41 Revision Surgery of the Maxillary Sinus

Charles P. Kimmelman

The newly augmented maxillary ostium should incorporate the natural ostium. Thus, it is important to identify the natural ostium and enlarge it, rather than place a secondary opening in a different position.1 Heterotopic ostia may not lie within the path of the flowing mucus blanket powered by cilia programmed to beat in the direction of the natural opening.² The resultant stasis of secretions can allow proliferation of microbes and/or more prolonged retention of inhaled toxins and pollutants. A similar mechanism also may lead to failure in previously operated antra with an inferior meatus antrostomy, in which the so-called recirculation sinusitis has been described. In this condition, infected mucus does not “drain” from the inferior antrostomy. Instead, it serves as an entry point for secretions that exit the natural os. Secretions are recycled instead of transported posteriorly into the nasopharynx.

Surgical Technique

Endoscopic surgery within the small, cramped space of the middle meatus favors contact of the delicate epithelium with instruments during their repeated insertion and removal. To limit injury to retained mucosal surfaces, the operator must adhere to a philosophy of extremely delicate handling of tissue. Small abrasions induce an inflammatory response that can at a minimum impair ciliary activity, and at worst avulse mucosa and induce synchiae and stenosis. The coating of instruments with viscoelastic substances, such as hylan B, can provide a measure of protection.³ The presence of foreign material, such as free bone chips, or denuded bone (leading to an osteitis) can produce localized inflammation and subsequent scarring.⁴ All foreign material must be removed and exposed bone covered or excised.

Failure to Recognize and Rectify Structural Anomalies

Anatomical anomalies, such as a hypersegmented sinus, Haller cells, persistent uncinate, septal deviation and perforation, and odontogenic processes (e.g., congenital cysts, apical cysts, oral antral fistula), allow foci of inflammation to persist or impair ostial function. Scarred sinus lumens from previous Caldwell-Luc procedures may entrap mucosa. These nascent mucoceles must be removed and exteriorized, a sometimes difficult task with a purely transnasal endoscopic approach.⁵ Careful review of radiographs and complete inspection of the sinus should allow identification of unsuspected pathology. Depending on the anomaly, a canine fossa approach may be indicated. Dental disease should be evaluated in concert with an oral surgical colleague.

Elimination of Adjacent Sinus Disease

The antrum does not exist in a vacuum. Adjacent chronic inflammation and infection of the ostiomeatal complex involving the ethmoid labyrinth, the infundibulum, and the frontal recess must be identified and removed, or a recurrence of the maxillary sinus disease is possible.⁴ All polypoid mucosal changes, granulation tissue, scarring, and stenosis should be removed in the region of the ostiomeatal complex.⁶

Postoperative Care

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