Antral Lavage; Endoscopic Middle Meatal Antrostomy/Antrochoanal Polyp

History of present illness:

• a.

  What are the patient’s presenting complaints?

  • 1)

    The four cardinal symptoms of sinusitis are nasal obstruction, discolored nasal drainage, facial pain, or pressure and hyposmia.

  • 2)

    Duration of symptoms should also be elicited.

  • 3)

    Odontogenic infections that ascend into the maxillary sinus should also be considered and evaluated.

Past medical history:

• a.

  Prior treatment:

  • 1)

    Medical therapy: Has this patient previously been treated with oral antibiotics? Has he or she used intranasal or systemic corticosteroids? Have other nasal sprays or saline irrigations been tried?

  • 2)

    Surgical history: Prior sinonasal surgery, including septoplasty and prior sinus surgery

  • 3)

    Dental history: Prior infections, root canals, implants, or “sinus lifts”

• b.

  Trauma history: Prior nasal bone fracture or trauma to the orbital rim, floor, lamina papyracea, or nasal septum

• c.

  Medical illness:

  • 1)

    Systemic illnesses that may have sinonasal manifestations such as sarcoidosis, granulomatosis with polyangiitis (formerly Wegener granulomatosis), or vasculitis

• d.

  Family history of coagulopathy or anesthesia complications

• e.

  Medications:

  • 1)

    Antiplatelet medications or other blood thinners

  • 2)

    Herbal products or supplements (e.g., vitamin E, ginseng, gingko biloba, garlic)

• f.

  Social history:

  • 1)

    Tobacco and alcohol history

  • 2)

    Environmental exposures (e.g., woodworking and heavy metals)

All patients evaluated by an otolaryngologist should undergo a comprehensive examination of the head and neck.

Nasal endoscopy

• a.

  The nose should be examined before and after being decongested with oxymetazoline and anesthetized with topical lidocaine to achieve an adequate examination while minimizing patient discomfort.

• b.

  What anatomic factors may be contributing to the patient’s complaints or limit future surgical intervention?

  • 1)

    Is the nasal septum deviated? Is there a concha bullosa? Is there an accessory os and if so, is there evidence of recirculation?

    • a)

      The natural ostium is the only functional ostium within the sinus, and the inferior meatus will be ignored by mucociliary activity. Patients who have a patent inferior meatal antrostomy can easily be examined in the office through that opening with 0- and 30-degree endoscopes, and not infrequently, an obstructed natural ostium can be seen despite a surgically patent inferior meatal antrostomy ( Fig. 103.1 ).

      

• c.

  What is the health of the mucosal lining? Is there evidence of active infection?

  • 1)

    This can only be appreciated if the patient has previous surgery or an accessory ostium.

  • 2)

    Abnormal secretions can be sampled endoscopically for culture-directed therapy, and abnormalities that might impact surgical access to the ostiomeatal complex should be noted.

• d.

  Detailed notes of the nasal endoscopy and, if possible, clinical photographs allow better preoperative surgical planning.

• e.

  Are there signs of prior surgical intervention?

• f.

  Diagnostic information about nasal tumors, as well as diseases of the mucous membranes such as Kartagener syndrome, cystic fibrosis, and granulomatosis with polyangiitis, can be gleaned from nasal endoscopy.

When should imaging be completed?

• a.

  Patients whose symptoms persist despite adequate medical therapy should undergo imaging. Fine-cut coronal computed tomography (CT) without contrast enhancement is the most informative. High-quality coronal scans effectively delineate the area of the maxillary sinus ostium or ostiomeatal complex and provide verification of anatomic abnormalities that may be contributing to the sinus obstruction. When using the standard window approach described in the 1980s, no mucosa should be apparent, so any amount of mucosal thickening seen within the boundaries of the maxillary sinuses is considered abnormal.

Correlation of endoscopic findings with those on CT allows further evaluation of the anatomy and function of these highly variable and important structures.

Chronic rhinosinusitis refractory to medical management

Recurrent acute sinusitis refractory to medical management

Nasal polyposis

Antrochoanal polyp

Maxillary sinus mucocele

Fungus ball

Benign or malignant tumors involving the maxillary sinus

Endoscopic endonasal access to the pterygopalatine fossa or infratemporal fossa

Inadequate trial of medical management of rhinosinusitis

Odontogenic etiology that will predictably resolve (>60% of the time) once the dental issue has been addressed

Asymptomatic maxillary opacification or mucus retention cyst

Coronal CT scans are mandatory for preoperative planning in patients who are expected to undergo endoscopic surgery. The surgeon should review the CT scans with particular emphasis on the important structures that lie adjacent to the sinus cavities. For the maxillary sinus, this primarily entails a thorough evaluation of the lamina papyracea and the floor of the orbit to look for anatomic anomalies or any areas of dehiscence. Additionally, intramaxillary ethmoid cells (Haller cells) should be identified preoperatively. Radiographic evaluation of an antrochoanal polyp reveals unilateral opacification of the maxillary sinus and antrum along with rarely associated opacification of the ethmoid sinuses ( Fig. 103.2 ).

Discontinue blood thinning and antiplatelet agents if possible

Controversy continues regarding the optimal extent of surgery that should be performed in patients with chronic sinusitis, and surgical treatment of the maxillary sinus is no exception. Some surgeons recommend wide antrostomy to improve sinus drainage and access for topical medications. Others maintain that the goal of maxillary sinus surgery should be removal of a minimal amount of tissue necessary to restore patency of the outflow tract. Practitioners of both schools continue to espouse their own philosophies, and these approaches appear to achieve comparable results. We believe that the extent of surgery should be dictated by, and individualized, for each patient’s pathology. This should be carefully planned preoperatively.