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IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)
e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 17, Issue 3 Ver. 4 March. (2018), PP 45-54
www.iosrjournals.org
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 45 | Page
Middle Meatal Antrostomy inthe Management of Chronic
Maxillary Sinusistis
Sauvagini Acharya1 Siddharth Panditray2, Nilamadhab Prusty3
Subha Saumya Dany4
1. Associate Professor, Dept. Ent And Headnecksurgery, Vssimsar, Burla
2. Junior Resident, Dept. Of Ent And Headnecksurgery, Vssimsar, Burla
3. Senior Resident, Dept.Of Ent And Headneck Surgery, Vssimsar, Burla.
4. Senior Resident, Dept. Of Dental Surgery, Vssimsar, Burla.
Abstract: Introduction: sinusitis is a group of disorders characterized by inflammation of the mucosa of the
paranasal sinuses.Chronic sinusitis is defined as symptoms lasting longer than 8 weeks, with a global
prevalence of around 10.9% with significant impairment in health related quality of life. Imaging advances,
increased understanding of the anatomy and the pathophysiology of chronic sinusitis, and image-guided surgery
have allowed surgeons to perform more complex procedures with increased safety.FESS emerges as the primary
surgical modality for sinus diseases, the most common procedure being middle meatal antrostomy
(MMA).Controversy exists over the effectiveness of FESS, judging on subjective and objective parameters
.Hence it warrants further research.
AIM:To determine the efficacy of middle meatal antrostomy in the management of chronic maxillary sinusitis in
subjective and objective parameters.
Methodology:A hospital based prospective study done in the department of otorhinolaryngology and head neck
surgery, VSSIMSAR Burla from October 2015 to September 2017 with a sample size of 60 patients, who meet
inclusion and exclusion criteria after clearance from the institutional ethical committee. Pre and post-operative
endoscopic and radiological scoring [Lund Mackay], mean area of maxillary ostium as well as symptom and
complication charting was done and compared.All data was entered into excel sheets and statistical analysis
was done by SPSS version 20 using Pearson chi square test. Data was compared between baseline and 6
months, baseline and 1 year and 6months and 1 year. Statistical significance was set at p <0.05.
Results: There was significant improvement in the post-operative period in SUBJECTIVE (symptoms) and
OBJECTIVE (endoscopic/radiological) parameters.
Conclusion: Our study is conclusive evidence that Middle meatal antrostomy is a safe and effective procedure
in patients suffering from chronic maxillary sinusitis with significant improvement in subjective symptomatology
as well as objective parameters.
Keywords:middle meatal antrostomy, MMA, maxillary sinusitis.
---------------------------------------------------------------------------------------------------------------------------------------
Date of Submission: 26-02-2018 Date of acceptance: 10-03-2018
---------------------------------------------------------------------------------------------------------------------------------------
I. Background
Sinusitis refers to a group of disorders characterized by inflammation of the mucosa of the paranasal
sinuses. Categories based on duration as1Acute sinusitis, defined as symptoms of less than 4 weeks’ duration,
Sub acute sinusitis, defined as symptoms of 4 to 8 weeks’ duration and Chronic sinusitis, defined as symptoms
lasting longer than 8 weeks Recurrent acute sinusitis, often defined as three or more episodes per year, with each
episode lasting less than 2 weeks. Sinusitis is more common in cold and wet climate, atmospheric pollution,
smoke, dust overcrowded condition. Increased cases are found in people with poor general health, with recent
history of exanthematous fever measles, chickenpox, in nutritional deficiencies, systemic disorders like diabetes,
immune deficiency syndromes etc.Impairment of drainage of sinuses by inflammatory oedema of the mucosa is
an important contributor to the process.Current thinking supports the concept that chronic rhino sinusitis (CRS)
is predominantly a multifactorial inflammatory disease. Confounding factors that may contribute to
inflammation are persistent infection (including biofilms and osteitis) , allergy and other immunologic disorders,
intrinsic factors of the upper airway, super antigens, colonizing fungi that induce and sustain eosinophilic
inflammation, metabolic abnormalities. Functionally active L-selectin ligands guiding leukocyte traffic into
maxillary sinus mucosa have been suggested preferentially in patients with severe findings of chronic maxillary
rhino sinusitis 2.

Middle Meatal Antrostomy In The Management Of Chronic Maxillary Sinusistis
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 46 | Page
Uncommonly sinusitis is component of many systemic syndromes as Wegener granulomatosis, ataxia
telangiectasia, cystic fibrosis, immotile cilia syndrome, kartagener syndrome etc. Acute sinusitis may give rise
to chronic sinusitis, particularly when there is interference in drainage.Prominent symptoms of acute sinusitis
include nasal congestion, purulent rhinorrhea, facial-dental pain, postnasal drainage, headache, and cough.
Chronic sinusitis symptoms are similar but might be even more subtle. Clinical signs of both acute and chronic
sinusitis include sinus tenderness on palpation, mucosal erythema, purulent nasal secretions, increased
pharyngeal secretions, and periorbital edema. There is an overlap in these symptoms with those of perennial
rhinitis, and there is a frequent need to perform imaging procedures to confirm the diagnosis. Because of this
overlap, some have suggested the use of the term rhinosinusitis.In clinical experience, maxillary sinuses are the
most commonly effected, in adults. The maxillary antra are the largest of the paranasal sinuses and are
pyramidal-shaped cavities occupying the maxillae. Chronic maxillary sinusitis may or may not involve
pathogenic organisms. Maxillary sinusitis may occasionally arises by extension of a peripheral infection through
the bony floor of sinus (odontogenic infections).In other cases it is associated with diseases of lower respiratory
tract.
The frequency of the disease has sufficient justification for a close study of the disease in view of the
serious effects of such chronic type of infection. Roughly ninety percent of adults have had sinusitis at some
point in their life 3.The global prevalence of chronic rhino sinusitis is around 10.9% 4with significant impairment
in health related quality of life5.
Occasionally it leads to complications like Orbital cellulitis, Orbital abscess, Cavernous sinus
thrombosis, Encephalitis etc. which lead the patient to a life threatening conditions. Despite the fact that medical
therapy is indicated in all cases of rhino sinusitis and many cases do respond to it, there still exists a number of
patients who improve only after surgical management. The majority of surgical procedures in the treatment of
sinusitis were originally described in pre-antibiotic era when rapid surgical intervention was often necessary to
avert disaster. Today, although the operations remain the same, the indications for their use and the relative
frequency with which they are required have altered.
Surgery for sinusitis aims to drain purulent secretions either by way of natural ostium or more usually
by the creation of an alternative drainage pathway which may be temporary or permanent. In so doing,
complications are avoided and the sinus lining is given opportunity to recover. Antral washout or lavage was a
form of conservative surgery done used for draining out the antral secretions through the inferior meatus and for
subsequent microbiological study. It has been deemed obsolete in modern times due to its blind nature and
limited long term benefits. With the advent of endoscopic nasal procedures focusing on preservation of
physiological mucosa, the management of sinusitis has taken a major leap. FESS caters to a wide range of
inflammatory sinus conditions. Imaging advances, increased understanding of the anatomy and the
pathophysiology of chronic sinusitis, and image-guided surgery have allowed surgeons to perform more
complex procedures with increased safety. Endoscopic sinus surgery has undergone radical changes in the last
15 yr. Minimally invasive techniques, combined with advances in instrumentation and computers have reduced
postoperative discomfort and improved patient satisfaction 6. Evidence suggests that adenoidectomy and ESS
are the most frequent surgical procedure performed in RS management 7. FESS emerges as the primary surgical
modality for sinus diseases, the most common procedure being middle meatal antrostomy (MMA) for chronic
maxillary sinusitis (CMS). Creation of middle meatal antrostomy is also sometimes needed for the following
cases: biopsy of an antral mass; resection of a maxillary sinus fungal ball or inverted papilloma; presence of
accessory ostia leading to maxillary recirculation; and sometimes to allow for the application of topical
medication or outpatient antral lavage in selected cases. Questions over the potential risks of middle meatal
scarring, interruption of mucociliary clearance, improper ostial function, development of maxillary recirculation
by not including the natural ostia in the middle meatal antrostomy, and the likely need for revision maxillary
sinus surgery have raised the issue of whether middle meatal antrostomy is necessary in ESS(Catalano 2006).
We decided to conduct a study on Indian patients and judge the effectiveness of FESS on subjective and
objective parameters.
II. Aim
To determine the efficacy of middle meatal antrostomy in the management of chronic maxillary sinusitis in
subjective and objective parameters
III. Objectives
1.To compare pre and postoperative symptoms in patients 2.To compare pre and postoperative Computed
Tomography findings.3.To compare pre and postoperative endoscopic findings and 4.To assess complications of
the procedure and their management.

Middle Meatal Antrostomy In The Management Of Chronic Maxillary Sinusistis
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 47 | Page
IV. Methodology
A hospital based prospective study done in the department of otorhinolaryngology and head neck
surgery, VSSIMSAR Burla fromOctober 2015 to September 2017 with a sample size of 60 patients after
clearance from the institutional ethical committee.
Inclusion criteria was moderate to severe sinus-related symptoms lasting at least 12 weeks despite
maximal medical treatment (intranasal corticosteroid and/or antihistamine with or without antibiotics), e.g., at
least two major factors ( headache, facial pain, nasal obstruction ,nasal discharge, olfactory disturbances etc.)
with or without other symptoms(sneezing, post nasal discharge, epistaxis or Sino-nasal polyps etc.) With
endoscopic findings (mucosal edema, purulent discharge, nasal polyp) and radiographic evidence (on computed
tomography) of maxillary sinus opacity.
Patients with age under 15years or over 60 years, on oral corticosteroid treatment during the two
months prior to surgery, with previous nasal surgery for any indication, with history or physical examination
suggestive of severe nasal septal deviation (that causes only unilateral nasal obstruction and/or requires
septoplasty before performing ESS) and maxillary sinusitis of other origins as dental/ oro-antral fistula etc.,
aspirin sensitivity, chronic bronchitis, cystic fibrosis, tumor or disease with severe, with impact on general
immunity and patients with severe co morbidities( complications of diabetes , asthma, tuberculosis,
hypertension , chronic renal or liver disease etc. withrecurrent antro-choanal polyps or primary polyps of other
sinuses and without consent for surgery were excluded from the study.
Figure 1:Study Flowchart
TOTAL ATTENDANCE IN ENT OPD
( 2015 - 17 ) (n = 60,2 08)
NO. OF CASES DIAGNOSED AS RHINOSINUSITIS (n = 8,76 2)
NO. OF PTS. DIAGNOSED AS CHRONIC SINUSITIS (n = 2701 )
n = 112 PTS. MEETING INCLUSION CRITERIA PTS. MEETING EXCLUSION CRITERIA n = 38
DROPOUTS
n = 13
PTS. IN FINAL STUDY GROUP CONSERVATIVE MANAGEMENT
PRE OPERATIVE
ENDOSCOPIC
EVALUATION
RADIOLOGICAL EVALUATION SYMPTOM CHARTING
DROPOUTS
n = 8
PTS. UNDERGOING SURGERY n = 91
POST OPERATIVE MANAGEMENT AND
DISCHARGE WITH ADVICE FOR FOLLOW UP
n = 91
DROPOUTS
n = 2
ASSESSMENT OF COMPLICATIONS AT 15 DAYS MA NAGEMENT OF COMPLICATIONS
n = 89
DROPOUTS
n =3
ASSESSMENT OF COMPLICATIONS AT 2 MONTHS n = 86
DROPOUTS
n = 12
POST OPERATIVE 6m
n = 74
ENDOSCOPIC
EVALUATION
RADIOLOGICAL EVALUATION SYMPTOM RECHARTING
ASSESSMENT OF
COMPLICATIONS IF ANY
DROPOUTS
n = 14
POST OPERATIVE 1 Year
n = 60
ENDOSCOPIC
EVALUATION
SYMPTOM
RECHARTING

Middle Meatal Antrostomy In The Management Of Chronic Maxillary Sinusistis
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 48 | Page
Preoperative and postoperative assessment and surgical methods: During the patient’s preoperative visit to
the department, a complete medical history was taken, and the diagnostic criteria, the execution of proper
conservative treatment, and the presence of exclusion criteria were recorded. All patients underwent complete
otorhinolaryngological examination with nasal endoscopy under local anesthesia. A clinical
otorhinolaryngological examination and nasal endoscopy was repeated on visits 2 weeks, 3 months, 6 months
and 1 year postoperatively. Pre and postoperative symptoms were assessed and tabulated. Postoperative
computed tomography scans were repeated at 6 months and maxillary sinus grading and scoring [LUND
MACKAY] was done. Postoperative nasal endoscopic assessment was done at 6 months and 1 year done and
maxillary sinus grading and scoring [LUND MACKAY] was done. Postoperative complications were assessed
at 2 weeks and 2 months. Radiographicgrading [LUND MACKAY] of other sinuses (ethmoid, frontal and
sphenoid) were done preoperatively. All the values were tabulated at baseline and at follow ups.High-resolution
CT imaging of the nasal airways and paranasal sinuses was performed. The ostiomeatal complex was
reconstructed with a 1 mm slice thickness.
Postoperatively, endoscopy and CT scans provided identical information about the ostiomeatal complex area
and maxillary sinus. Two blinded authors calculated the anterioposterior (AP) and the cephalocaudal (CC)
dimensions of the ostium on one occasion using variable sized feeding tubes(6FG to 24 FG)( External
diameters 2.6 to 7.92 mm).The maxillary sinus ostium was considered to be an ellipse with AP and CC
dimensions as the major and minor axis respectively. Thus, the postoperative ostium size was determined to be
0.25πAPCC.
Endoscopic sinus surgery was performed under local anesthesia. Cotton applicators soaked in a
solution of 4% xylocaine with5µg/ml adrenaline were applied for 30–40 minutes before the operation under the
middle and lower turbinates and in the roof of the nose cavity to block the sphenopalatine and ethmoidal nerves.
At the beginning of the operation, 1 ml of 2% xylocaine with adrenaline ( 1: 200000) was injected
submucosally into the medial infundibular wall .Intravenous sedation (midazolam 1–2 mg and/or fentanyl 0.05–
0.1 mg were given at the beginning of surgery and repeated thereafter when needed. The operation was
performed using the endoscopic sinus surgery technique, using rigid 4 mm endoscopes (Karl-Storz, Tuttingen,
Germany) with deflection angles of 0° and 30° and sometimes 70.The maxillary sinus ostium was first identified
using an ostium seeker. The uncinated process was then identified and medialized, and the lower two-thirds was
removed using back biting forceps. If mucosa blocked the maxillary sinus ostium on the uncinectomy only side,
as little as possible was carefully removed from it without disturbing the bony ostium. Otherwise, the bony
ostium was left intact. On the additional middle meatal antrostomy side, the diameter of the ostium was
duplicated in the posterior direction with cutting forceps. Of the 8 patients with sino nasal polyps (antro
choanal, 7 U/L, 1 B/L), polypectomy was done prior to the procedure and included in study after
histopathological confirmation.The posterior ethmoidal cells, sphenoidal sinuses and frontal sinuses were left
undisturbed. Hemostasis was achieved with nasal packing (Merocel) under the middle turbinate. The packing
was removed on the within 24 – 48 hours by the surgeon. Patients were discharged with post-operative
antibiotics, antihistaminic, anti-inflammatory drugs with advice on nasal irrigation with sodium chloride (2.3
gm.) and sodium bicarbonate (700 mg) in 100 ml of warm water. Complications were managed as follows:
crusts removed under endoscopic vision with irrigation and manipulation, synechiae released and barrier plating
done, all other complications were managed conservatively in all cases.
All data was entered into excel sheets and statistical analysis was done by SPSS version 20 using
Pearson chi square test. Data was compared between baseline and 6 months, baseline and 1 year and 6months
and 1 year. Statistical significance was set at p <0.05.
V. Results
Of the 60208 patients attending our OPD chronic rhino sinusitis was diagnosed in 2701.We had no
patients less than 10 years and more than 60 years, opting for surgery. Maximum no of patients (~ 65%) were
adults between 31 to 50 years of age. Of the subgroups, the highest no. of patients were between31- 40 years of
age. The average age of the series was (34.8 ± 9.24) years. 32 of 60 patients in our study were male and hence
there was no significant gender difference.
The patients were equitably distributed in lower and middle socio –economic strata with the upper class
patients constituting less than 10% of the study pool. There was no relation found between class and duration or
severity of presenting symptoms.Nearly 2/3rd of the patients were from rural areas.Majority of patients
practiced Hinduism with Islam being the 2nd predominant religion .The duration of symptoms ranged between
3months to 4 years. Mean duration was (16.1 ± 11.78) months. Only 2 patients with a longer standing history
opted for surgery. There was no co relation between patient age and duration of symptoms at presentation. No
correlation could be found between duration and severity of presenting symptoms. Most of the patients were not
able to give an exact duration of onset to presentation.

Middle Meatal Antrostomy In The Management Of Chronic Maxillary Sinusistis
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 49 | Page
Only 8 patients had concomitant Antrochoanal polyps and maxillary sinusitis. 7/8 cases had uni-lateral
polyps ( 4 on left, 3 on right and 1 case bi lateral).All the polyps were histo-pathologically confirmed.
Nearly 40% cases were unilateral (on radiographs) .7 out of the 25 cases of uni lateral maxillary
sinusitis presented with antrochoanal polyps. One case of 35 bilateral cases presented with bilateral antrochoanal
polyps. Patient symptoms were not necessarily limited to the side of sinus involvement.
Table 1
BILATERAL CASES
No. of cases with score 0
No. of cases with score 1
No. of cases with score 2
LEFT
2
12
21
RIGHT
1
10
24
(The radiological grading and scoring system was as follows: SCORE 0- NO OPACITY: SCORE 1– SOME
OPACITY/ PARTIAL OPACITY: SCORE 2- COMPLETE OPACITY)
Of the unilateral cases, only 3 patients had no depiction of opacity on radiographs. They were chosen on basis of
symptoms and endoscopic grading. Majority of cases had complete opacity (12/25) followed by partial opacity
(10/25).Of the bilateral cases (70 maxillary antra), majority( 45/70) had complete opacity followed by partial
opacity ( 22/70).Hence less percentage of maxillary antra (4% vs 12% ) had absence of opacity which might
indicate the bilateral cases being longer standing and more severe. However no such facts could be proven from
our study. The right maxillary antra had a higher combined score ( 80 vs 66) suggesting that right maxillary
antra were more frequently and more severely involved than the left. We could not find any striking difference
in anatomical variations between the sides, etiology and previous history to render a logic for the above
difference.
Table 2
SYMPTOM SCORE PREOPERATIVE
SYMPTOMS
No. OF PATIENTS
PERCENTAGE
Facial Pain / Pressure
38
63.3
Headache
54
90
Nasal blockage / congestion
36
60
Rhinorrhea
35
58.3
Post nasal discharge
19
31.7
Olfaction disturbance
18
30
Sneezing
23
38.3
Epistaxis
6
10
Nasal mass
3
5
Headache was by far the most common symptom presenting in 54/60 patients. The next common were
facial pain, nasal congestion and nasal discharge having almost equal patient share. Only 3/60 patients presented
with a nasal mass co relating as 3/8 polyp patients. Almost all patients who had facial pain or pressure had a
subjective headache (37/ 54).Post nasal discharge was the next most co related symptoms with the former
presenting in 17/ 35 cases of rhinorrhea. All cases presenting with nasal mass had feeling of nasal blockage.
More than 50% of patients (36/60) presented with 4 or more symptoms.4/6 cases of epistaxis had history of
rhinorrhea.14/18 patients with olfactory disturbances (hyposmia, anosmia, parosmia) did have a history of nasal
obstruction making this symptom very subjective as alterations in taste could not be analyzed
simultaneously.Sneezing was an associated symptom in almost 40% cases of the present series. Two reasonable
explanations are possible. It may be that the patients were allergic prior to their present ailment which probably
has predisposed them to chronic sinusitis or that the patients acquired it afterwards being subjected to bacterial
allergen as a result of chronic infection in their sinuses.
RADIOLOGICAL STAGING OF CASES WITH MAXILLARY SINUSITIS
UNILATERAL CASES
No. of cases with score 0
No. of cases with score 1
No.of cases with score 2
LEFT
2
4
4
RIGHT
1
6
8

Middle Meatal Antrostomy In The Management Of Chronic Maxillary Sinusistis
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 50 | Page
Table 3
Score O: No Polyps; Score 1: Polyp Only In Middle Meatus; Score 2: Polyps Extending Beyond Middle
Meatus; Score 3: Polyps Filling The Nasal Cavity
Mucosal Oedema Score 0: No Edema;Score 1: Mild / Moderate Edema;Score 3: Polypoid Degeneration
SecretionScore 0: No Discharge;Score 1: Hyaline;Score 2: Thick Or Mucopurulent
All patients had review endoscopic scoring at 6 months and 1 year postoperative. The most important role for
endoscopy in patients with CRS is in medical management, particularly in cases involving eosinophilic
inflammation8. Edema on endoscopic observation was the most altered factor followed by secretion.
There was no significant improvement in pre and postoperative assessment of polyps [PEARSON CHI-
SQUARE (p-VALUE) =8.241 (0.221) (LEFT)] and [PEARSON CHI-SQUARE (p-VALUE) =8.182 (0.225)
(RIGHT)]
Endoscopic scores for edema showed highly significant improvement postoperatively [PEARSON CHI-
SQUARE (p-VALUE) =86.521 (0.000)* (LEFT)] and [PEARSON CHI-SQUARE (p-VALUE) = 89.179
(0.000)* (RIGHT)]
There was highly significant improvement in secretion scores on post op endoscopic assessment [PEARSON
CHI-SQUARE (p-VALUE) = 71.566 (0.000)*(LEFT)] and [PEARSON CHI-SQUARE (p-VALUE) =70.285
(0.000)*(RIGHT)]
Table 4
There was overall improvement is symptoms at 6 months postoperative. Headache, present in 90% of
pre op patients, was relieved in more than 50% patients completely. Of the 54 patients preop, only 26 patients
had residual headache at 1 year (52% recovered).Persistent patients complained of a lesser degree of headache,
more tolerable than before.
Facial pain and pressure was also significantly relieved in >60% to < 15% of patients at 6 months,
which further decreased to 5% at 1 year. Of the 38 patients preop, only 3 patients had residual facialpain (91%
recovery).Persistent patients also had headache.
Nasal blockage and rhinorrhea was also relieved in the majority (60%, 58.3% vs 11.7%, 15%vs 5%,
5% respectively). Of the 36 patients preop, there was residual nasal stuffiness in only 3 patients (91.6%
recovery).
Rhinorrhea present in 35 patients preop persisted in 3 patients at 1 year (91.5% improvement).Post
nasal discharge showed a recovery of 85%in patients.
Sneezing was the symptom which showed least improvement over 12 months (<40%). This could be
attributed to allergic etiology in the patients. Patients who complained of epistaxis and nasal mass before
ENDOSCOPIC APPEARANCE SCORE ( TOTAL)
BASELINE
6 MONTHS
1
YEAR
Polyp Left (0,1,2,3)
9
0
2
Polyp Right (0,1,2,3)
8
0
0
Oedema Left (0,1,2)
68
11
2
Oedema Right(0,1,2)
81
24
5
Secretion Left(0,1,2)
59
13
2
Secretion Right(0,1,2)
62
14
6
SYMPTOM SCORE AT 6MONTHS POST OPERATIVE
AT 1 YEAR POSTOPERATIVE
SYMPTOMS
No. OF PATIENTS
PERCENTAGE
No. OF PATIENTS
PERCENTAGE
Facial Pain / Pressure
8
13.3
3
5
Headache
28
46.7
26
43.3
Nasal blockage / congestion
7
11.7
3
5
Rhinnorhea
9
15
3
5
Post nasal discharge
3
5
3
5
Olfaction disturbance
12
20
9
15
Sneezing
15
25
14
23.3
Epistaxis
0
0
0
0
Nasal mass
0
0
0
0

Middle Meatal Antrostomy In The Management Of Chronic Maxillary Sinusistis
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 51 | Page
surgery, had no postoperative recurrence of the symptoms, hence showing complete improvement. Olfactory
disturbances too persisted (in 50%), although to a lesser subjective degree. All symptoms showed a gradual
decrease in severity over 1 year.
TABLE 5
Repeat CT scans were done at 6 months in the postoperative period
There was highly significant improvement in radiological scores for maxillary sinus in the postoperative period
[PEARSON CHI-SQUARE (p-VALUE) = 37.189 (0.000)* (LEFT)] and [PEARSON CHI-SQUARE (p-
VALUE) =48.125 (0.000)* (RIGHT)]
Table 6
Osteomeatal Complex Score; Score 0: No Opacity; Score 2: Opacity
The pre and postoperative ostiomeatal complex score showed highly significant improvement in radiological
findings. [PEARSON CHI-SQUARE (p-VALUE) = 12.836 (0.000)*(LEFT)] and [PEARSON CHI-SQUARE
(p-VALUE) = 15.983 (0.000)*(RIGHT)]
Table 7
COMPLICATIONS
NUMBER OF PATIENTS
PERCENTAGE
Epistaxis
3
5
Crusts in middle Meatus
35
58.3
Cheek edema
8
13.3
Synechiae
14
23.3
Infraorbital numbness/ Neuralgia
2
3.3
Closure of antrostomy
1
1.7
Discharge from middle Meatus
3
5
Crusts in middle meatus and nasal cavity was the most common post-operative complication. Synechiae were
observed in nearly 1/5th of the patients, associated universally with crusts. Epistaxis was seen in a small
proportion and so was infraorbital numbness and discharge from the middle meatus. Only one patient reported a
post-operative closure of the antrostomy.
VI. Discussion
The results of our study were mainly aimed at the symptomatic benefit and overall gain in comfort of
the patients. The demography could be summarized to be favoring adult male Hindus, of lower socio economic
class living in rural areas of the geographical region aged between 31- 50 years.Of the 8 patients presenting with
nasal polyps, no patient had recurrence at the end of 1 year although there was polypoidal degeneration of
mucosa in 2 patients. Chronic sinusitis and allergic rhinitis seem to play a major role in establishing the ACP.
RADIOLOGICAL GRADING OF CHRONIC
MAXILLARY SINUSITIS
LEFT
RIGHT
PRE OPERATIVE
66
80
POSTOPERATIVE
13
19

Middle Meatal Antrostomy In The Management Of Chronic Maxillary Sinusistis
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 52 | Page
These inflammatory processes cause mucosal edema and also mucous retention cyst formation9,10.One of the
suggested etiological theories for ACP described that inflammatory-related closure of ostiomeatal complex and
increase of pressure in maxillary sinus force mucous retention cysts to herniate into the nasal cavity11. The
incidence of polyps in our study (1in 6 patients) was consistent with previous studieS12.
Majority of cases were bi lateral on presenting radiographs although they did not necessarily
corroborate with clinical findings.7 of 8 polyp cases occurred in unilateral cases which contradicts the findings
of 13, although we both agree that the duration of unilateral sinusitis is usually shorter than that of bilateral
sinusitis.
All the patients were staged based on computed tomography findings pre and postoperatively, using the
Lund- Mackay scoring system. It is still the most widely used radiological method for assessing the diagnosis
and the severity of CRS 14,15,although clinical studies have shown that they have little correlation in symptom
severity. In the present series positive radiological finding were detected in 89 sinuses (out of 60 cases-
120sinuses). The percentage of positive findings indicative of chronic maxillary sinusitis (i.e. mucosal
thickening, fluid level of hazy antrum / opaque antrum) is 74.25%. This is very near the percentage of cases
with radiological findings of chronic maxillary sinusitis in Vuorinen et al’s, McNeill’s, and Jensen.C‘s series.
CT scan scores can help clinicians to predict severity of symptom for nasal obstruction and discharge but not for
other symptoms of chronic rhinosinusitis16. However, there was no association of CT score with the overall
disease severity score 16.CT findings did not associate with queried symptoms postoperatively. Poor correlation
between symptoms and CT findings has also been detected in other studies 17,18. In our study, there was highly
significant statistical improvement in pre and postoperative CT scores at 6 months postop (p< 0.000). The
ostiomeatal complex is a vital anatomical and surgical area which needed to be evaluated separately. Pre and
postoperative CT scores show significant improvement [PEARSON CHI-SQUARE (p-VALUE): 12.836
(0.000)*{L} 15.983 (0.000)*{R}]
The dominant symptoms in our study were headache, facial pain, nasal congestion and rhinorrhea,
corroborating with the observations of many previous studies. There was no correlation of specific symptoms
with duration of disease. There was overall significant improvement in symptoms and quality of life of the
patients, though not quantified. Reviews of the results of endoscopic sinus surgery have reported excellent
subjective results with overall improvements of about 90 % in both short and long term 19,20 .However studies
have demonstrated that symptom improvement does not correlate well to objective endoscopic evidence of
disease persistence 21,22. Our study differs as there was statistically significant improvement in endoscopic
parameter scores except polyp after surgery at 6 months and 1 year postop [PEARSON CHI-SQUARE (p-
VALUE): polyp8.241 (0.221){L} 8.182 (0.225){R} : oedema 86.521 (0.000)*{L} 89.179 (0.000)*{R}:
secretion 71.566 (0.000)*{L} 70.285 (0.000)*{R}] . But it is imperative to note that endoscopic surveillance
postoperatively is continued until a stable cavity is achieved 23.
Crusts in middle meatus was the most common postoperative complication followed by nasal
synechiae and cheek edema. The reason could be attributed to the hot and dry climate of the region. Crusts were
managed by nasal douching as well as removal under direct vision. Synechiae were released in the earliest
postoperative visit with intranasal X ray plating or merocel pack. Other complications as infraorbital numbness,
antrostomy closure and persistent discharge from middle meatus were seen in a small proportion of patients (~
10%). Similar findings were observed in other studies. The findings include perforation of the septum, retained
secretions, small surgical ostium caused by postoperative ostial stenosis, previous Caldwell Luc procedure,
recirculation of mucus, hyperplastic nasal disease, synechiae, recurrent disease in previously unaffected sinuses,
empty nose syndrome, frontal sinus disease, dental disease, and other, more complicated entities 24.The mean
area of preop antrum was (5.58 ± 2.64) mm2vs post op antrum size of (28.45 ± 9.16) mm2. The difference was
statistically significant (p=0.0001).Only one patient in our study had partial closure of the antrostomy on
postoperative endoscopic evaluation. This befits findings of other long term studies25. No correlation could be
accounted for between the patency of antrostomy and presenting symptoms, which again accorded with previous
studies 26. It has been postulated that a minimum ostial diameter of 3.95 mm is needed in order to guarantee the
penetration of a topical treatment to paranasal sinuses 27. Our observation firmly adheres to this concept with a
widely patent maxillary ostium in >90% of patients in postoperative period. Postoperatively, endoscopy and CT
scans provided identical information about the ostiomeatal complex area and maxillary sinus. Owing to the
limited sample size and short follow up period, long term observation of patency could not be documented in
our study. Endoscopic middle meatal antrostomy is superior to Caldwell-Luc in intraoperative and postoperative
parameters and complications 28 and results of our study can be inferred for further research.
Radiological grading of other sinus systems was done concurrently and tabulated, although they were not
operated postoperatively as the surgery was only limited to the maxillary antrum and puncture of the bulla
ethmoidal. Studies have concluded that Functional endoscopic sinus surgery therefore aims at the primary
infective foci in the anterior ethmoid and usually cures disease in the larger sinuses without an attack upon the
latter sinuses 29. Hence our study holds value in evaluation of the maxillary sinus system without extension to

Middle Meatal Antrostomy In The Management Of Chronic Maxillary Sinusistis
DOI: 10.9790/0853-1703044554 www.iosrjournals.org 53 | Page
other sinuses. When the focus of chronic sinusitis appears to be situated in the infundibulum/anterior ethmoid
region, the functional endoscopic surgery seems preferable; for cases where the inflammatory process was
restricted largely to the maxillary sinus a modified inferior meatal antrostomy technique proved to have a higher
success rate in few studies30. Our study proves otherwise with certainty given the subjective improvement in
patients, also paving way for further research.
Despite the existing controversies on optimal management of rhino sinusitis current knowledge of
chronic rhino sinusitis, functional endoscopic sinus surgery is the approach that has shown success in the past
when compared to medical management 31,32. Given the outcome of our study, Middle meatal antrostomy makes
the most sense when surgery is truly required in the management of chronic maxillary sinusitis.
VII. Conclusion
Our study is conclusive evidence that Middle meatal antrostomy is a safe and effective procedure in
patients suffering from chronic maxillary sinusitis with significant improvement in subjective symptomatology
as well as objective parameters.Patients with recurrent chronic sinusitis after prior surgical intervention pose a
particular challenge to the otorhinolaryngologist.
Establishing a correct diagnosis is the first step and requires review of the original pre-surgical
symptoms and imaging with endoscopic evaluation; review of the more recent symptoms and images; and
reevaluation of environmental, general, and local host factors that may contribute to persistent disease.
Sourcesof Funding:NIL
Conflicts Of Interests: NIL
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Sauvagini Acharya "Middle Meatal Antrostomy in the Management of Chronic Maxillary
Sinusistis."IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), vol. 17, no. 3, 2018, pp
45-54.