Irrigation of Maxillary Sinus through Middle Meatus versus Inferior Meatus: A Randomized Controlled Trial

Introduction

The term sinusitis is now changed to rhino sinusitis as the mucosa of the paranasal sinuses are in direct contact with the nasal cavity [1]. Rhinosinusitis is a relatively common disease affecting 6-15% of the population each year [2]. CRS is defined by the American Academy of Otolaryngology – Head and Neck Surgery as 12 weeks, or longer, of two of a defined group of symptoms/signs: mucopurulent drainage, nasal congestion, facial pressure/pain, or decreased sense of smell and inflammation documented by one of the following: purulent mucus on endoscopy, polyps in the nasal cavity, or radiographic imaging showing inflammation [3]. Over the past decade, patients with CRS have been frequently subdivided into two main categories based on their specific pathophysiology: CRS with nasal polyps (CRSwNP) vs. CRS without nasal polyps (CRSsNP) [4]. There are many factors which can cause or influence the severity of chronic rhino sinusitis including asthma, aspirin exacerbated respiratory disease (AERD), cystic fibrosis and immunodeficiency [5]. Medical treatment of chronic rhino sinusitis usually commences with nasal saline irrigations, topical nasal steroids, nasal decongestant, oral antibiotics, and possibly oral steroids [3]. However, medical management often times fails to sufficiently alleviate the patient’s symptoms, and, for these patients, surgical intervention may be considered to be a logical next step in their treatment. Surgical management is needed for two main subcategories: chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS). For chronic maxillary sinusitis there are four surgical options which include antral wash out, intranasal antrostomy, Cald Well Luc operation and FESS. Osteomeatal complex block causing chronic sinusitis can be treated with simple middle meatal antrostomy (MMA) and anterior ethmoidectomy (Mini FESS) but in extensive polypoid diseases with sinusitis a more complete fronto-spheno-ethmoidectomy (full house FESS) is needed [2]. In recent years a minimally invasive options such as balloon sinus dilatation are now available [6].

Materials and Methods

This prospective randomized study was done at Maleka Nursing Home and Matin Specialized Hospital Hospital, Bogura and CDM Hospital Rajshahi from January 2001 to December 2015. All patients of radiologically confirmed chronic maxillary sinusitis and acute maxillary sinusitis not responding to medical treatment were included. The patients were selected considering exclusion and inclusion criteria. The procedure were done under local or general anaesthesia along with septoplasty operation in some cases. For middle meatal puncture Karl Storz antrum sucker nozzle and 0 degree telescope with or without TV monitor are used and for inferior meatal puncture, antrum trocher and cannula and killian’s speculum are used (Figure 1). For irrigation of maxillary sinus through middle meatus five minutes after giving 10% xylocaine spray to the middle meatus, antrum sucker nozzole is gently pushed above the inferior turbinate towards the maxillary sinus through the uncinate process (uncinotomy). Once the cannula is in the maxillary sinus, it is irrigated with normal saline with the help of 50 cc syring (Figure 2). Irrigation is continued until return fluid is clear. Antral wash was done to other group as usual way through the inferior meatus. Any difficulties or complications were noted in each group.

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Results

Age of the patients ranged from 12-55 years with a mean age 34.9 years in middle meatal group and 38.7 in inferior meatal group (Table 1). There were 25 male and 15 female patients with male female ratio of 1.67:1 (Table 2). Any difficulties or complications of both procedures were noted in (Table 3).

Discussion

In adults, the maxillary sinuses are most commonly affected with acute and chronic sinusitis. Most of these cases can be managed with medications alone. When medical management failed to control the symptom of chronic maxillary sinusitis surgical intervention is frequently considered. Although functional endoscopic sinus surgery is becoming more popular by doing middle meatal antrostomy in the treatment of chronic maxillary sinusitis, irrigation of the maxillary sinuses or antral wash is still a gold standard of practice done by many of the ENT Surgeons. Although the more generally accepted method of irrigating the maxillary sinus is by the way of the inferior meatus using antral trocar and cannula this paper is presented primarily to stimulate interest in irrigation of the maxillary sinus through the middle meatus using Karl Storz antral sucker nozzle to puncture the middle meatus without telescope. I adopted this procedure out of interest when I faced some difficulties puncturing the inferior meatus with trocar and cannula like bleeding, failed to puncture or check swelling which are the recognized complications of antral wash out using trocar.

From that experiences I started doing irrigation through the middle meatus using antral sucker nozzole and I found this procedure very easy, effective and painless procedure without any complication. My aim of presenting this procedure is to encourage doctors who are still doing antral wash through the inferior meatus, so that they can adopt this technique. By searching internet it is found that the first paper of irrigation of the maxillary sinus through the middle meatus was presented by Mervin C Meyerson MD to the American Laryngologic, rhinologic and otological society in California, USA on 19 January 1958. Later he published this paper in the Laryngoscope Vol. 68, no 8 in 1958 [7] It has been noted by Mervin that it is easier to enter the maxillary sinus by the way of the middle meatus in children than adult

Conclusion

It is concluded that this new technique of puncturing the middle meatus is a safe, easy and effective procedure of irrigation of the maxillary sinus instead of antral wash out via the inferior meatus for the treatment of chronic maxillary sinusitis