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Unknown Etiology Right Upper Jaw Osteomyelitis Case Presentation

February 14-20, 2003
Mr. Andrey Aleksanyants MD,
ENT Physician at Goris Hospital,
Goris, Syunik District, Armenia

Patient: M.
Gender: Male, Age: 64
Occupation: Peasant


The Patient Was admitted to the surgical department of the Goris Hospital in November 9, 2002 Complained of: the lesion under the skin of the right buccal area, total stuffiness in the right nasal passage, profuse purulent discharge from both nostrils, numbness of the right cheek.

According to patient’s deposition the first symptoms were appeared in 2-3 months before hospitalization.

Physical Examination

External inspection: painless round mass under the skin of the right buccal area with restricted mobility, size 3 to 4 cm., palsy of the buccal branch of right facial nerve (m. levator anguli oris, m. buccinator),tenderness to palpation of the anterior wall of the left maxillary sinus, the cervical lymphatic nodes are not enlarged.

Oral cavity examination: all upper teeth are missing; gums are pink, smooth, free of lesions.

Rhinoscopy: the right nasal passage is totally obscured by multiple polyps, the nasal septum is deviated to the left.

Laboratory & Instrumental Evaluation

Blood Glucose- 4.6
Hemoglobin- 115
WBC- 6.2 (low expressed deviation of the differential count to the left)
C-Reactive protein-  +
Mantoux test- negative
The culture of the pus smear: Staphylococcus aureus

X-Ray film in occipitomental view: total opacification of the right maxillary sinus and right nasal passage, air-fluid level in the left maxillary sinus.

Histological examination (was performed in the Histological Department of the "Armenia" Medical Center , Yerevan, on November 14, 2002): The specimen consists of fibrous connective tissue with multiple inflammatory demarcation , no malignant cells are found.

Treatment & Hospital

Surgical management:
The operation was performed on November 10, 2002
  1. Surgical approach: The incision was performed in vertical direction on the right buccal area, the lesion was separated from the skin and residual walls of the right maxillary sinus by blunt method (anterior and medial walls including right lower turbinate were almost totally destructed, others were intact).
  2. Revision and removal of the pathologic tissues with residual mucous membrane of the maxillary sinus and nasal polyps through operation cavity and right nostril, surgical debridement of necrotic parts of bone.
  3. Tightly packing of the operation cavity and right nasal passage by the gauze coated with antibiotic ointment (was removed after 3 days).
  4. Approximating suture of the sides of incision (removed after 8 days).
Medical management:
IM-Cephasoline 1.0 – 3 times a day – 8 days.
Punctions and irrigations with antiseptic solutions of the left maxillary sinus every 2 days – 8 days.


The patient was discharged from Goris Hospital on November 17, 2002.
Improvement, satisfactory condition, residual palse of the buccal branch of right cheek, chronic purulent left maxillary sinusitis.

Questions to be asked

  1. How to determine the etiology of osseous destruction in this case?
  2. What is the probability of the same process progressing in the left maxillary sinus and what prophylactic methods can be recommended?
  3. What additional treatment can be carried out for best recovery?

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Trepanation Technique Using Experience In Cases Of Purulent Frontites

Materials of Panarmenian International Surgical Congress,
October 2003, Yerevan, Armenia
A. Aleksanyants., MD, A. Petrosyan, MD,
Goris Hospital

Purulent frontites are met in ENT practice frequently enough and, according to many statistical research reports, take the second place among purulent sinusites. Until recently, there have been certain disagreements regarding the advantages and disadvantages of current methods in approaches to treatment of the given pathology, such as: lower efficiency of the conservative medical treatment used in out-patient practice; the inadequacies of tissue injury, cosmetic problems and the high cost of the procedure in radical surgical approaches; painful lavage procedures and high risk of intraorbital complications during trepanopuncture of an orbital wall of a sinus. Taking into consideration the abovementioned methods we would like to suggest a technique of trepanation of anterior wall of the frontal sinus. In 2001-2002, this method was tested in our hospital in 9 patients with cases of unilateral purulent frontitis.

Trepanation Technique

Anesthesia – local infiltrative (Sol. Lidocaini 2% - 5.0 + Sol Adrenalini 0.1 % - 1/1000) above the hair of the eyebrow arch in a medial part of the same eyebrow. Section the whole depth of soft tissues in length up to 2 cm with the subsequent subperiostal separating of anterior wall of the frontal sinus. After that, using spherical and cylindrical stomatologic drill, wall trepanation was done with 3.5 mm aperture formation. Sinus was drained by a rigid plastic tube of appropriate size with suturing of the tube to edges of a wound. In 7 cases out of 9, the X-ray diagnosis of purulent frontitis was confirmed. Of the other two cases one was diagnosed "Acute Catarrhal Frontitis" and in the other the final diagnose was "Cyst of the right frontal sinus". Lavage of the frontal sinus was performed every day by antiseptic solutions (Sol. Betadini, Sol. Yodinoli). As a result it was observed that within 5 to 8 days, there was a cleaning of lavage waters and full restoration of drainage function of fronto-nasal channel. The tissue edema in the wound area decreased on the 2nd to the 3rd day after trepanation without any local complications. The drainage tube was removed simultaneously with sutures on the 7th to the 9th day post procedure. The spontaneous healing of wound edges was observed in all cases in 2-3 days after extraction of the tube.

After 8-12 months, a repeat examination of the given group of patients was performed. In 6 cases there was no sign revealed of recurrence during the whole period. In 2 cases it was observed that the residual catarrhal frontitis was caused by acute viral respiratory infection (ARI). In only one case, recurrent purulent frontitis was diagnosed. It is for this reason that repeated trepanation using the same method was performed, and within 10 days the condition of the patient was completely normalized.

Thus, the given technique combines the following advantages:

  1. Easy performance and availability in out-patient practice
  2. Less tissue trauma and good cosmetic effect.
  3. Less procedural pain and good tolerance in all patients.
  4. Improved recovery rate; decreased rate of chronicity and recidivism.
  5. Absence of any complications due to method technique.

In view of the advantages of this method, we recommend utilization of the abovementioned technique in ENT practice, especially in ambulatory or out-patient facilities and in regional hospitals.

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