Some problems in the diagnosis and treatment of maxillary sinus cyst
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https://www.eduzhai.net American Journal of Medicine and Medical Sciences 2021, 11(5): 455-457 DOI: 10.5923/j.ajmms.20211105.20 Some Questions in Diagnostics and Treatment of Cysts of the Maxillary Sinus U. N. Vokhidov, A. Sh. Butaev Tashkent State Dental Institute, Uzbekistan Abstract The aim of the study was to assess the correspondence of the X-ray manifestations of the pathological process in the sinuses with the results of histopathological studies in patients with maxillary sinus cysts. The study group included 50 patients with a preliminary diagnosis of a cyst of the maxillary sinus, confirmed by clinical manifestations, by survey radiography and computed tomography of the paranasal sinuses. All patients underwent surgery. The research showed, that all of the above indicates that on the basis of complaints, physical examination data and X-ray manifestations, it is not always possible to carry out a reliable differential diagnosis of changes similar to cystic ones found in the maxillary sinuses. At the same time, the strategy of patient management, namely the choice of surgical or expectant tactics (depending on the size of changes in the sinus and the presence of complaints), practically does not depend on the pathological changes detected intraoperatively. Keywords Inflammatory diseases of the nose and paranasal sinuses, Cysts of the maxillary sinuses, Diagnose, Computed tomography, Pathomorphological examination, Treatment, Rhinosinusosurgery 1. Introduction Inflammatory diseases of the nose and paranasal sinuses in recent decades have firmly occupied the first place in the overall structure of the incidence of ENT organs, both in the analysis of accessibility to the polyclinic and in the group of patients undergoing treatment in inpatient conditions [1,4,8]. Sinus cysts are one of the most common diseases in clinical practice. According to the classification of sinusitis, cysts are chronic [2,9,12]. Cysts of the maxillary sinuses are a very common disease, often an incidental clinical finding on radiography and computed tomography of the paranasal sinuses [3,5]. At the same time, there are few reports in the literature about the localization of cysts in the frontal and sphenoid sinuses [2,7]. It is especially difficult to diagnose cysts of the sphenoid sinus, since the known X-ray packing does not allow them to be diagnosed. The problem of diagnosing cysts of the paranasal sinuses was resolved with the introduction of computed tomography into practice [1,10]. Modern diagnosis and treatment of cystic lesions of the paranasal sinuses is one of the urgent problems of otorhinolaryngology. Among all sinuses, cystic processes in 93,3% of cases affect the maxillary sinuses [3,11]. In the last decade, there has been an increase in the incidence of chronic sinusitis, respectively, the number of patients Received: May 5, 2021; Accepted: May 25, 2021; Published: May 31, 2021 Published online at https://www.eduzhai.net suffering from cystic sinusitis [2,4], which often do not have characteristic clinical symptoms, is increasing; they are detected during X-ray examination of patients for another disease as a “chance find” . One of the main research methods that make it possible to diagnose cystic sinusitis is the X-ray method; the most reliable is computed tomography of the paranasal sinuses, which allows you to choose the appropriate surgical method of treatment (endo- or extranasal), to avoid complications during the operation and relapses in the future [7,12]. According to the literature, X-ray manifestations of cystic processes in the maxillary sinuses are shadows of various shapes (round, semicircular, in the form of a "hanging drop") with a clear even contour, flattened, reminiscent of a fluid level, meniscus-shaped. Their sizes vary from total to parietal darkening [4,9]. To date, only a few studies have been devoted to the issues of morphogenesis of cysts of the paranasal sinuses . In foreign literature, the focus is on odontogenic and dysontogenetic cysts . At the same time, only the pathohistological method makes it possible to assess the type of morphological changes in the mucous membrane of the affected sinus and to make a final diagnosis . The literature contains information on the morphogenesis and pathohistological structure of cystic processes . However, in this data set, there are no works in the course of which an analysis was made of the correspondence of the radiological manifestations of the cystic processes of the maxillary sinuses to the data of the pathological examination of tissues removed from the sinuses in patients with a diagnosis of 456 U. N. Vokhidov and A. Sh. Butaev: Some Questions in Diagnostics and Treatment of Cysts of the Maxillary Sinus cystic sinusitis. With the advent of endoscopic methods of rhinosinusosurgery, various options for endonasal and extranasal interventions began to be performed to remove cysts of the maxillary sinus: after puncture of the canine fossa , through the lower nasal passage , after expansion of the fistula in the middle nasal passage , by the method of posterior fontanellotomy . However, there are no works summarizing the experience of treating a large number of patients with maxillary sinus cysts. The aim of the study was to assess the correspondence of the X-ray manifestations of the pathological process in the sinuses with the results of histopathological studies in patients with maxillary sinus cysts. 2. Research Materials and Methods The study group included 50 patients with a preliminary diagnosis of a cyst of the maxillary sinus, confirmed by clinical manifestations, by survey radiography and computed tomography of the paranasal sinuses. All patients underwent surgery. Fragments of soft tissues removed from the maxillary sinuses during surgical treatment were the objects for pathomorphological examination. Histological sections after staining with hematoxylin and eosin, as well as by the Van Giesen method, were examined using a light microscope at various magnifications. 3. Research Results and Their Discussion During X-ray examination, pathological processes in the maxillary sinuses with a preliminary diagnosis of cystic sinusitis were characterized by the following features: the shadows had different sizes (occupied the entire maxillary sinus, half of the sinus, 1/3 of the sinus or were in the alveolar bay), different localization was often located in the maxillary sinus (on the posterior inferior and medial walls, rarely on the anterior wall), differed in a variety of shapes (round, semicircular, in the form of total darkening, fluid level, in the form of parietal changes). Such changes were recorded both on plain radiographs and computed tomograms. The results obtained clearly fit into the X-ray picture of cystic lesions. As a result, the patients included in the study group had a preoperative diagnosis: maxillary sinus cyst. However, histopathological confirmation of this diagnosis was obtained only in 58,8% of cases. Histopathological diagnoses were distributed as follows: The largest number (42,8%) were samples with a diagnosis of a true cyst. Their wall was represented by connective tissue, lined on both sides with a flattened multi-row ciliated epithelium, in which goblet cells were encountered with an unchanged basement membrane. The lamina propria consisted of connective tissue fibers with blood vessels and cellular elements. The second group consisted of false cysts - 16% of the studied samples. The morphological difference between the pseudocyst wall was the presence of a one-sided epithelial lining. The cyst wall was represented by fibrous tissue with dystrophic changes in the form of hyalinosis without an internal epithelial lining, although in some places the epithelial lining was preserved. In the wall of the cyst, blood vessels with signs of plethora, symptoms of sclerosis with hyalinosis, and stromal-vascular dystrophy were visible. The connective tissue is characterized by a predominance of mucoid degeneration of the intercellular substance and a meager, more plasmacytic-cell composition. The proper lamina of the mucous membrane is transformed into a low-vascular structure formed by pseudocystic cavities, which enlarge and merge. Inflammation in these areas has a perivascular localization up to panvasculitis. These changes are combined with the expansion of lymphatic gaps, lymphangiectasias. In a quarter of the examined samples (25%), a fibro-edematous polyp was detected, manifested as a hyperplastic process with excessive proliferation of connective tissue, squamous metaplasia of the ciliated epithelium into a stratified squamous epithelium. Fibro-edematous polyp with cystic transformation was detected in 16,2% of cases. Its wall was lined with multi-row epithelium, in some cases sclerotic changes were visible in the wall. On the basis of four types of changes revealed during the pathological examination of the surgical material, all examined patients were also divided into 4 groups. In the formed groups, a detailed analysis of the clinical manifestations of the pathological process was carried out: complaints presented during the initial examination, data from the anamnesis of the disease, the results of anterior rhinoscopy and endoscopic examination of the nasal cavity, which did not reveal any reliable pathognomonic symptoms for each group. In the visual analysis of plain radiographs and computed tomograms, in most cases it was difficult to establish a diagnosis that would correspond to the four groups of pathological changes identified by us. For example, in the radiographs presented below, the shadows of pathological formations that have the appearance of total darkening of the maxillary sinuses should correspond to the same pathological diagnosis, however, such changes were found in all selected groups of patients. The detected changes in the form of rounded shadows with a clear even outline should correspond to the diagnosis of a true cyst. But with pathohistological confirmation, such radiological manifestations corresponded to the diagnoses of both fibro-edematous polyp and pseudocyst. Changes in the form of semicircular shadows with a clear even contour, characteristic of false cysts, with pathological confirmation corresponded to the diagnoses - a true cyst, fibro-edematous polyp, fibro-edematous polyp with cyst formation. When analyzing the computed tomography data, we also found the similarity of radiological changes, which corresponded to all four groups. For example, we visualized American Journal of Medicine and Medical Sciences 2021, 11(5): 455-457 457 round shadows with a clear, even outline in patients of all four groups, although they had to correspond to the diagnosis - a true cyst. The density of pathological shadows found on computed tomograms corresponded to different figures (from 7 to 38 HU units) and did not have any regular values for the selected groups. Thus, after conducting a detailed analysis of clinical and radiological data, we found that the diagnosis of cystic sinusitis, established on the basis of clinical manifestations and the results of an X-ray examination, does not always correspond to the pathological diagnosis. It turned out that the histological diagnosis of a cyst (true or false) corresponded to the clinical diagnosis in two thirds of the patients. In the rest of the patients, pathohistological examination revealed such changes as fibro-edematous polyp or fibro-edematous polyp with cyst formation. At the same time, analyzing the clinical manifestations in the groups of patients formed according to the pathological diagnosis, we did not find any significant features that would allow us to initially establish the correct diagnosis, and further analysis showed that the results we obtained did not matter when choosing a patient's treatment tactics. The therapeutic tactics did not depend on the pathological changes, but on their localization in the sinus, the severity of the patient's complaints and the size of the formations. In addition, having studied the long-term results of surgical treatment of patients, we came to the conclusion that the presence or absence of relapses of the pathological process also did not depend on the pathological diagnosis. Relapses occurred in all groups formed according to pathological signs with approximately the same frequency (3-5%). 4. Conclusions 1. All of the above indicates that on the basis of complaints, physical examination data and X-ray manifestations, it is not always possible to carry out a reliable differential diagnosis of changes similar to cystic ones found in the maxillary sinuses. 2. At the same time, the strategy of patient management, namely the choice of surgical or expectant tactics (depending on the size of changes in the sinus and the presence of complaints), practically does not depend on the pathological changes detected intraoperatively. 3. Along with this, our findings suggest that the various pathological changes in the mucous membrane of the maxillary sinuses with a similar clinic and radiological manifestations (with the exception of false cysts) may be the result of different stages of development of the same pathological process. REFERENCES  Albuquerque-Neto A. D. et al. Surgical treatment of orthokeratinized odontogenic cyst in maxillary sinus: Case report in pediatric patient //Journal of Oral Diagnosis. – 2018. – Т. 3. – №. 1. – С. 1-5.  Arslan İ. B. et al. Paranasal Sinus Anatomic Variations Accompanying Maxillary Sinus Retention Cysts: A Radiological Analysis //Turkish archives of otorhinolaryngology. – 2017. – Т. 55. – №. 4. – С. 162.  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Published by Scientific & Academic Publishing This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/
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