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The missed maxillary sinus ostium syndrome.

A 41-year-old woman came to the office with nasal congestion and a history of recurrent sinus infections Approximately 4 years earlier, she had undergone functional endoscopic sinus surgery, including middle meatal antrostomies. Nasal examination revealed the presence of polypoid tissue in the left middle meatal area. Computed tomography of the paranasal sinuses detected chronic polypoid changes in both maxillary sinuses and in the left middle meatal areas. It also showed what appeared to be a patent left maxillary antrostomy.

The polypoid tissue was removed from the left middle meatus with a microdebrider (figure 1, A). It was originating from the area of the anterior ethmoid. A well-healed, previously performed middle meatal antrostomy was seen in the posterior meatal wall of the left middle meatus (figure 1, B). The anterior and inferior uncinate remnants of the previous operation were removed. A distinct, oval-shaped natural maxillary sinus ostium was located just anterior to the surgically created ostium. Polypoid tissue could be seen anteriorly through the natural ostium. This finding represented a case of a "missed maxillary sinus ostium." The two ostia were then joined with a micrcodebrider (figure 1, C and D) to eliminate mucus reeirculation. A polypoid mass was removed from the left maxillary sinus. Postoperatively, the revised left maxillary antrostomy remained patent and was well epithelialized. At the 6-month follow-up, the patient was symptom-free (figure 2).


In the maxillary sinus, secretion transport originates in the floor of the sinus in a stellate pattern. The mucus is transported along the anterior, medial, posterior, and lateral walls of the sinuses and along the roof. All these secretion routes converge at the natural ostium of the maxillary sinus. When the secretions have passed through the maxillary sinus ostium, they are transported into the narrow ethmoid infundibulum. Here, maxillary sinus secretions join with those from the frontal and anterior ethmoid sinuses and pass toward the nasopharynx. (1) When the natural maxillary sinus ostium is missed, the so-called recirculation phenomenon of the maxillary sinus develops. Upon closer examination with a 0[degrees] or 30[degrees] telescope, the mucus will be seen originating in the area of the natural ostium of the maxillary sinus and flowing back into the maxillary sinus via a surgically created middle meatal window. (1) This can predispose the patient to postnasal discharge, nasal obstruction, and persistent or recurrent sinus disease.

In the traditional anterior-to-posterior uncinectomy described by Messerklinger, an anterior inferior uncinate remnant may remain. This remnant can hide the natural ostium of the maxillary sinus and cause it to be missed. This series of events is what Parsons et al called the "missed ostium sequence." (2) When performing revision endoscopic sinus surgery, the surgeon might find that the previous middle mental antrostomy had been placed at the wrong location. (3)

The retrograde uncinectomy approach has been reported to be safe and efficient for identifying the natural ostium of the maxillary sinus during a middle meatal antrostomy. (4,5) In this approach, the posterior edge of the uncinate process is identified, and a retrograde uncinate window is made with a small backbiting forceps. The window is enlarged with a microdebrider, and a complete uncinectomy is performed, including removal of the anterior and inferior uncinate remnants. (5)

When patients complain of recurrent sinusitis following endoscopic sinus surgery, the recirculation phenomenon in the maxillary sinus may be the cause. When the missed maxillary sinus ostium syndrome is recognized, endoscopic surgery to connect the natural maxillary ostium with the surgically created middle meatal window may remedy the condition.


(1.) Yanagisawa E. Atlas of Rhinoscopy: Endoscopic Sinonasal Anatomy and Pathology. San Diego: Singular Thomson Learning. 2000.

(2.) Parsons DS, Stivers FE, Talbot AR. The missed ostium sequence and the surgical approach to revision functional endoscopic sinus surgery. Otolaryngol Clin North Am 1996;29:169-83.

(3.) Owen RG, Kuhn FA. The maxillary sinus ostium: Demystifying middle meatal antrostomy. Am J Rhinol 1995;9:313-20.

(4.) Setliff RC III. The hammer: A remedy for apprehension in functional endoscopic sinus surgery. Otolaryngol Clin North Am 1996;29:95-104.

(5.) Christmas DA, Yanagisawa E, Joe JK. Transnasal endoscopic identification of the natural ostium of the maxillary sinus: A retrograde approach. Ear Nosc Throat J 1998;77:454-5.

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante), and the Section of Otolaryngology, Hospital of St. Raphael, New Haven, Conn., and the Section of Otolaryngology, Yale University School of Medicine. New Haven (Dr. Yanagisawa).
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Title Annotation:Rhinoscopic Clinic
Author:Yanagisawa, Eiji
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Aug 1, 2003
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