Endoscopic view of two adjacent unilateral inferior meatal nasoantral windows

Ear, Nose & Throat Journal, Dec, 2004 by Dewey A. Christmas, Joseph P. Mirante, Eiji Yanagisawa

A 57-year-old woman was referred to us with recurrent sinus infections that had been treated medically by her family physician. Fourteen years earlier, she had undergone nasal septal surgery and maxillary sinus drainage through the inferior meatus on the left side.

Computed tomography (CT) demonstrated extensive bilateral antral opacification with a bony defect in the medial wall of the left maxillary sinus at the level of the inferior meatus (figure, A). We performed endoscopic sinus surgery. Intraoperatively, the left middle meatus exhibited no evidence of the previous sinus surgery. The left inferior meatus contained polypoid tissue that extruded from the maxillary sinus (figure, B). Removal of this tissue with a microdebrider revealed the presence of two adjacent, previously placed nasoantral windows (figure, C). We joined the windows surgically to form a single window (figure, D). The left maxillary sinus was filled with polypoid tissue, which we removed with a curved microdebrider blade. Following removal of the uncinate process to promote drainage, we performed a left middle meatal antrostomy. One year postoperatively, the patient was asymptomatic; the left inferior meatal window was widely patent, and both middle meatal antrostomies were open.

The placement of an inferior meatal nasoantral window (inferior meatal antrostomy or intranasal antrostomy) was a popular surgical procedure for the management of maxillary sinus disease in the 1980s. (1) Interest in inferior meatal antrostomy, however, declined when we became aware that mucociliary transport moved toward the natural maxillary ostium (2-4) and when we found that endoscopic middle meatal antrostomy is a preferable method of promoting sinus drainage. (5) Arguments against inferior meatal antrostomy have included reports of persistent sinus disease following surgery (5) and low patency rates, (1) as well as concerns about possible injury to the nasolacrimal duct and the technical difficulty associated with performing the procedure.

Stammberger observed endoscopically that maxillary sinus drainage originates in the floor of the sinus and always travels upward toward the natural ostium, even in the presence of a widely patent middle or inferior meatal window. (3)

Adequate examination of the inferior meatus is often difficult because it is so narrow. For a patient who has a history of inferior meatal antrostomy, the surgeon should decongest the inferior turbinate and examine the inferior meatus carefully with a telescope. A polyp may be found in the inferior meatus that extends from the maxillary sinus via the inferior meatal window, as happened in the case reported here. In some cases, a polyp may extend posteriorly into the choana or the nasopharynx and present as an antrochoanal polyp.

Although the popularity of inferior meatal antrostomy has declined, it is still a useful procedure for the management of sinus disease in some patients. Gravitation-dependent drainage and aeration through an inferior meatal antrostomy may benefit patients with disturbed mucociliary transport secondary to mucosal stripping during a Caldwell-Luc procedure or secondary to cystic fibrosis. (1,6) In such a case, the inferior meatal window should be made large enough and as close to the floor of the lateral nasal wall as possible. This procedure has also been shown to be useful for the endoscopic removal of cysts, polyps, and foreign bodies in the maxillary sinus.

A finding of two unilateral nasoantral windows is unusual. Two separate windows might be caused by scar tissue. If such a situation is found at the time of surgery, it would be wise to join the separate windows surgically.

References

(1.) Lund VJ. Inferior meatal antrostomy. Fundamental considerations of design and function. J Laryngol Otol Suppl 1988;15:1-18.

(2.) Hilding AC. Experimental sinus surgery: Effects of operation windows on normal sinuses. Ann Otol Rhinol Laryngol 1941;50: 379-92.

(3.)Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: B.C. Decker, 1991.

(4.) Yanagisawa E. Endoscopic view of mucociliary transport following middle meatal antrostomy. Ear Nose Throat J 1997;76:434-5.

(5.) Muntz HR, Lusk RP. Nasal antral windows in children: A retrospective study. Laryngoscope 1990; 100:643-6.

(6.) Yanagisawa E, Joe J. Inferior meatal antrostomy: Is it still indicated? Ear Nose Throat J 1997;76:368-70.

Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

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 Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group; the Section of Otolaryngology, Hospital of St. Raphael; and the Section of Otoloaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa).