eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Sinusitis, Maxillary, Chronic, Surgical Treatment

Author: Ankit Patel, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, St Joseph Medical Center, Silver Cross Hospital
Coauthor(s): Winston C Vaughan, MD, Founder and Director, California Sinus Institute and Foundation; Director, CSI Advanced Sinus Surgery and Rhinology
Contributor Information and Disclosures

Updated: Mar 6, 2008

Introduction

Sinusitis affects approximately 35 million people annually in the United States, with an attendant medical cost of $5.8 billion annually.

In adults, the maxillary sinuses are most commonly affected with acute and chronic sinusitis. Most of these cases can be managed with medications alone. For the instances where medical management fails, surgery may be needed to treat chronic maxillary sinusitis.

For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center and Eye and Vision Center. Also, see eMedicine's patient education articles Sinus Infection and Eye Pain.

History of the Procedure

Open approaches to the maxillary sinus were first described in the early 1700s. The well-known Caldwell-Luc operation was first described in the United States by George Walter Caldwell in 1893 and then by Henri Luc of France in 1897. Subsequent advances in the understanding of the physiologic drainage pattern of the maxillary sinus led to intranasal middle meatus antrostomy in the late 1960s and the early 1970s. Functional endoscopic sinus surgery (FESS) is based on the surgical approach performed by Messerklinger and Wigand in Europe via the ostiomeatal complex.^1,2 FESS has become the standard surgical treatment for chronic maxillary sinusitis, with external approaches being used as an adjunct in more complicated cases or in tumor management.

Problem

In 1996, the American Academy of Otolaryngology-Head & Neck Surgery convened a multidisciplinary Rhinosinusitis Task Force (RTF). This group defined adult rhinosinusitis diagnostic criteria. In 2003, this definition was amended to require confirmatory radiographic or nasal endoscopic or physical examination findings in addition to suggestive history. The following paragraphs provide a summary of these criteria.

Rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses. Chronic rhinosinusitis is rhinosinusitis of at least 12 consecutive weeks' duration. The 1996 diagnostic criteria, as defined by the RTF, required 2 or more major factors or 1 major factor and 2 minor factors. Major factors for diagnosis include facial pain or pressure, nasal obstruction or blockage, nasal discharge or purulence or discolored postnasal discharge, hyposmia or anosmia, purulence in nasal cavity, and fever (for acute rhinosinusitis only). Minor factors were defined as headache, fever (for chronic rhinosinusitis), halitosis, fatigue, dental pain, cough, and ear pain, pressure, or fullness. Of note, facial pain requires another major factor associated with it for diagnosis (facial pain plus 2 minor factors is not deemed sufficient for diagnosis of rhinosinusitis).

The 2003 diagnostic criteria for chronic rhinosinusitis require the above criteria for longer than 12 weeks or more than 12 weeks of physical findings. In addition, one of the following signs of inflammation must be present:

• Discolored nasal drainage from the nasal passages, nasal polyps, or polypoid swelling as identified on physical examination with anterior rhinoscopy after decongestion or nasal endoscopy
• Edema or erythema of the middle meatus or ethmoid bulla on nasal endoscopy
• Generalized or localized erythema, edema, or granulation tissue (If the middle meatus or ethmoid bulla is not involved, radiologic imaging is required to confirm a diagnosis.)

Imaging modalities confirming the diagnosis include the following:

• CT scanning demonstrating isolated or diffuse mucosal thickening, bone changes, or air-fluid levels OR
• Plain sinus radiography revealing air-fluid levels or greater than 5 mm of opacification of one or more sinuses
• MRI not recommended for routine diagnosis because of its excessive sensitivity and lack of specificity

In general, plain radiography has low sensitivity and specificity. CT scanning is considered the imaging standard for evaluation of chronic sinusitis.

Etiology

See Future and Controversies.

Pathophysiology

Much remains to be elucidated about the pathophysiology of chronic maxillary sinusitis. The main theory lies in obstruction at the level of the ostiomeatal complex leading to stasis and infection of secretions within the maxillary sinus. Obstruction may occur secondary to any number of inciting factors including upper respiratory tract infection (viral, bacterial, or fungal), allergic rhinitis, trauma, or prior surgery.

Presentation

Chronic maxillary sinusitis is defined as sinusitis lasting longer than 12 weeks. Suggestive history as above may include chronic facial pressure (maxillary region), headache, rhinorrhea, postnasal drip, decreased sense of smell, or dental pain. Confirmatory findings on the physical examination include intranasal edema, purulence, or rhinorrhea. Other etiologies for headache and rhinitis should be ruled out because migraine, tension headache, or allergic rhinitis can mimic chronic sinusitis. Often, allergic rhinitis may be observed in conjunction with chronic sinusitis.

Preoperative workup should include a complete history and physical examination along with CT scanning of the paranasal sinuses. The physical examination should include a nasal endoscopy with a culture and/or biopsy if needed. Screening CT scanning (3- to 5-mm direct coronal cuts) can be used for clinical diagnosis. Thereafter, surgical CT scanning may be obtained for finer anatomic detail and preoperative planning.

Indications

Surgery for chronic sinusitis is reserved for those patients who did not respond to medical therapy. Medical treatment should include 3-6 weeks of antibiotics, nasal steroids, and nasal saline irrigations. Antibiotics should be chosen after cultures are obtained endoscopically if possible. Oral steroids are used if significant nasal edema is observed on nasal endoscopy. A short course of decongestants and mucolytics should be considered for patients with significant nasal congestion and thick nasal secretions.

CT scanning should be obtained to confirm clinical suspicion of chronic sinusitis. Findings may include significant mucosal thickening, air-fluid levels, ostiomeatal complex obstruction, polyposis, or calcification suggestive of fungal sinusitis.

Relevant Anatomy

Embryology

The maxillary sinus is present at birth, undergoing further expansion with age. Two main points of rapid growth occur, from birth until age 3 years and then from age 7 years through early adolescence. The sinus then slowly grows until it reaches adult size by age 18 years. Later in adult life, the sinus continues to pneumatize inferiorly and may expand to contain tooth roots. The average size of the maxillary sinus is 34 mm X 33 mm X 23 mm, with an average volume of 14.75 mL. In an adult, the floor of the maxillary sinus is below the level of the nasal floor.

Anatomy

An understanding of the lateral nasal wall anatomy is critical to performing safe and effective endoscopic sinus surgery.

The maxillary sinus is housed in the body of the maxilla, with the inferior orbital wall as the superior border, the lateral nasal wall as the medial boundary, the alveolar process of the maxilla as its inferior border, and the canine fossa as the anterior border.

The main functional component of the maxillary sinus outflow tract is the ostiomeatal complex, which is collectively constituted by the uncinate process, the maxillary ostium, the infundibulum, and the ethmoid bulla. These structures form a functional complex through which the maxillary sinus contents egress. Obstruction of the ostiomeatal complex and its relief with surgery form the basis for FESS.

The uncinate process is a sickle- or L-shaped bone that starts anterosuperiorly and then slopes posteroinferiorly, running horizontally from anterior to posterior. It has a free edge along its superior surface, which is taken down during uncinectomy. Superiorly, the uncinate process may attach to the lamina papyracea (most common configuration), the middle turbinate, or the skull base. At its most posterior point, it attaches to the inferior turbinate at the ethmoidal process.

Once the uncinate process is taken down, the natural maxillary sinus ostium can be visualized. The cilia of the maxillary sinus beat uphill toward the natural maxillary sinus ostium. Therefore, the natural ostium of the maxillary sinus must be included with maxillary antrostomy for maximal functional benefit. If the natural ostium is missed, mucus recirculation may be a problem. The ethmoid bulla lies just posterior to the uncinate process and may be visible along with the uncinate process on routine nasal endoscopy. The ethmoid bulla is the most constant anterior ethmoid air cell.

Contraindications

No absolute contraindications to endoscopic surgical treatment of chronic maxillary sinusitis exist.

• Search for CME/CE on This Topic »

• Sinusitis, Chronic, Medical Treatment (Otolaryngology and Facial Plastic Surgery)
• Pediatric Sinusitis, Medical Treatment (Otolaryngology and Facial Plastic Surgery)
• Sinusitis (Emergency Medicine)
• Pediatric Sinusitis, Surgical Treatment (Otolaryngology and Facial Plastic Surgery)

• Ear, Nose, and Throat Center
• Sinus Infection Overview
• Sinus Infection Symptoms
• Eye Pain Overview
• Sinus Infection Causes
• Sinus Infection Treatment
• Eye and Vision Center

• Premature Ventricular Complexes May Be a Cause of Chronic Cough
• Eccentric Exercise Technique Offers Easy, Affordable Intervention for Chronic Lateral Epicondylitis
• Adenotonsillectomy Reduces OSA in Infants and Toddlers

• Acute and Chronic Rhinosinusitis: Practical Clinical Treatment Strategies
• Rhinosinusitis in Children and Asthma Severity
• Examining the Ears, Nose, and Oral Cavity in the Older Patient

• Chronic Leukemia Resource Center
• IBS and Chronic Constipation Resource Center
• Anemia of Chronic Kidney Disease Resource Center