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

Sinusitis, Maxillary, Chronic, Surgical Treatment: 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

Treatment

Medical Therapy

Medical therapy is the first-line treatment of chronic sinusitis. It should consist of a 3- to 6-week course of oral antibiotics (eg, fluoroquinolone or macrolide, a broad-spectrum penicillin class drug with beta lactamase inhibitor), steroids, and nasal saline irrigations. If significant intranasal edema is observed on endoscopic examination, a course of oral steroids (7-28 d, depending on severity) may serve as a useful adjunct therapy. Consider a short course of decongestant to provide symptomatic relief for patients with symptoms of significant nasal congestion. High doses of guaifenesin (600 mg PO bid) may also be beneficial as a mucolytic for patients with tenacious nasal secretions.

Culture-directed antibiotics may be used based on endoscopically obtained cultures of middle meatus mucopurulence, if empiric antibiotics have already failed.

Surgical Therapy

Surgery is reserved for patients with confirmed chronic sinusitis, as documented by findings on history, physical examination findings, and CT findings, who have not responded to medical therapy.

Three main surgical options are available: (1) endoscopic uncinectomy with or without maxillary antrostomy, (2) Caldwell-Luc procedure, and (3) inferior antrostomy (naso-antral window).

Today, endoscopic maxillary antrostomy and uncinectomy are the standard for treatment of refractory chronic maxillary sinusitis. The Caldwell-Luc and inferior antrostomy approaches are reserved for rare circumstances (an example may be a case of severe allergic fungal sinusitis where standard antrostomy alone does not allow complete extirpation of fungal concretions or complete drainage).

Additionally, further FESS with mucosal sparing techniques may be performed if additional disease is present within the ethmoid, sphenoid, and frontal sinuses.

Preoperative Details

Consent should be obtained prior to any surgical procedure. This should include a thorough discussion of possible risks such as orbital injury, blindness, nasolacrimal duct injury, epiphora, epistaxis, cerebrospinal fluid leak, meningitis and brain abscess, and of course persistent rhinosinusitis.

A preoperative antibiotic course may be administered in the weeks prior to surgery if an active infection is present. A preoperative steroid course may be administered if significant edema or polyps are observed on examination.

Intraoperative Details

Endoscopic maxillary antrostomy

Before entering the operating room, the surgeon should select, inspect, and prepare all instrumentation, including image guidance devices. In the preoperative holding area, nasal decongestion is begun with the patient receiving sprays of oxymetazoline. Following the commencement of general endotracheal anesthesia, the eyes are protected with eye ointment and thin strips of tape. The nasal passages are decongested with appropriate vasoconstrictors such as topical cocaine if not medically contraindicated.

If septoplasty is to be performed, the septum should be infiltrated with 1% lidocaine with 1:100,000 epinephrine in the submucochondrial plane. Then, the patient is draped and prepared for surgery. A 4-mm 0- or 30-degree endoscope may be used, depending on the surgeon's preference. If septoplasty is to be performed, it may be done either before or after sinus surgery. Place the septoplasty incision in the unobstructed nasal passage to allow better visualization of the more obstructed side.

Under endoscopic guidance, the middle turbinate may be gently moved medially, with care to avoid fracturing the turbinate–skull base junction. At this point, the uncinate process should be within view, and it is injected with 1% lidocaine with 1:100,000 epinephrine. Local injections can be made using a 10-mL control syringe with a luer lock 27-gauge needle attached. First, the root of the uncinate process is injected. Next, the inferior portion of the uncinate process is injected. The root of the middle turbinate is infiltrated as well. Finally, an injection is placed at the inferior junction of the basal lamella with the lateral nasal wall. This serves to vasoconstrict the sphenopalatine artery. Approximately 1-2 mL of local anesthetic is used at each injection site, with the bevel down (toward mucosa). An appreciable blanche of the mucosa should be observed with each injection.

If using an image-guided system, it can be calibrated at this time (thereby giving time for vasoconstriction from the injections to take effect). Alternatively, the system may be calibrated prior to beginning the case. When using an image-guided system, checking the position of the guidance tracking in a few different known points and confirming the accuracy in 3 dimensions is important. Typically, for isolated chronic maxillary sinus disease, image-guided surgery is not necessary.

After decongestion, uncinectomy is the next step. Uncinectomy can be performed in numerous ways. The following is the authors' preference. Under endoscopic guidance, a maxillary ostium seeker is insinuated just behind the uncinate process and carefully used to outwardly and anteriorly displace the free edge of the uncinate. Care is taken to only very gently manipulate the uncinate process and not to penetrate deeply to prevent lamina papyracea injury.

Next, 90-degree upbiting forceps are used to grasp the free edge of the uncinate process. In a controlled push and pull fashion, staying parallel to the lacrimal duct, the uncinate process is then removed. Care is taken to engage the uncinate process parallel to the lateral nasal wall to prevent injury to the lamina papyracea. Any remaining uncinate process may be removed using a combination of microdebrider powered instrumentation and pediatric forceps. All portions of the uncinate should be taken down completely to permit visualization of the natural maxillary sinus ostium, roughly parallel to the inferior portion of the middle turbinate.

Once the natural ostium is identified, an ostium seeker can be placed through the ostium and then carefully pushed posteriorly to widen the ostium. Using a through-cutting forceps, the ostium is enlarged, thereby completing a maxillary antrostomy. The maxillary sinus should be inspected with a 30- or 70-degree scope to ensure that no further disease is present within the sinus and that the natural ostium was included in the antrostomy. If either a microlith or a polyp is present, it may be removed using curved giraffe forceps or a curved suction. Further endoscopic work can be performed if disease is present in other sinuses.

If lateralization of the middle turbinate is a concern and to allow easier postoperative examination of the maxillary antrostomy in the office, the controlled synechiae technique as described by Bolger et al in 1999 may be used. Briefly, this involves abrading the opposing areas of mucosa from the medial middle turbinate and septum. With healing, the two roughened areas appose, thus medializing the turbinate for improved postoperative visualization of the maxillary sinus antrostomy.

The middle meatus may be packed with various products if either postoperative bleeding or lateralization of the middle turbinate is a concern. Many packing materials have been described, ranging from rolled Gelfilm to Merocel packing. The authors' preference is for a latex-free glove-covered trimmed Merocel in the middle meatus. This should be removed at the first postoperative visit (3-5 d).

Caldwell-Luc procedure

For patient comfort, this procedure is typically performed under general anesthesia. However, if medical comorbidities preclude general anesthesia, the procedure may be performed with local anesthetic and sedation. It may be performed in conjunction with nasoantral window (inferior antrostomy) to facilitate postoperative surveillance.

Lidocaine, 1% with 1:100,000 epinephrine, is injected in the incision site, and time is allowed for vasoconstriction. Make a 3-cm incision centered over the canine tooth and first premolar while leaving about 0.5-1 cm of gingiva intact above the dentition to facilitate closure. Using electrocautery, dissection is carried down through the soft tissue and periosteum to bone. Next, a periosteal elevator is used to widely elevate periosteum from the anterior wall of the maxilla. Care is taken to identify and avoid injury to the infraorbital nerve, which is vertical and inferior to the mid pupillary line. In the canine fossa, with mallet and osteotome, the maxillary sinus is entered through its anterior thin bone. Thereafter, rongeurs are used to enlarge the opening. Any pus from the maxillary cavity may be sent for culture. The disease within the sinus can be appropriately addressed. Next, the sinus is irrigated. The incision is then closed using 3-0 or 4-0 absorbable suture.

Inferior antrostomy

Vasoconstriction is begun with topical oxymetazoline on pledgets. Next, 1% lidocaine with 1:100,000 epinephrine is injected under endoscopic guidance along the lateral nasal wall underneath the inferior turbinate. A 3-mL syringe with a 27-gauge needle facilitates the injection. Because the nasolacrimal duct lies approximately 1 cm anterior to the natural maxillary ostium, the injection and surgical antrostomy site is about one to two thirds of the distance back along the inferior turbinate. Next, the maxillary sinus is punctured in this region using a curved suction or trocar. This antrostomy should then be enlarged with through-cutting forceps. The maxillary sinus disease should then be extirpated as appropriate.

Postoperative Details

The stomach and nasopharynx should be suctioned prior to extubation. The surgeon should confirm with the anesthesiologist that an appropriate antiemetic was administered during surgery.

After extubation, the patient is taken to the postoperative care unit for recovery. Once the patient is awake, the patient is examined to check extraocular motility and to check for evidence of excessive bleeding or proptosis. If the patient is doing well, he or she may be discharged home after all postanesthesia protocol parameters have been satisfied.

Follow-up

Postoperative care of the patient with chronic sinusitis is essential for long-term success. The patient is sent home with appropriate pain medications and instructions for nasal saline irrigations.

The patient returns for the first postoperative visit 3-5 days after surgery. At this time, the middle meatus packing is removed and all crusts and dried blood clots are carefully débrided. Weekly follow-up may be needed for the first month, and then biweekly follow-up with débridements may be indicated for the second month. After the second month, the patient is usually monitored quarterly for the first year. Further follow-up is then determined by the severity of the patient's disease, healing, and symptoms.

Further medical management after surgery with antibiotics, nasal steroids, antihistamines, allergy medications, and oral steroids is individualized based on the patient and further flares of sinusitis.

Complications

Pitfalls

Several studies have been conducted to elucidate the common causes of failure in FESS. These may include incomplete uncinectomy or failure to include the natural maxillary sinus ostium within the antrostomy and thereby creating recirculation between two ostia. Lateralization of the middle turbinate or turbinate remnant and postoperative synechiae formation are also common. These pitfalls may be carefully avoided by performing a complete uncinectomy, identifying and enlarging the true maxillary sinus ostium, being gentle with medialization of the middle turbinate, and using a mucosal-sparing technique with through-cutting instrumentation to avoid excess mucosal stripping.

Postoperative nasal endoscopic debridement is critical to decrease scarring and synechiae formation. The mucosa of the maxillary sinus should not be stripped routinely. The mucosa should be left intact because the mucosa that replaces stripped areas is devoid of proper ciliary function. This contributes to postoperative problems with mucus stasis and recurrent infection.

Occasionally, either secondary to scar band formation or in association with inferior antrostomy, recirculation may occur. This refers to the recirculation of maxillary sinus contents out of the natural ostium, along the mucosal band, and then back into the surgical antrostomy, thus creating an endless cycle of mucus build-up. To correct this, the intervening band of mucosa should be taken down to enlarge the antrostomy and to eliminate the cause of the recirculation.

Complications

Endoscopic maxillary antrostomy

Complications of endoscopic surgery for chronic maxillary sinusitis may include orbital injury, blindness, orbital hematoma, nasolacrimal duct injury, epiphora, and postoperative epistaxis. Skull base injury and cerebrospinal fluid leak are very rare possible complications that should be discussed with patients undergoing endoscopic sinus surgery. With simple maxillary antrostomy, however, the risk of skull base injury should be negligible.

Caldwell-Luc procedure

The main complications associated with the Caldwell-Luc procedure include oroantral fistula, infraorbital nerve injury with associated hypesthesia, and injury to the tooth roots.

Inferior antrostomy

The main risk associated with inferior antrostomy is nasolacrimal duct injury. Recirculation of mucus from the natural maxillary ostium through the newly created inferior antrostomy is possible. This usually occurs when inferior turbinate reduction is also performed.

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