Endoscopic view of a long-term inferior meatal antrostomy

Ear, Nose & Throat Journal, June, 2007 by Eiji Yanagisawa, Dewey A. Christmas, Jr., Joseph P. Mirante

A 70-year-old man sought treatment for postnasal drainage. He had undergone sinus surgery 33 years earlier. At that time, inferior meatal antrostomies were performed without stripping of the maxillary sinus mucosa. The natural ostia of the maxillary sinuses and the uncinate processes had not been disturbed. Postoperatively, the patient appeared clinically to have satisfactorily functioning sinuses with adequate drainage and ventilation.

At this latest visit, endoscopic evaluation in the office revealed normal-appearing maxillary sinus mucosa on both sides and widely patent inferior meatal antrostomies (figure, A and B). Coronal computed tomography (CT) of the sinuses also showed minimal antral mucosal changes and widely patent inferior nasoantral windows (figure, C). The natural ostia of the maxillary sinuses had remained patent (figure, D). The patient's complaint of postnasal drainage improved with medication over a 3-week period. There was no need to consider further maxillary or ethmoid surgery through the middle meatus, and at follow-up, he was doing well.

[FIGURES A-D OMITTED]

The maxillary sinus was probably the first of the paranasal sinuses to attract significant surgical attention. Cowper was probably the first surgeon to propose draining the maxillary sinus through the alveolar ridge in 1707. (1) The concept of antral drainage through the alveolus persisted through the centuries. (1) In 1887, Mikulicz developed an operative procedure to drain the maxillary sinus through the lateral wall of the nose. (2) This technique was further refined by Lothrop, who gained entrance into the maxillary sinus through the inferior meatus of the nose. (3) The inferior meatal antrostomy window was commonly used in the surgical treatment of maxillary sinusitis until use of the middle meatal antrostomy for maxillary sinus drainage and ventilation became popular. (2) Since the introduction of functional endoscopic sinus surgery to the United States by Kennedy and colleagues in 1987, middle meatal antrostomy has become the surgical treatment of choice for maxillary sinus disease. (4)

The effectiveness of an antral window in treating maxillary sinus disease and determination of the exact location to establish the window have been subjects of much controversy and discussion. Studies by Hilding suggested that an inferior meatal window might harm long-term maxillary sinus mucociliary clearance. (5) A study by Friedman and Toriumi in rabbits showed that an inferior meatal window did not disturb mucociliary clearance toward the maxillary sinus ostium. (6)

Although the use of inferior meatal antrostomy has declined, this procedure might still be useful for the management of sinus disease in some cases. Dependent drainage through an inferior antrostomy may benefit patients with disturbed mucociliary transport--for example, patients with cystic fibrosis or those who have undergone mucosal stripping during a Caldwell-Luc procedure. In such cases, the window should be located as close to the floor of the lateral nasal wall as possible to facilitate dependent drainage. (7) The inferior approach has also been shown to be useful in performing endoscopic biopsy or in excising inferomedially situated antral lesions or foreign bodies of the maxillary sinus.

References

(1.) Christmas DA, Yanagisawa E, Mirante JP. Powered endoscopic maxillary sinusotomy. In: Yanagisawa E, Christmas DA, Mirante JP, eds. Powered Instrumentation in Otolaryngology-Head and Neck Surgery. San Diego: Singular-Thomson Learning; 2001:35-53.

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

(3.) Loeb HW. Operative Surgery of the Nose, Throat and Ear. St. Louis: Mosby; 1917.

(4.) Kennedy DW, Zinreich SJ, Shaalan H, et al. Endoscopic middle meatal antrostomy: Theory, technique, and patency. Laryngoscope 1987;97(8 Pt 3 Supp143):1-9.

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

(6.) Friedman M, Toriumi DM. The effect of a temporary nasoantral window on mucociliary clearance. An experimental study. Otolaryngol Clin North Am 1989;22(4):819-30.

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