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Since the 1980s, the surgical approach to the maxillary sinuses has been revolutionized by the endoscopic endonasal approach. The goals of treatment of maxillary sinus disease are aeration and resumption of normal mucociliary flow. Additionally, there is an increasing number of surgeons who now operate with a goal of access for topical medications. Although often believed to be the one of the most straightforward steps of endoscopic sinus surgery, the surgical approach to the maxillary sinus is not without potential complications and controversy.
Many primary cases without nasal polyps can be managed with a minimally invasive approach that marsupializes the natural ostium into the nose using an uncinate window. For more complex cases or in the setting of more advanced disease, endoscopic middle meatal antrostomy can facilitate long-term management of patients with chronic maxillary sinusitis by allowing for easy in-office and home antral lavage. These antrostomies are also the treatment of choice for other middle meatal pathologies such as antrochoanal polyps and can serve as a corridor to the middle fossa in skull base surgery.
Antrochoanal polyps were first described by Killian in 1906. The polyp originates within the maxillary sinus and eventually is extruded through the natural ostium into the nasal cavity, obstructs the choana, and is characterized by the symptoms of unilateral nasal obstruction, rhinorrhea, and postnasal drainage. It is more common in the pediatric age group and represents the most common nasal and sinus growth in children. In the general population it is said to account for 4% to 6% of all nasal polyps, and in one study of 24 patients the mean age was 23 years (range, 11 to 40).
The etiology of antrochoanal polyps remains controversial, and both allergic and infectious causes have been suggested. Although medical treatment such as antibiotics, decongestants, and steroids may provide temporary relief, the treatment of choice for antrochoanal polyps is complete surgical excision. We prefer an endoscopic approach to these lesions, but in cases of recurrence or in those where the stalk of the polyp is not clearly visualized, the endoscopic approach may be combined with a canine fossa puncture or inferior meatal antrostomy for placement of an endoscope or instruments or a mini-Caldwell Luc.
The natural ostium of the maxillary sinus is located in a parasagittal plane and is identifiable after an uncinectomy is performed.
In cases that require a maxillary antrostomy, the natural ostium of the maxillary sinus must be incorporated into the maxillary antrostomy to prevent recirculation.
The best results occur when operating with adequate vasoconstriction resulting in minimal bleeding, proper visualization, and minimal trauma to the mucosa.
Antrochoanal polyps are often found exiting an accessory os in the posterior fontanelle. Polyps exiting the natural os should raise suspicion for other pathologies including inverted papilloma.
History of present illness:
What are the patient’s presenting complaints?
The four cardinal symptoms of sinusitis are nasal obstruction, discolored nasal drainage, facial pain, or pressure and hyposmia.
Duration of symptoms should also be elicited.
Odontogenic infections that ascend into the maxillary sinus should also be considered and evaluated.
Past medical history:
Prior treatment:
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?
Surgical history: Prior sinonasal surgery, including septoplasty and prior sinus surgery
Dental history: Prior infections, root canals, implants, or “sinus lifts”
Trauma history: Prior nasal bone fracture or trauma to the orbital rim, floor, lamina papyracea, or nasal septum
Medical illness:
Systemic illnesses that may have sinonasal manifestations such as sarcoidosis, granulomatosis with polyangiitis (formerly Wegener granulomatosis), or vasculitis
Family history of coagulopathy or anesthesia complications
Medications:
Antiplatelet medications or other blood thinners
Herbal products or supplements (e.g., vitamin E, ginseng, gingko biloba, garlic)
Social history:
Tobacco and alcohol history
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
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.
What anatomic factors may be contributing to the patient’s complaints or limit future surgical intervention?
Is the nasal septum deviated? Is there a concha bullosa? Is there an accessory os and if so, is there evidence of recirculation?
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 ).
What is the health of the mucosal lining? Is there evidence of active infection?
This can only be appreciated if the patient has previous surgery or an accessory ostium.
Abnormal secretions can be sampled endoscopically for culture-directed therapy, and abnormalities that might impact surgical access to the ostiomeatal complex should be noted.
Detailed notes of the nasal endoscopy and, if possible, clinical photographs allow better preoperative surgical planning.
Are there signs of prior surgical intervention?
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?
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.
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