etiology
1. Acute frontal sinusitis is not treated in time or improperly, which seriously damages mucosa, loses normal function and becomes chronic inflammation.
2. Allergic frontal sinusitis, nasofrontal duct mucosal edema, decreased ciliary transport function, hindering drainage during acute inflammation and becoming chronic inflammation.
3. The nasal septum is bent at a high position, and the drainage of middle turbinate hypertrophy, nasal polyps and nasal orifice complex is blocked.
4. Air pressure injuries, such as falling in the air, swimming and diving, can cause chronic frontal sinus infection.
5. Systemic factors, such as decreased immune function, diabetes, malnutrition and vitamin deficiency.
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pathological change
Pathological changes are similar to chronic maxillary sinusitis, such as mucosal thickening, cilia disappearance, sinus cavity empyema, allergic inflammation with mucosal edema and polyposis. In contrast, chronic frontal sinusitis is prone to osteitis and osteomyelitis due to poor drainage, which can produce fistulas at the front wall and bottom and continuously discharge pus. Fistula holes are mostly in the upper wall of orbit, and scar formation can be seen in the upper eyelid.
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clinical picture
The forehead is stuffy and the affected side is more obvious. If frontal sinus drainage is blocked, headache, reflex headache in trigeminal nerve distribution area, obvious nasal congestion, often heavier in the morning, or persistent nasal congestion may occur. Nasal secretions are sticky or purulent, mostly in the morning, often related to head drainage. Loss of smell. If there is osteomyelitis of the frontal bone, it can form a frontal pus fistula, which is mostly located at the front wall and bottom of the frontal sinus, and the bone wall contains bone marrow. Headache symptoms of frontal sinusitis begin with full-scale headache, and then gradually limit to the affected orbit and the upper corner of forehead. The pain has an obvious time pattern, starting every morning, getting worse gradually, getting the heaviest at noon, and gradually reducing in the afternoon, until the headache disappears at night and recurs the next day. Touching and pressing the upper corner of the orbit has obvious tenderness.
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cheque
(1) Anterior nasal endoscopy
Mucosal congestion can be seen, and purulent secretions are found in the anterior upper part of the middle nasal meatus. The pus of maxillary sinusitis is mostly located behind the middle nasal meatus, and there are purulent secretions in the middle nasal meatus and olfactory fissure of ethmoid sinusitis, which can be used for differentiation.
(2) Head position test
When no purulent secretion is found in the examination of anterior nasal endoscope, the mucosa of middle turbinate and middle nasal meatus can be contracted with 1% ephedrine, then the head is kept in the middle position for 5 minutes, and then the nasal cavity is examined to see if there is pus in the middle nasal meatus. When accompanied by maxillary sinusitis, the maxillary sinus can be punctured, washed and drained first, and then the head is drained to judge whether there is frontal sinusitis.
(3) X-ray film of frontal sinus
Take the frontal position of the nose, compare the transmittance of bilateral frontal sinuses, and judge the lesions. Bilateral frontal sinus asymmetry is normal and has nothing to do with the diagnosis of frontal sinusitis. A well-developed frontal sinus may have a bony diaphragm, which is also normal.
(4) CT scanning
Coronal and axial scanning can show the size and range of frontal sinus, the situation of anterior and posterior bone walls, and no thickening of sinus mucosa.
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treat cordially
(1) Non-surgical therapy
Including nasal mucosal vasoconstrictors and antibiotics, nasal drops, replacement, physical therapy and so on. , may only be effective for early mild symptoms.
(2) Intranasal surgery
Including correcting the height curvature of nasal septum, nasal polypectomy, partial middle turbinectomy and so on. This operation is suitable for patients with chronic suppurative frontal sinusitis who are ineffective in non-surgical treatment, but not for patients with a history of frontal sinus injury and complications. This kind of surgery is also called auxiliary surgery.
(3) Frontal sinus surgery
The patient lies on his back and is anesthetized on the inner surface of the nose or under general anesthesia. Make a V-shaped incision at the root of the nasal wall, peel off the mucosa, remove the uncinate process and open the anterior ethmoid sinus. In case of turbinate hypertrophy, the middle turbinate should be broken and displaced first, or the middle turbinate should be partially removed, and the posterior edge of maxillary process should be chiseled to enlarge the nasofrontal canal. Pay attention to the inner and posterior cribriform plates of nasofrontal canal during operation, reset the mucosal flap after operation, drain the frontal sinus with 6mm silicone tube, and rinse it after 6 days. This operation is relatively simple. Mucosal injury is less and safer, and it is not easy to cause nasofrontal canal stenosis, and there will be no scar on the forehead, so it is not necessary to do more complicated intranasal frontal sinus surgery. If the effect is not good, frontal sinus surgery is feasible.
(4) Extranasal surgery (radical frontal sinus surgery)
65438 0. Lynch operation
(1) indication
(1) The patients whose nasal operation and frontal sinus operation are ineffective;
② Patients with chronic frontal sinusitis complicated with osteomyelitis or fistula;
③ Chronic frontal sinusitis with orbital or intracranial complications;
④ Fungal frontal sinusitis;
⑤ Forehead sinus foreign body and frontal sinus fracture.
(2) During the operation, the patient lay on his back, his face was disinfected with alcohol, the nasal mucosa was anesthetized with surface, and the inner canthus and eyebrow arch were anesthetized with 1% procaine or lidocaine plus a few drops of 0. 1% adrenaline. The eyebrows were not shaved, and the affected eyes were covered with a surgical towel. The strength and eye conditions were observed at any time during the operation.
Cut along the eyebrow and turn the inner end slightly below the medial canthus plane of the frontal process of the maxilla. Don't hurt the orbital wall when peeling off the periosteum. Carefully peel off the lacrimal sac and the upper oblique pulley about 0.5cm deep in the upper corner of the orbit, move them to the inside and cover them with a small piece of gauze for protection. After proper treatment, the lacrimal bone and ethmoid cardboard were exposed inward and the anterior ethmoid artery was ligated. Chisel out the base of frontal sinus, enter the frontal sinus, peel off the diseased mucosa, and chisel out the frontal process, lacrimal bone and ethmoid board to complete the opening of ethmoid sinus. If necessary, the anterior wall of sphenoid sinus can be excavated to facilitate sphenoid sinus drainage and treat inflammation. Finally, a 0.6cm thick silicone drainage tube was inserted, and the skin and subcutaneous tissue were sutured in two layers with silk thread. Before suturing the incision, pay attention to restore the upper inclined pulley to its original position to avoid diplopia after operation (Figure 1).
2. The anterior frontal sinus bone flap packing operation was first reported by Schonborn( 1894) and Breger (1895). They turned up the frontal sinus bone flap and blocked the sinus cavity with transplanted fat, which is called frontal sinus osteoplasty. Beck, Winker and Hoffmann improved it in 1904, but it was not easy to find infection at that time, so it could not be popularized. In 198 1 year, Gibso, Kergera and Itoiz reported the successful experience of applying this method. In 1954, Macbeth reported the treatment of frontal sinusitis, cyst and osteoma with bone flap. In 1972, Bosley and Session reported more than 100 cases of frontal sinus bone flap formation and fat filling. Luo Zhaoping (1956), Wang Tianfeng (1964) and Gu Zhiping (1980) have reported satisfactory results in China, but there are few cases, which may be related to the low incidence of this disease.
(1) indication
(1) Patients with chronic frontal sinusitis who have recurrent attacks and cannot be cured after long-term treatment;
② Fistula holes have been formed in the anterior wall of patients with chronic frontal sinusitis;
③ Frontal sinus surgery or Lynch surgery failed;
④ Frontal sinus cyst, osteoma or anterior wall fracture trauma.
(2) Contraindications
① Multiple sinusitis, other sinus diseases should be treated first;
② If it is found that the lesion invades the posterior wall of frontal sinus and the lesion mucosa adheres to dura mater, it is not suitable for fat filling.
(3) preoperative preparation
① Take X-ray film of frontal sinus to confirm the range of frontal sinus cavity. Cut out the shape of bilateral frontal sinuses on the forehead film, aim at the upper edge of the orbit, and disinfect with disinfectant for later use.
② Trim eyebrows and prepare skin for abdomen.
③ Routine preoperative examination, including routine hematuria, cardiac and renal function and penicillin allergy test.
(4) Anesthesia and posture Because of the long operation time, general anesthesia and tracheal intubation are often used. In order to reduce intraoperative bleeding, the incision was infiltrated with 1% procaine or serum caine plus a few drops of 0. 1% adrenaline. The patient takes a supine position with his head slightly raised so that his forehead is in a horizontal position.
(5) Surgery
① Cover the forehead with the frontal X-ray film cut before operation, and draw the frontal sinus boundary with gentian violet solution on the skin. Arc incision was made from the upper canthus 1cm to the outer edge of frontal sinus. Bilateral frontal sinus surgery can extend the incision to the opposite side and make a transverse incision at the root of the nose. If the frontal sinus is large, bilateral operation can be performed, and hairline incision can be used to make the flap turn down, so as not to leave scars and fully expose the part, and be careful not to cut through the bone coat.
(2) Separate the flap, cut the skin, subcutaneous tissue and muscle layer, separate the flap, fully expose all the frontal sinus, and peel it off slightly.
③ Periosteal incision Put the sterilized lateral radiograph of frontal sinus on the corresponding part of the periosteum, mark the position and shape of frontal sinus, make a periosteum incision along the contour of frontal sinus, keep the periosteum on the upper orbital margin, and slightly separate the periosteum at the incision with a stripper of about 0.5cm.
④ Turn over the bone flap at the periosteal incision, drill a row of small holes with a small round drill, and the spacing between holes is about 0.5cm. For each hole, probe the scope of sinus cavity, and then continue to drill holes on both sides until the upper edge of orbit. Be careful not to drill beyond the frontal sinus to avoid drilling into the skull by mistake. Break the fracture between holes with a flat chisel or a wire saw, and pay attention to the direction of the chisel inclining to the center of the sinus cavity, so that the edge of the bone flap is inclined, which is beneficial to the joint of the bone flap after reduction and can prevent the bone flap from sinking. The bone on the upper orbital margin is thick and needs a little force to chisel it off. Then put the periosteum stripper or chisel into the frontal sinus cavity, gently pry open the bone flap and turn it down. The bone wall at the bottom of the frontal sinus is very thin, and a neat linear fracture can appear when the bone flap is turned, completely exposing the frontal sinus cavity.
⑤ Remove sinus mucosa. Use a stripper and gauze to remove all mucosa in the sinus, including the mucosa on the bone flap. It is necessary to peel the mucosa at the nasofrontal canal into a cylinder, turn it down and push it to the nasal cavity to make it adhere and close. Using a polishing drill to lightly grind the cortical surface of sinus to remove residual mucosa and make it rough can increase the blood supply of transplanted fat. Observe whether there is mucosal residue with surgical microscope. If there is still mucosa, it should be completely removed under the microscope to avoid frontal sinus mucocele after operation.
⑥ Filling fat Subcutaneous fat was taken from the left lower abdomen, mixed with 400,000 U penicillin powder (negative skin test before operation) and filled in the sinus cavity.
⑦ Replace the bone flap.
8 Periosteum, subcutaneous tissue and skin were sutured layer by layer with catgut and silk thread, without drainage, and the forehead was bandaged with pressure.
(6) After the operation, broad-spectrum antibiotics 10 ~ 14 days were applied to the whole body, and the stitches were removed for 5 ~ 7 days to relieve the compression bandage.
3. Endoscopic sinus surgery is a new technique developed in recent 20 years. Its principle is to maintain adequate ventilation and drainage at the ostium of sinus, and the inflammation of mucosa in sinus can gradually subside. When treating chronic frontal sinusitis, ethmoid sinus lesions in the anterior and middle groups must be removed.
(1) The preoperative preparation of patients and surgical instruments is the same as endoscopic sinus surgery (Fess).
(2) Body position and anesthesia
① The position is supine.
② First use 2% dicaine 15ml, then add 2ml of 0. 1% adrenaline, and perform surface anesthesia on the middle nasal meatus, olfactory cleft and the whole nasal cavity twice, which can effectively prevent intraoperative bleeding. Then submucosal infiltration anesthesia was performed with 1% lidocaine and a small amount of adrenaline at the middle turbinate and nasal mound.
(3) Surgery
① Incision A longitudinal incision or an L-shaped incision is made at the root of the front end of the middle turbinate along the lateral wall of the nasal cavity to separate the mucosa and expose the ethmoid bone.
② Clean the anterior ethmoidal chamber, gently press the ethmoidal vesicle with nasal septum stripper, open the ethmoidal vesicle with ethmoidal sinus forceps under the guidance of 0 degree endoscope, and clean the anterior ethmoidal chamber with 70 degree endoscope and 70 degree ethmoidal sinus forceps to find the frontal sinus opening upward. If the ostium of frontal sinus is covered by polyp or swollen tissue, it can be found with a probe.
③ After opening the frontal sinus to find a new ostium, open the sinus floor with a curette. The floor of the frontal sinus is located at the top of the ethmoidal chamber of the anterior superior group, which is the thinnest part of the frontal sinus wall and easy to open. But be careful not to drive too far backwards, so as not to damage the anterior skull base. During the operation, it is necessary to aspirate the secretions in the sinus and insert a 70-degree endoscope for observation. The frontal sinus cavity is not filled after operation, which is convenient for drainage.
4. Cranioplasty of frontal sinus is a new technique initiated and applied by Donald in 1982, which is suitable for posterior wall fracture of cranial sinus, and has the advantages of preventing intracranial infection and keeping forehead depressed.
(1) Body position and anesthesia method are the same as above.
(2) Make a coronal incision on the forehead and turn the flap downward.
(3) The bone plate on the anterior wall of frontal sinus was completely drilled out, then washed and soaked in povidone iodine solution for preservation.
(4) Resect the posterior wall of frontal sinus with bone forceps, strip the mucosa of the anterior and posterior walls, and grind the residual mucosa with electric drill.
(5) After the mucosa of the nasofrontal tube is completely peeled off, it is transferred to the nasal cavity, and then the tube is stuffed with muscles to completely isolate the nasofrontal tube from the nasal cavity.
(6) Take the anterior wall of frontal sinus out of the soaking solution, rinse it with salt water, fix it at the defect of anterior wall with stainless steel wire, and finally suture the skin of frontal sinus coronal incision. After operation, the dura mater of frontal sinus bulged forward and contacted with the anterior wall of frontal sinus, making the anterior wall of frontal sinus become skull.
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Preventive nursing
[ 1]? 1, pay attention to nasal hygiene at ordinary times, and develop good hygiene habits of washing nose in the morning and evening.
2. Pay attention to the method of blowing your nose. If you have a stuffy nose or excessive runny nose, you should press one nostril and blow slightly outward. And then alternately. When the runny nose is too thick, wash your nose with salt water to avoid damaging the nasal mucosa.
3, swimming posture should be correct, try to make your head out of the water.
People with dental diseases should be treated thoroughly.
5, when acute attack, rest more. The bedroom should be bright and keep the indoor air circulating. But avoid direct blowing and direct sunlight.
6, according to the doctor's advice to take medicine in time.
7, chronic sinusitis, treatment should have confidence and perseverance, pay attention to strengthen exercise to enhance physical fitness.
Smoking, drinking and eating spicy food are strictly prohibited.
9. Keep a cheerful personality, avoid mental stimulation, and be careful not to overwork.
10, you can often do nose massage at ordinary times.
1 1. Washing your face with cold water every morning can effectively enhance the disease resistance of nasal mucosa;