ДОКТОРУ
Научные статьи
V.S. KOZLOV RHIINOLOGICAL CENTER YARTEC, YAROSLAVL, RUSSIA.
introduction. The present-day treatment of chronic sinusitis tends to apply surgical methods (Draf W.,Weber R., 1992; Kennedy D. W.,1992; St.ammberger H, Posawetz W., 1990.). However there is a large group of patients with chronic sinusitis who sometimes do not want to and sometimes can not be subjected to surgical treatment, or they have already been treated surgically but still retain the sinusitis symptoms. All those patients should receive conservative treatment.
In 1926 an american rhinologist A.W. Proetz offered a displacement irrigation method for sinusitis treatment which was based upon the creation of different pressure in nasal cavities and paranasal sinuses (PNS). This method has widely been practiced since then in out-patient clinics but it obviously has several short-comings e.g. one cannot fill up all the PNS with a solution or it is very difficult to do so if there is thick secretion inside the sinuses or if the ostia of the sinuses are blocked.
Method. In 1980 Professor G. I. Markov suggested that a device with controlled pressure in nasal and PNS cavities should be created. By the present moment several, types of the device have been developed under the name of sinus-catheter YAMIK (Yaroslavl, Markov, Kozlov). The working principle of the device was presented in detail earlier (Kozlov V., Markov G., 1991) so herein it is done but briefly.
Figure 1 shows the diagram of sinus-catheter YAMIK-3 model. It consists of body 1 with passage 4 inside to inflate vessel 2 at the side of the body. There is also a flexible rod 8 in the body, able to modify the body to fit nasal cavity anatomy. Movable with regard to the body there is an inflatable cuff 3 with tube 5 rigidly attached to the cuff and having working passage 6. The passages designed for inflating vessel 2 and cuff 3 is provided with valves 7.
Operation principle. After application anesthesia of nasal mucosa the sinus-catheter is inserted into nasal cavity. Vessel 2 is inflated in rhinopharynx and choane while cuff 3 is inflated in the vestibule of nose. The nasal cavity is sealed off from both sides, thus making a closed space inside. A syringe is connected to the working passage making it possible to create both negative and positive pressure in nasal cavities and PNS. When negative pressure is created pathological secretion can be evacuated out of PNS through the natural ostia. The procedure finished, the patient is positioned in such a way that the ostia of the sinuses are located higher than their bottom. Then a syringe containing a medicine is attached to the working passage 6, and from 1 to 1.5 cc of the solution is introduced into nasal cavity. Moving the syrimge piston we change the pressure in nasal cavity from (+) to (-], this resulting in the replacement of the air in the sinuses by the medicinal substance. Thus there appears a new opportunity to influence the entire PNS mucosa and a possibility to know exactly the amount of the secretion evacuated out of the sinuses and the amount of the medicine introduced. These data make it possible to control the course of treatment with a high degree of accuracy. The fact that the procedure is well endured by both adults and children is also of no small importance.
Results and Discussion. The YAMIK method was used in treating chronic sinusitis in the following cases. l. The patients refused to be operated and there were contra-indicatioris to the operation. 2. While preparing the patients for F.E.S.S. 3.The sinusitis recurrence after the patients having been operated according to the Cadwell-Luce method. 4. The sinusitis recurrence after the F.E.S-.S.
As a method chosen in treating chronic exudative sinusitis the YAMIK method was used in 180 cases at the acute stage. Average age was 32 years. The number of procedures depended on the expression of the disease and ranged from 2 to 6. Soluions of antibiotic combined with hydrocortison were introduced into PNS. Healing of the inflammation process was reported in 135 cases, improvement in 28 cases, no effect in 17 cases.
As a pre-operation stage for F.E.S.S. YAMIK method was used in 50 cases. Average age of patients was 27 years. The treatment course comprised from 2 to 3 procedures within a week. The aim was to reduce the inflammatory reaction of the mucosa, to reduce polyps in size. The results of treatment in this group of patients showed that the reduction of mucosa swelling in the area of middle nasal passage improved visualization of the operation field and, what is of most importance, minimized bleeding. Hence, the risk of intraoperational complications also lessened.
Aggravation of sinusitis after the Cadwell-Luce operation was reported in 24 cases, average age was 41 years. The number of YAMIK prosedures in this group of patients was from 2 to 6. The sinusitis symthoms ceased in 16 cases, there was no effect in 8 cases with pronounced deformations of s.nasi and (structures of osteomeatal complex.
The best results were received in the cases when the ;patients had sinusitis recurrence after F.E.S.S., total number 30, average age was 32 years. Opened PNS ostia create optimum prerequisites for the YAMIK method application. Principal is the question which medicine should be used and in which concentration it should be introduced into PNS. Cessation of sinusitis symptoms was reported in 28 cases of this group of patients, from 2 to 3 YAMIK procedures within 10 days being sufficient in 23 cases, from 5 to 6 procedures required in the rest 5 cases. There was no effect in 2 cases when the patients heeded a more radical operation.
Conclusion. The YAMIK method offers new opportunities for an otorhinolaryngologist in conservative treatment of chronic sinusitis. The fact that the method is atraumatic, lack of collateral effects, high effectiveness enable us to recommend it for wide clinical application.
Reference.
1. Draf W.,Weber R. — Endonasal mikro-endoskopische Pansinusoperation bei chronischer Sinusitis. Otorhinolaryngol Nova 1992; 2:1-4
2. Kennedy D. W. — The role and techniques of nasal endoscopy. Rhinology. Supplement 14 1992. P.191-193
3. Proetz A. W. — Displacement Irrigation of Nasal Sinuses. Arch, of Otolaryngology, Vol.4, P. 1-12., July, 1926
4. Stammberger H. and Posawetz W. — Functional endoscopic sinus surgery. Eur. Arch. Otorhin. 1990. 247:63-76
5. Kozlov V., Markov G. — New Method and Devices for Diagnosis and Treatment of Paranasal Sinusitis. The Journal of Japan Rhinologic Society. Vol.30 Nl 1991. P.336
Chemosurgery with Trichloroacetic Acid in Allergic Rhinitis
Yao Kazuo, Shitara Tetsuya. Nishiyama Kouichiro, Iguchi Yoshiaki and Yamamoto Kazuhiro
Department of Otolaryngology.School of Medicine, Kitasato University
Introduction
From 1986,we have treated allergic rhinitis with chemo-surgery using 80w/v % trichloroacetic acid (TCA) applied to the bilateral inferior turbinate. Some of the clinical results of this method have already been reported [1]. In this sturdy, we will report on the clinical results of over 3 years taken from patients recieving this treatment up to 1992 and examine both the pharmacological and histopathological effectiveness of TCA.
Subjects and methods
We examined cases of perennial rhinitis (house dust / mite allergy) who had been studied for over 3 years from April 1986 to December 1992 and compared the differences between before and after the treatment. Diagnosis was mainly made from the first examination of the nasal cavity and also from skin tests, RAST, nasal provocation tests and smear tests of the nasal discharge for eosino-phils results. TCA was applied by first using topical anesthesia (4& lidocaine and 5000 diluted adrenalin) and then applying TCA usually to both the inferior turbinate at the same time. Fig.l shows the region that the drug was applied to.