Evaluation of combined middle and inferior meatal antrostomies for endonasal eradication of severe maxillary sinusitis Adel Said El-Antably

This figure shows the bony anatomy of the maxilla (Clemente, 2005). Anatomy of Maxillary sinus. This figure shows the bony anatomy of the maxilla (Clemente, 2005).

Introduction Maxillary rhinosinusitis: CRS epidemiology: Definition. Classification. CRS epidemiology: CRS affects approximately 25 to 31 million people annually with about 18 to 22 million physician visits a year in the United States. Its prevalence is estimated to be between 5 % and 15 % in urban populations. CRS classification: CRSsNP, CRSwNP and AFRS.

Introduction CRS Treatment? Surgical Extranasal Endoscopic Medical vs.

This figure shows the bony anatomy of the maxilla (Clemente, 2005). Introduction Endoscopic Combined meatal antrostomies Conventional (MMA) This figure shows the bony anatomy of the maxilla (Clemente, 2005). vs.

Aim of the work

Ciliary beat (Christen and Berger, 2005) Basic considerations Mucociliary clearance. Ciliary beat (Christen and Berger, 2005)

Basic considerations Mucociliary clearance.

Basic considerations Mucociliary clearance.

Patients and methods Complete opacification on CT; Patients recruitment Inclusion criteria Exclusion criteria Complete opacification on CT; No history of previous nasal surgery; Failure of medical treatment ≥ 3 months; Difficulty of disease eradication by the use of conventional endoscopic procedures. Any patient that can be managed using conventional endoscopic procedure.

Patients and methods Complaint. Present history. Past history. Preoperative preparation History taking Otorhinolaryngological examination Radiological investigations Complaint. Present history. Past history. Family history. Endoscopic grading: Mucosa, Discharge. CT scan. Lund-Mackay classification .

Patients and methods MMA Submucous partial resection of IT bone IMA Operation MMA Submucous partial resection of IT bone IMA Eradication of pathology

Patients and methods MMA NLD IMA Submucous partial resection of IT bone NLD IMA

Patients and methods MMA NLD IMA Submucous partial resection of IT bone NLD IMA

Patients and methods MMA NLD IMA Submucous partial resection of IT bone NLD IMA

Patients and methods Improvement of clinical symptoms. Postoperative evaluation History taking Otorhinolaryngological examination Mucociliary clearance test [India ink test] (6th_month postop.) Radiological investigations (6th_month postop.) Improvement of clinical symptoms. Endoscopic grading: Mucosa, Discharge, IMA patency. CT scan. Lund-Mackay classification .

Patients and methods Mucociliary clearance test [India ink test].

Results

Family history of atopy [no. (%)] Results Patients demographics. Disease Patients no. Age range Mean age ± SD Asthma [no. (%)] Family history of atopy [no. (%)] BANP 9 27 - 66 42.3 ± 14.0 5 (55.6 %) 2 (22.2 %) ACP 7 24 -52 34.9 ± 11.4 AFRS 4 17 - 29 22.8 ± 5.3 2 (50 %) This table shows patients demographics according to each disease. Bilateral allergic nasal polypi (BANP), antrochoanal polyp (ACP), allergic fungal rhinosinusitis (AFRS).

Results Preoperative and postoperative symptoms. Patients no. Percentage (%) * P value Nasal obstruction Preoperative At 2 weeks postop. At 1 month postop. At 2 months postop. At 3 months postop. At 4 months postop. At 5 months postop. At 6 months postop.   19 2 95 10 0.00 Nasal discharge 20 18 9 100 90 45 Headache / Facial pain 50 Results Preoperative and postoperative symptoms. This table shows the preoperative and postoperative (during follow-up period) symptoms. * Statistically different percentage from preoperative symptoms (P < 0.05).

Results Postoperative endoscopic gradings. Sign Patients no. * P value Grade 0 Grade 1 Grade 2 Maxillary mucosa At 2 weeks postop. At 1 month postop. At 2 months postop. At 3 months postop. At 4 months postop. At 5 months postop. At 6 months postop.   2 7 15 18 19 13 5 1 0.00 Nasal discharge 12 4 8 20 16 IMA patency 0.42 Results Postoperative endoscopic gradings. Grades of endoscopic mucosal changes according to Hong et al. in 2001. Grades of endoscopic nasal discharge according to Lanza and Kennedy in 1997. This table shows the grades of maxillary antral mucosal changes, nasal discharge and inferior meatal antrostomy (IMA) patency during the postoperative period. * Statistically different from preoperative scores (P < 0.05).

Results Mucociliary clearance test results. Patient no. Discharge from MMA Discharge from IMA Circular flow 1   — 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Mucociliary clearance test results. This table shows the results of india ink test at the sixth postoperative month. Middle meatal antrostomy (MMA); Inferior meatal antrostomy (IMA).

Maxillary sinus CT scan score Results Preoperative and postoperative CT scan scores. Grade Maxillary sinus CT scan score * P value Preoperative (Patients no.) Postoperative 19   0.00 1 2 20 This table shows preoperative and postoperative (at the sixth postoperative month) maxillary sinus CT score. * Statistically different from preoperative scores (P < 0.05).

This figure shows preoperative CT scan of a case of ACP. Results A case of ACP CT scans. This figure shows preoperative CT scan of a case of ACP.

This figure shows postoperative CT scan of a case of ACP. Results A case of ACP CT scans. This figure shows postoperative CT scan of a case of ACP.

Results Marked improvement of symptoms was recorded postoperatively (P < 0.05) in all our patients (100 %). The maxillary sinus was lined by thin normal-looking mucosa within 3 – 5 months postoperatively in 19 cases (95 %). CT scans’ scores showed statistically significant improvement (P < 0.05) at the sixth postoperative month in 19 patients (95 %). No recurrence. No mucus recirculation.

Results Complications: No destabilization of IT; No excessive bleeding; No NLD disturbance; No mucus recirculation; Temporary paraesthesia of the upper central and lateral incisors was encountered in one patient for 2 months postoperatively and improved gradually later on; Stenosis of IMA in one patient.

This figure shows stenosis of IMA. Results This figure shows stenosis of IMA.

Discussion Previous studies: Hinohira et al. in 2009 and Albu et al. in 2011 (same principle). Ochi et al. in 2003 (Mucociliary clearance test). Kane in 2003 (Mucus recirculation).

Conclusion Dependable procedure for surgical treatment of the severely diseased maxillary sinus. Allows removal of severe mucosal disease within the maxillary sinus that cannot be reached through the middle meatal antrostomy. Easier postoperative management. No mucus recirculation.