1

Introduction

We frequently encounter patients with unilateral nasal or nose-related symptoms, such as nasal obstruction, foul odor, purulent discharge, headache, and facial or cheek swelling. Endoscopic examination may reveal pathological findings, such as septal deviation, hypertrophied inferior turbinate, concha bullosa, polypoid changes of the middle meatal area, visible polyps, and fungal debris. In these patients, varying degrees of unilateral sinus opacification may be observed in radiographic studies. Diverse disease processes can lead to unilateral sinus opacification, including acute or chronic sinusitis, nasal polyposis, allergic or non-allergic fungal sinusitis, antrochoanal polyp, mucocele, and benign or malignant neoplasia .

Among these patients, localized maxillary sinus lesions are not infrequently detected, while other sinuses remain clear. If appropriate medical management fails to improve the sinus disease, we usually perform an uncinectomy and a middle meatal antrostomy to eradicate the pathological condition in the affected maxillary sinus. However, removal of the entire uncinate process may be unnecessary to address a maxillary sinus lesion and this may delay healing, cause injury to the lamina papyracea or nasolacrimal duct, or risk iatrogenic stenosis of the frontal recess when the uncinate is attached to the skull base or synechia formation in the middle meatus . Thus, removal of the lower half of the uncinate may be sufficient to improve the entire maxillary sinus. Additionally, this method is easier to perform and the associated mucosal injury is less severe. In the present study, we evaluated the efficacy of partial uncinectomy versus total removal of the uncinate process in patients with localized maxillary sinus disease.

2

Patients and methods

This prospective clinical study was conducted from January 2011 to September 2013 in patients diagnosed with unilateral maxillary sinus lesion. They underwent endoscopic sinus surgery on the lesion side. All patients showed unilateral maxillary sinus opacification on preoperative computed tomography ( Fig. 1 ). The patients were allocated randomly to undergo a partial uncinectomy (group 1) or a total uncinectomy (group 2) as a part of the surgical procedure addressing the antrum. Randomization was performed according to a randomized list generated using a statistical random number table.

Computed tomography of maxillary sinus disease. Chronic sinusitis (A), fungal sinusitis (B), and antrochoanal polyp (C).

All participants provided written informed consent. The Institutional Review Board of the Soonchunhyang University approved the study.

Exclusion criteria were: 1) acute sinusitis, retention cyst, postoperative maxillary mucocele, and benign or malignant tumor, 2) patients with diffuse polyposis and sinusitis involving a sinus other than the maxillary sinus, 3) cystic fibrosis, ciliary dysfunction, immune deficiency, or immunosuppressed status, 4) previous sinus surgery, and 5) refusal to participate or study drop out before the 6-month follow-up endpoint.

A single surgeon (J.Y.L.) performed all surgical procedures. In group 1, the lower half of the uncinate process was incised with a sharp elevator and the infundibular space was identified ( Fig. 2 A ). Then, half of the uncinate and lower portion of the uncinate attachment was removed using small, straight-cutting forceps ( Fig. 2 B). Care was taken not to damage the lamina papyracea or the mucosal surface of the ethmoid bulla, and the cut margin was trimmed with straight and curved microdebriders (Stryker Instruments, Kalamazoo, MI). After identification and widening of the maxillary natural ostium, pathological mucosa, polyps, or fungal debris was removed using curved microdebrider blades, various forceps, and saline irrigation. It was performed under direct vision using a rigid, straight, 4-mm-diameter 70° endoscope (Karl Storz, Tuttlingen, Germany). In group 2, the surgical technique was similar; the only difference was removal of the entire uncinate process.

Intraoperative findings after partial uncinectomy. (A) The lower half of the uncinate process is incised with a sharp elevator. (B) The removed lower half of the uncinate process and natural ostium of the maxillary sinus can be seen.

After discharge, each patient visited our office once per week for the first 4 weeks, once per month for 2 months thereafter, and then at 6 months postoperatively. Meticulous nasal dressing was performed and appropriate medications were administered. The patients were educated about the saline irrigation method.

We compared the time required for the uncinectomy, healing period for the uncinectomy site, incidence of the lamina papyracea and nasolacrimal duct injury, obstruction or stenosis of the frontal recess, and synechia formation in the middle meatus between the groups. Operation duration was measured from the mucosal incision to the removal of uncinate process and healing period was defined as a complete covering of normal mucosa at the uncinectomy site ( Fig. 3 ).

Postoperative findings after partial uncinectomy.

Results were analyzed using the Mann-Whitney U-test. Statistical analyses were performed using the SPSS software (version 16.0; SPSS Inc., Chicago, IL). Statistical significance was set at p < 0.05.