Internal maxillary artery ligation via maxillary sinus

Severe intranasal arterial hemorrhage, bleeding point in the middle of the middle turbinate free edge, through the anterior and posterior nasal hole filling, external carotid artery ligation and other methods and failure to control bleeding, you can consider the main branch of the internal maxillary artery. Treatment of diseases: septal hematoma and abscess traumatic epistaxis Indication Severe intranasal arterial hemorrhage, bleeding point in the middle of the middle turbinate free edge, through the anterior and posterior nasal hole filling, external carotid artery ligation and other methods and failure to control bleeding, you can consider the main branch of the internal maxillary artery. Contraindications 1. Women with weak constitution or chronic diseases are not qualified for surgery, such as postpartum or postpartum hemorrhage, shock, severe heart disease and heart failure patients. 2, within 24 hours of measuring body temperature twice between 4 hours, all above 37.5 0C, should be suspended. 3, systemic infectious diseases, such as respiratory, urinary tract infections, internal and external genital infections and skin infections. 4, there are infections, such as abdominal skin infections, postpartum infections, pelvic inflammatory disease. 5, neurosis and women who have more concerns about surgery should be carefully considered. Preoperative preparation Take a sinus piece to understand the condition of the maxillary sinus. Surgical procedure The basic steps are performed according to maxillary sinus radical surgery, but with the following characteristics and additional steps: 1. Open the maxillary sinus: the anterior wall bone hole should be opened as much as possible to facilitate the expansion of the surgical field of view and easy operation. 2. Incision of the posterior wall of the maxillary sinus: a rectangular mucosal flap that is placed on the outside of the maxillary sinus. If the inflammation in the sinus is obvious and the mucosal lesion is heavier, it should be removed and fully stopped. 3. Chisel the upper part of the posterior wall of the maxillary sinus to facilitate the exposure of the artery. 4. Open the pterygopalatine fossa: After perforating the bone wall, the periosteum is seen. After periosteal infiltration with 2% procaine adrenaline 2ml, the periosteum is cut around and removed. If there is a microscope, it can be used at this time. 5. Exposure of the arteries: After removal of the periosteum, the fat connective tissue of the pterygopalatine fossa is seen, and the pulsatile needle or the elongated curved vascular clamp is carefully separated to find the pulsating internal maxillary artery (upward) and its branches. Arteries (downward). 6. Ligation of the artery: the iliac artery and the upper and lower jaw internal artery trunks are respectively ligated, or clamped with a silver clip, without cutting. After the ligation is completed, the nasal packing can be removed to check the hemostatic effect. 7. Respond to the rectangular mucosal flap to cover the wound. If the mucosa has been removed, it can be covered with a gelatin sponge. Then, the pressure of the water hole in the hole and the sinus is completed as usual. Maxillary sinus radical surgery steps: 1. The patient is in the supine position, the operator stands on the side of the operation, and the assistant stands on the opposite side. 2. After local disinfection, place a small gauze roll between the upper and lower molars on the surgical side, and let the patient bite gently to prevent blood from flowing to the pharynx. 3. The incision is used to pull up the upper lip with a hook, about 0.5cm from the labial sulcus. From the cusp to the second bicuspid, the round blade is used for a transverse incision of about 2 to 2.5 cm. The blade should be perpendicular to the mucosal surface. A single knife cut through the mucosa, periosteum, and directly to the bone. In order to prevent damage to the lips, you can use a cotton pad to wrap the back of the blade to expose only the front end, which is safer to use. 4. Exposing the anterior wall with the tonsil stripper along the bone wall, the soft tissue and mucous membrane connected to the periosteum up and down, the whole layer is peeled off, close to the inferior foramen, inward to the pear-shaped hole, the inner and outer distance is about 2.5cm. . If the periosteum is not completely cut, the tension is large, and it needs to be cut with a scalpel, and do not use a stripper to forcibly break. Pull the hook from the incision and pull it upwards (be careful not to pull excessively, so as to damage the supraorbital nerve, blood vessels, cause bleeding or numbness and swelling of the cheeks after surgery), and fully expose the anterior wall of the maxillary sinus centered on the cusp. 5. Cut the front wall with a round chisel at a distance of 0.3 cm from the outside of the pear-shaped hole to open the anterior wall of the maxillary sin in the order of inner, lower, outer and upper. The chisel should be sharp, avoid jumping or sliding on the bone surface when hammering, or causing bone fracture due to excessive force. It is also possible to drill the front wall with an electric drill or a hand drill. After cutting off some bone pieces and opening the maxillary sinus, you can use the mastoid rongeur to enlarge the bone hole to the circumference, and inward to the inner wall of the maxillary sinus. Do not injure the lower hole, and do not hurt the tip of the canine. The diameter of the bone hole is generally 1.5 cm, but the shape and size can be appropriately adjusted according to the needs of the operation. When removing bone and encountering intra-mammary arteriolar jet hemorrhage, it can be compressed by bone hemostasis, or partially filled with bone wax to stop bleeding. 6. Cleaning the sinus cavity When cutting and biting the anterior wall bone, often together with the removal of the mucosa, the sinus cavity is open. If the mucosa is still intact, it can be cut open, and the sinus pus and blood secretions and secretions are sucked by the aspirator to observe the nature and extent of the lesions in the sinus to determine the next treatment policy. If it is a polyp, cyst or hemorrhagic necrotic tissue, it can be peeled off with a septal stripper and removed with a ring-shaped tissue forceps; if the sinus cavity is only hyperemia, hypertrophy, and the surface is still smooth, it should be preserved because of surgery. Improve drainage, eliminate inflammation and possibly return to normal, do not easily decide to completely scrape off; if the sinus is full of cauliflower-like new organisms, it is estimated that the malignant tumor may be larger, then take a few biopsy tissue, you can close the surgery cavity, wait Pathological examination is clearly diagnosed and then treated; if the mucosal lesion is serious and cannot be preserved, it can be peeled off with a stripper and a curette, and completely removed. Note that when peeling off the top wall, that is, the mucosa of the lower side of the eyelid, do not use too much force to avoid causing a fracture of the sacral floor; when peeling off the bottom wall, do not scrape too deep to avoid postoperative toothache caused by exposure of the root tip of the tooth. After the sinus cavity is cleaned, the surgical cavity is rinsed with sterile saline, and then the dry gauze or the dipped adrenaline solution gauze is filled into the sinus cavity for a while, so that the cavity is clean, no active bleeding, and the gauze is taken out. After careful examination, the bone walls in the sinus are intact, and whether the diseased tissue remains. If so, remove it. 7. Establish the pair of holes in the front and lower side of the inner wall of the maxillary sinus, which is equivalent to the bone in the lower nasal passage. The bone is often raised, and the curved short chisel is used to cut the bone wall in the order of upper, lower and front, and then backward. Gently pick up, fold down a thin bone piece about 1.0cm in diameter, and then use the rongeur to enlarge the bone hole, so that the anterior edge of the anterior sinus cavity and the lower edge of the lower sinus cavity are formed, and finally form about 1.0cm×( 1.5 to 2) an elliptical bone hole with a cm size and a smooth edge. Thereafter, the lower nasal passage is inserted into the sinus with the elbow vascular clamp or the nasal septum stripper, and the mucosa is cut open from the sinus with the pointed blade, along the edge of the bone hole, in the order of anterior, posterior and superior. After that, a "" shaped mucosal flap is formed and turned into the sinus floor. 8. Block the sinus cavity, if it is blocked with iodoform gauze, send it to the end of the gauze from the lower nasal passage (can bind a silk thread for marking, and when the silk thread is removed, it means that the gauze has been completely exhausted) Press and hold, then fill the entire sinus cavity with the gauze, and the other end is left at the front end of the lower nasal passage. It can also be blocked with a water bladder (or airbag) made of latex. The water sac also enters the hole from the lower nasal passage, gradually injecting water (or air) to make it swell, pressing the mucosal flap, and filling the entire sinus cavity. Before using the water bladder, check whether there are any loopholes, and carefully scrape it when it is sent into the nasal cavity. Otherwise, water leakage (gas) will occur after the placement, and the compression will be lost. If the mucosal damage in the sinus is small or scrape completely, the bleeding is less, and the sinus cavity may not be blocked. 9. The suture is interrupted, continuous or sputum, and the periosteum should be sutured together. Finally, the gauze roll between the molars is removed. complication 1, nasal pain. 2. Neurosis. Due to lack of understanding of surgery, mental stress leads to nervous system excitability and inhibition process, caused by autonomic dysfunction. The clinical symptoms are emotional instability, depression, depression, heartiness, irritability, ribs, fatigue, fatigue, menstrual disorders, loss of appetite, dizziness, restlessness, sleepless nights.

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