Delayed reocclusion of a middle meatal antrostomy. (Rhinoscopic Clinic).
We obtained computed tomography (CT) of the sinuses, which detected bilateral maxillary sinusitis (figure, A). We also performed nasal endoscopy of the left middle meatus, which showed the previously created middle meatal antrostomy had completely closed (figure, B). We performed revision surgery to open the left membranous closure with a Lusk ball probe (figure, C) and to enlarge the opening circumferentially with a microdebrider (figure, D). On the right side, the status of the middle meatal antrostomy was similar, although the closure was not complete, and we performed the same surgical procedure. Postoperatively, the two middle meatal antrostomies remained widely patent, and the patient remained asymptomatic 8 months later.
Surgical enlargement of a maxillary sinus ostium can be used to treat diseased maxillary sinus mucosa. (1) The diameter of the natural ostium varies from 2 to 7 mm, (2) If the natural ostium is judged to be inadequate for ventilation, it can be enlarged with biting instruments or with a powered microdebrider. Experiments have suggested that the ostium must be at least 5 mm in diameter in order to allow for adequate gas exchange. (3) The maxillary sinus can be opened widely to an area of 1 [cm.sup.2], particularly if there is pathology within the maxillary sinus that requires surgical removal. (1)
The reported rates of stenosis of enlarged maxillary sinus ostia are quite low, despite initial concerns over long-term patency. Before enlargement of the maxillary sinus ostium became an accepted procedure, the possibility of closure of the ostium and subsequent chronic disease was a potent argument against manipulation of the natural ostium via a middle meatal approach. In 1987, Kennedy et al reported a 98% patency rate in a 4- to 32-month follow-up of middle meatal antrostomies. (4) Kamel reported a patency rate of 96.8%. (5) Krouse and Christmas compared the results of conventional endoscopic sinus surgery and powered instrumentation and found patency rates of 97 and 99%, respectively. (6) Yet although most authors have reported high success rates, others have reported somewhat lower rates. In an examination of surgical failures following endoscopic sinus surgery, Ramadan reported a patency rate of only 85% in the maxillary sinus ostium. (7) In cases where the ostium was associated with adhesions in the e thmoid areas, the patency rate fell to 73%. (7)
Although the long-term patency of an enlarged maxillary ostium has been well documented, the possibility of occlusion and subsequent recurrent disease cannot be overlooked. Two factors that contribute to stenosis include scar formation at the ethmoid dissection and an incomplete removal of the inferior uncinate remnant. Rust et al, in an animal model, suggested that the placement of a stent at the surgically enlarged maxillary sinus ostium can increase the risk of stenosis. (8)
Our case was uncommon in that it featured the complete membranous closure of a previously enlarged maxillary sinus ostium. Our experience illustrates the importance of performing an endoscopic examination of the middle meatus in patients with recurring maxillary sinusitis who have had a previous middle meatal antrostomy.
From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Otolaryngology Section, Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante), and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Center, New Haven, Conn., the Section of Otolaryngology, Yale University School of Medicine, New Haven, and the Section of Otolaryngology, Hospital of St. Raphael, New Haven (Dr. Yanagisawa).
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(2.) Hollinshead WH. The head and neck. In: Hollinshead WH. Anatomy for Surgeons. 2nd ed., vol. 1. New York: Harper and Row, 1968.
(3.) Aust R, Stierna P. Drettner B. Basic experimental studies of ostial patency and local metabolic environment of the maxillary sinus. Acta Otolaryngol Suppl 1994; 515:7-l0.
(4.) Kennedy DW, Zinreich SJ, Shaalan H, et al. Endoscopic middle meatal antrostomy: Theory, technique, and patency. Laryngoscope 1987; 97(Suppl 43):l-9.
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(8.) Rust KR, Stringer SP, Spector B. The effect of absorbable stenting on postoperative stenosis of the surgically enlarged maxillary sinus ostia in a rabbit animal model. Arch Otolaryngol Head Neck Surg 1996; 122:1395-7.