allows to eliminate cosmetic defect. Prostheses obturators from plastic were widely used (see. Obturators ), ekzoproteza. closing of defects of skin with free rags or on a leg.

The main method of radiation therapy at malignant tumors of Pct of N — gamma therapy (see). Depending on gistol. structures, localizations, the direction and growth of a tumor, a stage of process and the general condition of the patient conduct radiation therapy independently, in a combination with an operative measure or chemotherapy; radical or palliative courses of treatment are planned. Before radiation therapy sanify an oral cavity. Use the protective fixing bite blocks from plastic to protection against secondary radiation the ACRE-ITEM.

A preoperative course of a gamma therapy is conducted on 5 weekly during 4,5 — 5 weeks; the total focal dose makes 4500 — 5000 is glad (45 — 50 Gr). Postoperative radiation therapy is carried out if there are doubts in radicalism of an operative measure. Use outside gamma irradiation or the intracavitary method consisting in introduction to a postoperative cavity of a plastic model with radioactive drugs 60 Co.

At widespread process, failure of patients from operation, existence of the general contraindications radiation therapy is method of the choice. Radical radiation therapy is carried out during 5,5 — 6,5 weeks on 5 radiations a week, in a single dose 200 I am glad (2 Gr). A total dose 5500 — 6500 I am glad (55 — 65 Gr). Well transfer sick so-called the split course of radiation therapy consisting of two stages with a break between them in 2 — 3 weeks after receiving an exposure dose in 3000 — 3500 is glad (30 — 35 Gr). The single dose at the same time makes 200 is glad (2 Gr), a total dose of 6500 — 7000 races) (65 — 70 Gr).

During the performing radiation therapy with the palliative purpose the total dose makes 75% of a total focal dose of a radical course.

After radiation can develop beam damages (see) in the form of beam caries, osteomyelitis, a xerostomia. At inclusion in the field of radiation of eyes the keratohelcosis and conjunctivas are possible (see. Keratitis , Conjunctivitis ), hemorrhages in vitreous (see), atrophy of an eyeglobe, xerophthalmia (see), glaucoma (see), cataract (see).

The forecast at malignant tumors of Pct of N adverse. During the use of an operational method of treatment five-year survival according to various researchers, fluctuates on average from 18 to 35%, and during the performing radiation therapy as independent method of treatment — from 12,7% to 33%. Results after the combined treatment remain also unsatisfactory — a recurrence is observed in 30 — 60% in the nearest future, five-year survival reaches 53% of cases. Emergence of a recurrent tumor considerably worsens the forecast and is the indication for the combined treatment.

Operations

subdivide Operations on Pct of N depending on surgical approach to this or that bosom into intranasal (endonasal) and extra nasal (ekstranazalny).

Intranasal a Highmore's bosom operations are made through the lower and average nasal courses, and also by removal of a crest (edge) of piriform opening and by means of the temporary shift of a sidewall of a nose — Halle operation (see. Antritis , surgical treatment). Extra nasal operations on this bosom are made according to Caldwell — to Luke (see. Antritis ) and to Denker (see. Denkera operation ). Various modifications of these operations were not widely adopted. When there are persistent fistulas of a Highmore's bosom, e.g. after an odontectomy, make plastics of fistula, single-step with the main bosom operation.

Intranasal opening of a frontal sinus is applied rather seldom, at the same time Gallet and Reti's methods are usually used (see. Frontal sinusitis ). A number of methods of outside opening of a frontal sinus is offered. Most widely apply the frontal and trellised trepanation developed by A. F. Ivanov (see. Frontal sinusitis ). Operations with a temporary resection (according to Golovin) and a constant resection (on Kunta) do not apply a front wall of a frontal sinus now. Also Ridel's method is also almost left, at Krom completely is removed front and lower walls of a frontal sinus. Only at gunshot wounds or extensive injuries of frontal area Ridel's operation can be method of the choice.

In need of opening of bosoms of a sievebone and a wedge-shaped bosom use the same accesses, as at Caldwell's operations — Luke, Killian, Kunt. The operation giving access to all bosoms is Moore's operation (see. Moura operation ).

Bibliography:

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V. T. Palchun; Yu. I. Vorobyov (I am glad.), N. I. Elkin (An.), V. V. Kitayev (rents.), O. M. Maximova, A. I. Paches (PMC.).

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