The endoscopic surgical treatment of maxillary sinusitis has multiple options. These options range from balloon sinuplasty to partial maxillectomy. Balloon sinuplasty with access to, and dilation of, the maxillary ostium and ethmoid infundibular space can be performed using either a transnasal or a transantral approach. This chapter will describe transantral dilation of the maxillary sinus ostium and ethmoid infundibulum. Since the surgery is transantral, it can be performed either in the clinic or in outpatient surgery under local or general anesthesia.

The CT scan obtained after optimal medical treatment typically reveals bilateral narrowed ostiomeatal complexes with mild anterior ethmoid and maxillary sinus thickening (Fig. 12.1).

Whether surgery is done in the operating room or clinic, proper materials for anesthesia are necessary. The preoperative CT scan should be reviewed prior to the procedure to assess for any of the following: bowed nasal wall; hypoplastic antrum; infraorbital (Haller cells); accessory ostia; occluded maxillary ostia; ostium position; and amount of mucosal thickening/fluid. This review will help to identify not only the optimal location for antral access but also the presence of any challenging anatomy that may limit success of the transantral approach. Additionally, the CT scan should be available in the procedure room as it provides a road map for successful advancement of the balloon catheter to its desired predilation location. The transantral balloon kit (Fig. 12.2) including the microtrocar, access sheath, balloon catheter, inflation device, endoscope, and extension tube (optional) should be prepped and ready for use. Appropriate marking of surgical sides is performed.

The patient is brought into the clinic procedure room, seated in the examination chair, and reclined approximately 45 degrees for patient comfort and optimal positioning for access and equipment orientation during the procedure. Nasal topical decongestant (e.g., Afrin or Neo-synephrine) and 4% lidocaine (e.g., Xylocaine) anesthetic spray are administered. Nasal pledgets are soaked in topical decongestant either 4% lidocaine or 2% tetracaine (e.g., Pontocaine) and placed in the middle meatus between the inferior turbinate and the nasal septum. Benzocaine gel (Hurricaine gel) or 4% lidocaine-soaked pledgets are also placed beneath the lips at the location of planned access into the maxillary antrum through the canine fossa. After approximately 10 minutes of local anesthesia, all pledgets are removed and 2 to 3 mL per side of 1% lidocaine with epinephrine 1:100,000 is injected into the uncinate process, the root of the middle turbinate, the anterior middle turbinate, and at the canine fossa access site. A thorough blanching of the tissue should be observed. The pledgets are replaced, and a second 10-minute wait is recommended before starting the procedure.

To access the maxillary sinus and avoid injury to any branches of the superior alveolar nerves, the lip is retracted near the canine fossa recess and the gingival tissue is palpated to locate the intersection of the midline of the pupil and the vestibule of the nose (Fig. 12.3). The microtrocar and access sheath are advanced through the soft tissue and placed onto the surface of the bone. After reconfirming the microtrocar tip position at this intersection, light forward pressure is applied with simultaneous back-and-forth rotation (±120 degree) until complete penetration through the bone is achieved. Rotation continues while the handle of the microtrocar is angled gently downward and toward the medial canthus (Fig. 12.4)

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