Iatrogenic maxillary sinus recirculation and beyond. (Original Article).

Abstract

Recirculation of nasal mucus occurs when secretions that have been transported out of the natural maxillary ostium return to the sinus via a surgically created or accessory ostium. Recirculation increases the risk of persistent sinus infection. In this article, we describe a case of mucus recirculation in a patient who had not responded to two previous sinus surgeries for recurrent rhinosinusitis. We also postulate the possibility of ethmoid recirculation.

Introduction

Functional endoscopic sinus surgery has been a most successful procedure, and clinical failure rates of less than 10% have been reported in the literature. (1) According to the Messerklinger approach, the key to eliminating persistent sinus infection is to re-establish physiologic mucociliary clearance patterns. (2) Patients in whom sinus surgery has failed have often exhibited evidence that their mucociliary clearance pathways were functionally or anatomically obstructed. One functional mechanism that has been well described is the recirculation phenomenon. (3,4)

Recirculation occurs when secretions that have been transported out of the natural maxillary ostium return to the sinus via a surgically created or accessory ostium; the process then becomes cyclical. (5) Matthews and Burke described the adverse effect of recirculation: "The putative mechanism of sinus disease related to this recirculation involves the repeated presentation of allergens, bacteria, and inflammatory mediators contained in the mucus. If the mucus is not cleared, its viscidity increases, and its concentration of inflammatory agents increases its potential for inducing sinus mucosal inflammation and disease." (6)

In this article, we describe our endoscopic identification of an incontrovertible case of mucus recirculation in a patient who had not responded to two earlier sinus surgeries for recurrent rhinosinusitis. We also emphasize the principles of the diagnosis and treatment of recirculation, and we postulate the possibility of ethmoid recirculation.

Case report

In 2000, we evaluated a 48-year-old man who had recurrent rhinosinusitis despite having undergone sinus surgery in 1996 and 1997. He had experienced a brief period of relief following the second operation, but thereafter several acute infections of worsening severity ensued. During our initial evaluation, the patient complained of severe nasal congestion and thick postnasal drainage despite more than 4 weeks of culture-specific antibiotic therapy. Adjunctive nasal irrigation had also been unsuccessful in alleviating his symptoms.

Fiberoptic examination of the nasal cavities revealed that the iatrogenic ostia were patent bilaterally. A drop of turbid mucus was detected resting above the left iatrogenic ostium. Computed tomography (CT) detected a bilateral soft-tissue obstruction of the natural ostia, which were discontinuous with the surgically created ostia (figure 1).

Based on these findings, the patient was taken for revision endoscopic sinus surgery. Intraoperatively, we noted that a tenacious ring of clear mucus was circulating through the natural and iatrogenic maxillary ostia (figure 2). To connect the two ostia, we inserted the ball-tipped end of the Houser Freer-seeker (Instrumentarium Surgical Corp.; Terrebonne, Que.) into the natural ostium and pulled it downward into the large iatrogenic ostium. We then sharply debrided the tissue remnants with the Hummer microdebrider (Stryker Leibinger; Kalamazoo, Mich.). We also performed bilateral revision anterior and posterior ethmoidectomies, a right frontal sinusotomy, and a reduction of the inferior turbinates.

Follow-up endoscopy 3 months following surgery revealed that the new ostium was widely patent and well healed (figure 3). At 14 months, the patient reported a significant improvement in his condition; compared with his preoperative state, he was experiencing less congestion, mucus formation, and fatigue. Since then, he has required one course of antibiotic treatment. He continues to use a nasal irrigator periodically as needed (less frequently than before) and he continues to use a steroid nasal spray regularly.

Discussion

Under normal circumstances, clearance from the maxillary sinus proceeds from the natural ostium, which is usually located in the posterior third of the ethmoid infundibulum. (7) The secretions then traverse from the hiatus semilunaris to the medial wall of the inferior turbinate, and then they move posteriorly to the nasopharynx. It has been well established that mucus is cleared from the maxillary sinus via the natural ostium even in the presence of large nasoantral or middle meatal windows that are separate from the natural ostia. (2) In our patient, the CT finding of discontinuity between the natural and iatrogenic ostia led us to suspect that recirculation had been occurring. Our suspicion was confirmed endoscopically. During surgery, we re-established a physiologic mucociliary pathway by connecting the two ostia in the manner described by Coleman and Duncavage. (8)

Theoretically, recirculation can occur in any sinus that has an accessory or iatrogenic ostium through which mucus can return to the sinus. The recirculation phenomenon has been observed in the sphenoid sinus.9 It has also been documented in a maxillary sinus following the creation of nasoantral windows. Recirculation has even been documented by graphite tracing in the ethmoid cavity following posterior ethmoidectomy. (10) We suggest that recirculation can occur following an anterior ethmoidectomy as well; such a process has not been previously reported in the literature.

During an anterior ethmoidectomy, the typical first step is to perforate the anteroinferior wall of the ethmoid bulla. A microdebrider or forceps is then used to more fully open the bulla. If only an anterior ethmoidectomy is indicated, then the surgeon might inadvertently leave the posterior wall of the bulla intact. The posterior wall of the bulla tightly overlies the retrobullar space and basal lamella. The natural drainage point for the ethmoid bulla is frequently located at the most lateral part of the posterior bullar wall. This point would remain discontinuous with the iatrogenic defect if a bridge of posterior bullar wall that is medial to the natural ostium remains intact. According to the findings of Waguespack's study of mucociliary clearance following sinus surgery, mucus situated on the lamina papyracea, previously the lateral wall of the bulla, will flow posteriorly onto the basal lamella. (10) We suspect that this mucus could easily loop back over the surgically created bridge of tissue and est ablish a circular flow pattern.

In order to prevent ethmoid recirculation, we prefer to identify the ostium of the bulla and resect the bridge of the posterior bullar wall. To achieve this, we introduce a curved seeker along the lateral surface of the middle turbinate, back toward the basal lamella. We gently pass the seeker into the retrobullar space between the basal lamella and the posterior bullar wall. With careful manipulation, the seeker tip can be seen as it passes through the natural ostium of the bulla (figure 4). The seeker is then pulled back toward the surgeon to break the intervening bridge. A microdebrider can then effectively remove the remnants of the broken tissue bridge.

In conclusion, sinus surgery can be very successful if physiologic pathways of mucociliary clearance are reestablished. The sinus surgeon should be meticulous in connecting any accessory or surgically created drainage pathways with the natural ostia. Although recirculation following anterior ethmoidectomy is purely hypothetical at this point, its existence is anatomically intuitive. Ethmoid recirculation might account for some cases of persistent sinus disease and symptoms despite an otherwise satisfactory anterior ethmoidectomy. The technique we have described is fairly simple and adds minimal time to the length of the surgical procedure.

References

(1.) Citardi MJ, Sillers MJ. The management of chronic rhinosinusitis after failed sinus surgery. International Online Journal of Otorhinolaryngology--Head and Neck Surgery 1998;1:1-4.

(2.) Stammberger HR. Functional Endoscopic Sinus Surgery. The Messerklinger Technique. Philadelphia: B.C. Decker, 1991:17-37.

(3.) Yanagisawa E, Yanagisawa K. Endoscopic view of recirculation phenomenon of the maxillary sinus. Ear Nose Throat J 1997;76:196-8.

(4.) Chung SK, Dhong HJ, Na DG. Mucus circulation between accessory ostium and natural ostium of maxillary sinus. J Laryngol Otol 1999;113:865-7.

(5.) Kennedy D, Shanlan H. Reevaluation of maxillary sinus surgery: Experimental study in rabbits, Ann Otol Rhinol Laryngol 1989;98:901-6.

(6.) Matthews BL, Burke AJ. Recirculation of mucus via accessory ostia causing chronic maxillary sinus disease. Otolaryngol Head Neck Surg 1997;117:422-3.

(7.) Hollinshead WH. Anatomy for Surgeons. Vol. 1: The Head and Neck. 3rd ed. Philadelphia: Harper and Row, 1982:261-3.

(8.) Coleman JR, Jr., Duncavage JA. Extended middle meatal antrostomy: The treatment of circular flow. Laryngoscope 1996;106:1214-7.

(9.) Yanagisawa E, Weaver EM. Endoscopic view of the recirculation phenomenon of sphenoid sinus drainage, Ear Nose Throat J 1996;75:68-70.

(10.) Waguespack R. Mucociliary clearance patterns following endoscopic sinus surgery. Laryngoscope 1995;105(7 Pt 2 Suppl 71):1-40.

From the Department of Otolaryngology, MetroHealth Medical Center, Cleveland, and the School of Medicine, Case Western Reserve University, Cleveland.

Reprint requests: Steve Houser, MD, Department of Otolaryngology, MetroHealth Medical Center, 2500 MetroHealth Dr., Cleveland, OH 44109-1998. Phone: [phone]; tax: [phone]; e-mail: [e-mail]