Abstract
A 55-year-old man presented with a history of right-sided nasal congestion. He was complaining of a bad odor from his nose. He had been treated repeatedly with antibiotics over a 3-month period by his family doctor. He had no facial pain or upper toothache. Of note was that he had a history of nasal and sinus surgery on the right side 18 years previously.
Clinical examination revealed that the patient's nasal airways were poor, particularly on the right. An endoscopic examination showed mucopurulent drainage coming from the middle meatus. Computed tomography (CT) of the sinus showed an almost totally opacified right maxillary sinus in spite of evidence of a previous inferior meatal antrostomy (figure, A). Because of his poor response to medical treatment, the patient was taken to the operating room for endoscopic surgery.
CT scan of the sinuses shows an opacified right maxillary sinus with a patent, previously performed inferior meatal antrostomy. B: Telescopic view (0°, 4 mm) of the right nasal cavity shows a patent right inferior meatal antrostomy (arrow). C: Telescopic view (30°, 4 mm) of the maxillary sinus through the inferior meatal opening shows inspissated mucopurulent material in the right maxillary sinus, including near the area of the natural ostium. D: The maxillary sinus is seen after a completed right middle meatal antrostomy (arrow). E: The maxillary sinus, as viewed through the middle meatal antrostomy, is seen 6 months after surgery. F: Illustration shows the normal secretion transport pattern in the maxillary sinus. G: This illustration shows the secretions being transported superiorly toward the natural ostium around the large inferior meatal antrostomy.
At the time of surgery, we found a widely patent inferior meatal antrostomy (figure, B). Endoscopic evaluation of the maxillary sinus through the inferior meatal opening revealed inspissated mucoid material. Examination of the superior and medial portion of the maxillary sinus showed extensive mucopurulent secretions and what appeared to be an occluded natural ostium (figure, C). Therefore, a middle meatal antrostomy was carried out with a microdebrider (figure, D). Six months after the surgery, the patient was doing well (figure, E).
Secretion transport in the maxillary sinus starts inferiorly from the floor of the sinus and proceeds in a stellate pattern superiorly and medially to the natural ostium (figure, F).1,2 This discovery was described by Hilding 3 and later reinforced dramatically by Messerklinger. 4
Described in 1880 by Mikulicz, an inferior meatal antrostomy was a commonly performed sinus procedure for maxillary sinus disease.5,6 The rationale for performing this procedure was that dependent drainage of secretions would be expected. The use of inferior meatal antrostomy has decreased markedly and has been replaced by middle meatal antrostomy, which is the preferred method of draining and ventilating the maxillary sinus.
This case illustrates that maxillary sinus secretions will be transported toward the natural ostium even in the presence of a previously placed large and patent inferior meatal antrostomy (figure, G). Therefore, it is important to remove any obstruction of the natural ostium of the maxillary sinus or the ethmoid infundibulum.