The concept of perioperative period of endoscopic sinus surgery and the principles of handling each stage before and after surgery are proposed, which have important practical significance for improving the cure rate of endoscopic sinus surgery.
I. Pre-operative period
The preoperative period is actually the preoperative preparation period of 7 days, in which the main goal of treatment is to create conditions for smooth surgery. The most difficult problem in surgery is excessive bleeding, which leads to blurring of the operative field and not only affects the complete removal of the lesion and the delicacy of the surgery, but also is the main source of complications. If the congestion and edema of the nasal sinus mucosa caused by local inflammation and metaplasia can be properly controlled before surgery, intraoperative bleeding will be effectively reduced by.
1.Systemic antibiotics: cephalosporins, oral
2, systemic steroids: oral, prednisone 10mg 1 time / day
3, local steroids: nasal spray
4.Antihistamines orally
5.Maxillary sinus puncture rinse
Second, inpatient treatment period
Comprehensive physical examination, pay attention to communication with the patient
Determine the scope of surgery and anesthesia according to the patient’s specific situation (especially CT imaging data). After 24 hours to 48 hours after surgery, the stuffed gauze is withdrawn, and the nasal cavity is contracted once a day starting from the 4th day, and the nasal cavity and surgical cavity must be cleared of blood clots and secretions, saline washes the nasal cavity, and nasal spraying with hormones is performed. Postoperative hospitalization is usually 7-8 days, and a thorough nasal and surgical cavity cleaning and washing should be performed under the endoscope before discharge.
III. Post-operative follow-up period
The postoperative mucosal transition process is divided into three stages: the first stage is the surgical cavity cleaning stage (around 2 weeks); the second stage is the surgical cavity mucosal transition competition stage (in around 8-10 weeks); the third stage is the epithelialization completion stage (in more than 10-12 weeks).
The restoration of sinus mucosa morphology and function is the ultimate goal of functional endoscopic sinus surgery, and the measures taken to achieve this goal, such as protecting the basic structures of the nasal cavity (e.g., preserving the middle turbinate as much as possible), correcting anatomical abnormalities of the nasal cavity and sinuses (e.g., excessive septal curvature, inferior turbinate hypertrophy, hooking abnormalities, etc.), establishing drainage channels for each sinus centered on the septal sinus, and improving and restoring nasal ventilation and sinus ventilation, are the important principles. Based on these principles, protection of the mucosa is the most important tool in surgery. Surgery is only the first step in the overall treatment plan and is followed immediately by the beginning of the epithelial regeneration phase. Epithelial regeneration is a longer process that is actually a competing process of wound healing (or epithelialization) and lesion regeneration. This competition can develop in two different directions: either trauma healing becomes the main body so that the surgical cavity evolves toward epithelialization and eventually completes epithelialization, or lesion regeneration becomes the mainstay and vesicles, granulation, polyps, and connective tissue regeneration leads to incomplete epithelialization or adhesions, partial or even complete obstruction of the sinus opening and surgical cavity, forming a prolonged inflammatory disease that affects surgical efficacy or even surgical failure. The postoperative regression time of functional endoscopic sinus surgery is about 3 months. Surgery is the first step of treatment and postoperative treatment is the second step of treatment, and the close combination of the two constitutes the overall treatment of sinusitis and nasal polyps by functional endoscopic sinus surgery. Focusing only on surgery and neglecting postoperative treatment inevitably results in a lower cure rate.
Physiological saline cleansing of the nasal cavity helps to increase blood circulation in the avoidance area and promotes mucus cilia clearance. Steroid nasal sprays have potent local anti-allergic, anti-inflammatory and anti-edema effects, which can effectively control the growth of vesicles and small polyps.
Sinusitis, nasal polyps is a relatively long comprehensive treatment process, never a single rely on surgery can be completed, doctors and patients should be fully aware of the complex treatment process required before and after surgery, and give full confidence and recognition to the process.
IV. How to make good local anesthesia of nasal cavity
Anesthesia is the key to the success of surgery, and painlessness can create good surgical conditions for the surgeon, so that the surgery can be carried out smoothly according to the predetermined plan and scheme. It should be said that general trouble is the best anesthesia method, and the patient’s breathing, blood pressure, heart status, blood oxygen saturation and other important vital signs are under the reliable control of the anesthesiologist, especially when the patient has more bleeding, poor cardiopulmonary function (such as with coronary heart disease, bronchial asthma or chronic bronchitis), high blood pressure, unstable condition or fear of the surgical process.
However, in the current situation of our country, the affordability of patients becomes a limitation to the general anesthesia in general. Improving local anesthesia methods and improving local anesthesia effects.
Local anesthesia methods, in two steps within 10 minutes.
1, surface anesthesia: 1 % dicaine 25 ml added to 1:1000 adrenal mutual 3.0 ml, soaked with wet cotton in two steps. The focus areas are the olfactory fissure, middle nasal tract, and pterygoid septal crypt.
2. Infiltration anesthesia: 1% lidocaine is injected submucosally in the nasal mound, anterior margin of the hook, and pterygopalatine sieve crypt, total 2.0ml.
Local anesthesia can also be considered for first-time total sinus surgery, while general anesthesia should be preferred for repetitive surgery. In cases of whole group sinus lesions with septal sinus osteophytes (especially for repetitive surgery), general anesthesia should be routinely done to ensure patient safety, painless surgery, and successful completion of surgery according to the original plan.
Submucosal infiltration anesthesia in important nerve distribution areas.
1.Anesthetic drug and total amount: 1% lidocaine 5ml, 1:1000 epinephrine 3 drops mixed.
2.Anesthesia site sequence.
(1) Nasal mound, 0.5ml, where there is anterior septal nerve distribution.
(2)The superior, middle and inferior points of the anterior border of the leptomeninges, 0.5ml in total.
(3) 0.5 ml at the lateral level of the attachment of the posterior end of the middle turbinate, i.e., the lateral equivalent of 1:00 at the superior margin of the posterior nostril, where the pterygopalatine nerve travels.
After the above anesthesia is completed, the effective time is more than 40 minutes.
V. Several issues related to anesthesia.
1. The most sensitive sites for pain: anterior, inferior and posterior margins of the middle turbinate, around the frontal eminence of the sieve roof, around the natural mouth of the maxillary sinus, the pterygoid sieve crypt, and the anterior wall of the pterygoid sinus. Scar tissue and hyperplastic bone tissue in repeat surgery.
2. If local anesthesia is used to intensify the anesthesia, it is best to intensify at the beginning of the surgery. Most of the results are not good if the anesthesia is intensified when the patient feels pain. We often encounter in the clinic, once the patient opens his mouth to scream pain or cry, it is difficult to terminate no matter what method you use, here are some problems belonging to psychological methods.
3.Before local anesthesia, you should introduce the scope and steps of the operation to the patient in detail, so that the patient is clear about your purpose and procedure, so that they can cooperate actively in the operation.