Volume 2 No 1 2012

Maxillary sinus antrostomy Pitfalls

Dr T Balasubramanian
Abstract:
Endoscoic sinus sur!ery "#ic# is t#e commonly erformed nasal sur!ery #as its o"n roblems if
not erformed roerly$ %uccess of maxillay sinus antrostomy deends on includin! t#e natural
ostium to t#e antrostomy$ &or t#is to #aen t#e natural ostium s#ould be identified durin! t#e
sur!ical rocedure$ 'ommon cause of failure in endoscoic sinus sur!ery is t#e failure to address
t#e uncinate rocess$ (n all cases it s#ould be remo)ed comletely before roceedin! furt#er$
(ntroduction:
T#e concet of middle meatal antrostomy "as based on t#e at# brea*in! researc# by %tamber!er
"#o demonstrated t#at mucociliary clearance mec#anism
1
ensured t#at mucosal draina!e from
maxillary sinus antrum occurred )ia its natural ostium$ Endoscoic middle meatal antrostomy
#aens to be t#e commonly erformed
2
sinus sur!ery t#ese days$ T#is aarantly simle sur!ical
rocedure is not t#at simle and failure to erform a roer maxillary sinus antrostomy is t#e
fre+uent cause of failures in endoscoic sinus sur!ery$ (ncomlete remo)al of uncinate rocess #as
been cited to be t#e commonest cause for sur!ical failures
,
$ T#e absence of reliable landmar*s for
identification of natural ostium of maxillary sinus ma*es t#is rocedure difficult$ Et#moidal sinus -
s#enoid sinuses #a)e reliable sur!ical landmar*s in t#e form of s*ull base and lamina ayracea
.$
&actors resonsbile for &ess failures:
1$ (ncomlete remo)al of uncinate rocess
2$ &ailure to include natural ostium into t#e antrostomy
,$ (n)ol)ement of uncinate rocess in t#e inflammatory at#olo!y
&ailure to include natural ostium into t#e antrostomy "ill lead to recirculation of mucous bet"een
t#e natural ostium and t#e maxillary sinus antrostomy erformed$
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(t is t#e in)ol)ement of uncinate rocess in t#e disease rocess t#at causes failure of Balloon
sinulasty in t#ese atients
1$
'omlete uncinectomy s#ould ideally be erformed in t#ese atients$ T#is "ill ensure not only
ade+uate si0ed maxillary sinus antrostomy is erformed but "ill also #el in includin! t#e natural
ostium "it# t#e antrostomy$
Anatomically uncinate rocess is attac#ed to t#e bony co)erin! of nasolacrimal duct$ Bony
co)erin! o)er nasolacrimal duct is )ery dense$ T#is c#an!e in t#e bony t#ic*ness bet"een t#e
uncinate rocess and t#e nasolacrimal duct ensures t#at a comlete uncinectomy can be erformed
"it# minimal trauma to naso lacrimal duct if t#is anatomical fact is *et in )ie"$ Accordin! to
Bol!er a certain amount of minimal trauma occurs commonly durin! uncinectomy$
1andmar* for uncinate rocess:
T#e maxillary line is considered to be an ideal sur!ical landmar* if sic*le *nife is used to excise t#e
uncinate rocess from its anterior attac#ment$ Maxillary line is a mucosal rominence arisin! from
t#e anterior attac#ment of middle turbinate alon! t#e lateral nasal "all )ertically u to t#e uer
border of inferior turbinate
1
$ T#is line aroximates "it# t#at of t#e /unction bet"een uncinate
rocess and maxilla$ 2ncinate rocess is usually incised be#ind t#is line$
After comlete uncinectomy t#e natural ostium could be seen /ust under t#e inferior ed!e of t#e cut
uncinate rocess$ ,0
3
telescoe can be used at t#is /uncture to identify t#e natural ostium of
maxillary sinus$ (n atients "it# anteriorly laced natural ostium a ball robe can be used to !ently
robe t#e osterior fontanelle area$ T#is "ould cause air bubble to arise from t#e natural ostium
t#us enablin! its identification$
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Dia!ramatic reresentation of maxillary line and its relations#is
4
5#ile erformin! endoscoic sinus sur!ery it is imortant to differentiate natural ostium from
accessory ostium
6$
Presence of infraorbital cell 78aller9 "ill cause inferior dislacement of natural ostium ma*in! it
difficult to identify durin! routine endoscoic sinus sur!ery rocedures$
Difference bet"een natural and accessory ostium
Natural ostium Accessory ostium
Present anteriorly not )isible under routine
direct nasal endoscoic examination
Present osteriorly and can be easily )isuali0ed
durin! routin! nasal endoscoic examination
:)al in s#ae %#erical in s#ae
:riented trans)ersely :riented anteroosteriorly
Picture s#o"in! endoscoic )ie" of uncinate rocess
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Picture s#o"in! natural ostium oriented trans)ersely
'onclusion:
:steitic reaction t#at ta*es lace in t#e uncinate rocess leads to narro"in! of natural ostium of
maxillary sinus$ 8ence it is rudent to remo)e t#e entire uncinate rocess "#ile erformin!
endoscoic sinus sur!ery$
;eferences:
1$ <ennedy D5= >inreic# %?= %#aalan 8= <u#n &= Naclerio ;= 1oc# E$ Endoscoic middle
meatal antrostomy: t#eory= tec#ni+ue= and atency$ 1aryn!oscoe 1@ABC@B7A Pt , %ul
.,9:1D@$
2$ Endoscoic sinus sur!ery in Eeriatric atients ;on!Fsan! ?ian! ENT ?ournal Aril 2001
,$ #tt:--"""$drtbalu$com-fess$#tml
.$ Endoscoic Maxillary Antrostomy: Not ?ust A %imle Procedure Da)id <ennedy etal T#e
1aryn!oscoe 'V 2011 T#e American 1aryn!olo!ical= ;#inolo!ical and :tolo!ical %ociety=
(nc$
4$ #tt:--"""$drtbalu$com-EndoGdcr$#tml
6$ #tt:--"""$drtbalu$co$in-dne$#tml
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