Doctor of the VITAMED MEDICAL clinic Khudayberganov Said Igamberdievich

An otorhinolaryngologist of the highest category at the VITAMED MEDICAL clinic, Said Igamberdievich Khudaiberganov, will introduce you to an article on the topic “Pathological additional anastomosis, as a finding during endoscopic outpatient examinations of the nasal cavity, and its role in the pathogenesis of sinusitis.”

Many people are painfully familiar with such a disease as sinusitis, or, more precisely, an acute or chronic disease of the maxillary sinus.

There is a strong opinion that the chronic form of this disease is practically not treated until complete recovery and has relapses. Like any other disease, it has a root cause, a consequence and a burdened end result. Often, an insignificant and insignificant change is the cause of chronicity of this disease.

Nowadays, modern endoscopic equipment allows us to take a new look at the structural features of the anatomy and physiology of the human body. I would like to draw your attention to the essence of this disease, and, in my opinion, one of the common causes of relapses of sinusitis.

The maxillary sinuses were named after Nathaniel Highmore, an English surgeon and anatomist who first described maxillary sinus disease as an inflammation of the mucous membrane. This disease was later called sinusitis.

The location of the maxillary sinus is characterized by its distribution throughout almost the entire body of the upper jaw. The volume and shape of the sinus is individual for each person and depends on the anatomy of the skull. Over the course of life, the sinuses grow and change their shape. If in newborns they are small pits, then in older people they can reach maximum sizes.

The sinuses are connected to the nasal cavity by a narrow canal. Under normal conditions, the maxillary sinuses are filled with air. The sinuses are covered with a mucous membrane that allows the removal of harmful microbes, bacteria and other microorganisms.

The sinus consists of upper, lower, inner, anterior and posterior walls. The deviation of each of them from their normal state causes various pathological conditions. For example, inflammation of the outer wall has a negative effect on the organs of vision, since it borders the eye sockets. The inflamed area can put pressure on the eyes, compress the lacrimal gland canals, and lead to swelling of the eyelids and other tissues. All this causes various kinds of pain and can lead to vision impairment.

The lower wall may have structural defects, in which inflammation of the gums due to any infection is transmitted to the mucous membrane of the maxillary sinus and leads to odontogenic sinusitis. The inner wall, or, as it is also called, the medial wall, contains a passage in the form of a canal from the sinus area to the nasal cavity. Blockage of this canal is the main cause of sinusitis.

Excessive thickness of the anterior wall complicates the puncture during the treatment of sinusitis, which significantly complicates the procedure itself. Performing a puncture becomes not only ineffective, but also unsafe. The dorsal side of the posterior wall is in contact with a large plexus in which the venous channels are located. Because of this, there is a high risk of blood infection due to sinus inflammation.

The maxillary sinuses perform the following functions:

1. Participation in odor recognition. The surface of the sinus has a special structure that can enhance the olfactory receptors of the nasal cavity.

2. The process of air filtration during nasal breathing. Before entering the lungs, the air undergoes a process of purification, heating to a comfortable temperature and stabilizing the humidity of the inhaled air.

3. Protective function. It manifests itself in the retention of viruses and bacteria harmful to the body in the mucous membrane, which are subsequently eliminated from the body.

In addition, the maxillary sinus is involved in the formation of timbre and sound of the voice. The voids located in the sinuses perform a resonant function. When a variety of medications are taken orally, the mucous membrane ensures their rapid entry into the body due to absorption into the blood vessels.

But the microflora of the body is extremely vulnerable due to the high risk of clogging the connecting channel. Long-term obstruction of the anastomosis contributes to the accumulation of mucus and its thickening, up to its transformation into pus. This, in turn, leads to various kinds of inflammation of the sinus walls, causing various diseases.

Congenital defects in the structure of the nasal cavity or maxillary sinuses can also provoke a disease such as sinusitis. Human anatomy is such that even with the strongest immunity, precisely due to the structural featuresHowever, a person’s susceptibility to sinusitis is extremely high.

I would like to draw your special attention to one of these defects, namely this additional one - pathological anastomosis of the medial wall of the maxillary sinus.

At a time when endoscopic surgery was not developed, it was very difficult to determine the location of an additional pathological anastomosis. Sometimes, it was discovered as a find during radical, extremely traumatic operations on the maxillary sinus.

Endoscopic examination of the nasal cavity can be performed with a rigid or flexible endoscope with a diameter of 4 mm and a viewing angle of 300 degrees. If the nasal passages are very narrow, the nasal cavity can be examined with rigid endoscopes with a diameter of 2.7 mm or 1.9 mm. This method requires a minimum of time and is easily tolerated by the patient. The study is carried out after anemization and a single lubrication of the nasal mucosa with a 5% lidocaine solution. The study includes three main points: sequential examination of the lower, middle and upper nasal passages. At the same time, attention is paid to the color of the mucous membrane, the size and condition of the nasal concha, the presence and nature of discharge, the state of the natural anastomoses of the paranasal sinuses, the pharyngeal tonsil and the mouths of the auditory tubes. If the diameter of the anastomosis of the maxillary sinuses is > 4 mm or if it is localized in the lower nasal meatus (after surgery), the distal end of a flexible endoscope can be inserted into the sinus and examined for the condition of the mucous membrane and the presence of contents. The method allows you to identify additional anastomosis of the maxillary sinuses (MS).

The accessory anastomosis is located behind the main anastomosis. Most often, the accessory anastomosis is located in the fontanella, first described in 1893 by the Austro-Hungarian anatomist and anthropologist, E. Zuckerkandl. Fontanellas are considered as developmental anomalies of the medial wall of the maxillary sinus. In these areas, at varying lengths, there is no bone base, and the medial wall of the sinus is represented by a thin layer of contiguous mucous membranes of the sinus and nasal cavity.

In acute and chronic sinusitis, mucopurulent discharge from the affected maxillary sinuses is transported by the ciliated epithelium directly through the natural anastomosis into the nasal cavity, then along the lateral wall of the nasal cavity it flows to the bottom of the nasal cavity; along the way, the discharge enters the additional anastomosis and ends up back in the cavity of the maxillary sinus. This is one of the most important pathogenetic disorders in sinusitis. This pathological mechanism was given the name secretion recirculation syndrome.

In this syndrome, the contents of the upper jaw formed during the inflammatory process recirculate between the natural and additional anastomosis, thereby provoking the development of a pathological process in the upper jaw.

In chronic forms of rhinosinusitis, and in particular in case of inflammation of the maxillary sinus with the formation of polyps, cysts or the detection of foreign bodies, it is necessary to use a surgical treatment method. As a surgical treatment, the method used in world practice is endoscopic endonasal microsinlusrotomy.

Endoscopic micromaxillary sinusotomy is a more gentle method in which the integrity of the tissues for access to the operated site is not compromised. With its help, formations are removed: polyps, cysts, accumulations of purulent masses using an endoscope. They are carefully removed through the natural anastomosis (drainage hole) of the maxillary sinus; the instruments are inserted through the nose, without cutting or piercing anything. The surgeon can clearly see an enlarged image of the operated area on the monitor, so damage to healthy tissue is excluded. Thus, accurate diagnosis and treatment procedures are carried out. During this operation, the above-mentioned additional anastomoses are often discovered, which are the cause of frequent relapses of inflammation of the upper quadrant. The correct and correct tactic is to connect the additional and natural anastomosis, remove part of the fontanella and, if desired, smooth the edges with a special microderbrider.

I would like to attract the attention of primary care doctors, namely ENT doctors of clinics, to recommend that during endoscopic outpatient diagnostics of the lateral wall of the nasal cavity and when additional anastomoses are detected, they correctly explain the essence of this pathology to patients and suggest the correct treatment tactics, namely the endonasal endoscopic surgical method.

Be healthy and take care of your loved ones!

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