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

2. 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).

3. 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.

4. Introduction
CRS Treatment?
Surgical
Extranasal
Endoscopic
Medical
vs.

5. 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.

6. Aim of the work

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

8. Basic considerations
Mucociliary clearance.

9. Basic considerations
Mucociliary clearance.

10. 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.

11. 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 .

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

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

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

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

16. 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 .

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

18. Results

19. 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
42.3 ± 14.0
5 (55.6 %)
2 (22.2 %)
ACP 7
24 -52
34.9 ± 11.4
AFRS 4
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).

20. 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).

21. 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 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).

22. 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).

23. 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).

24. 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.

25. 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.

26. 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.

27. 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.

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

29. 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).

30. 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.