Extended inferior antrostomy for maxillary sinus surgery
Department of Oto-Rhino-Laryngology and Head and Neck Surgery, Assistance Publique, H
opitaux de Marseille, La Conception University Hospital, Marseille
Aix-Marseille University, Marseille Cedex, France
J. Michel, Department of Oto-Rhino-Laryngology and Head and Neck Surgery, Assistance Publique, H
opitaux de Marseille, La Conception University Hospital,
Functional endoscopic sinus surgery (FESS) has considerably evolved
over the past 20 years while minimally invasive surgery also applies to
sinus procedures. Development of new technologies combined with
better knowledge of risks has allowed surgeons to achieve improved
results in their FESS indications. One of the most difficult areas to visu-
alise using the exclusive endoscopic approach is still the anterior recess
of the maxillary sinus. Hence, external approaches, such as the Caldwell-
Luc procedure, are still used by many surgeons to ensure visual control
of this area in diseases such as fungal balls, mucoceles, inverted papil-
loma and other tumours. This external approach remains associated with
severe complications, among which trigeminal hypoesthesia, sinus
Atelectasis, residual pain and fistula, also found with the canine fossa
Some authors have proposed alternative endoscopic tech-
niques. Nakayama et al.,
for instance, reported a pre-lacrimal approach
that offers good exposure but may jeopardise the lacrimal duct. This
technique allows very good visual control over the superior part of the
anterior recess of the maxillary sinus but involves a medial maxillectomy.
We propose a rapid and easy-to-perform extended inferior antros-
tomy which, in most cases, allows good visualisation of the anterior
recess of the maxillary sinus without endangering the lacrimal ostium.
It also allows the surgeon to access to the orbital floor, the infratempo-
ral fossa or the pterygo
ıd bone for extensive endoscopic procedures.
The purpose of this technical note is to describe how we per-
form this extended inferior antrostomy in order to monitor the ante-
rior recess of the maxillary sinus.
These include all maxillary sinus pathologies requiring visual control
of the anterior maxillary recess: maxillary tumours (inverted papil-
loma), fungus balls, foreign bodies and mucoceles.
The procedure is performed under general anaesthesia. The nasal cav-
ity is decongested using naphazoline and xyloca
ın. We always use a
30° endoscope alone. The four-step procedure is performed following
middle meatal antrostomy. The inferior meatus is divided in four
regions: the anterosuperior region where the nasolacrimal duct arises,
the posterosuperior region in which inferior antrostomy is usually
performed and the anteroinferior and the posteroinferior regions. Fig-
ure 1 shows a step-by-step representation of the surgical procedure.
Step 1: The lacrimal ostium in the anterosuperior region of the
inferior meatus is visualised after medialisation of the inferior tur-
binate (Figure 1A,B).
Step 2: A “classical” inferior antrostomy is performed in the pos-
terosuperior part without mucosal flap (Figure 1C). We simply
locate the lacrimal ostium. Then, a suction tube is used to per-
form the inferior antrostomy 1.5 cm posteriorly to the lacrimal
ostium. The inferior antrostomy can be enlarged back to the pos-
terior wall of the maxillary sinus.
Step 3: The inferior antrostomy is extended forward by resecting
the anterior segment of the lateral nasal wall, immediately below
the lacrimal ostium. This opening is extended up to the piriform
aperture. We use a simple retrograde Ostrom-Terrier forceps to
resect the bony wall posteriorly to anteriorly (Figure 1D,E). The
nasolacrimal ostium has to be respected when performing the
bony portion resection. At this stage, it is possible to check the
anterior maxillary wall using the 30° endoscope.
Step 4 (optional): Also, when needed, we use a diamond burr to
drill away the lower part of the bony wall (downward to the floor
of the nasal cavities) and more anteriorly to the piriform aperture
(Figure 1F-H) to achieve good visual control of the maxillary sinus
anterior wall (Figure 1I). Figure 1J shows the intra-operative pro-
cedure showing the anterior wall of the maxillary sinus. Figure 2
shows an intra-operative procedure with image guidance.
Accepted: 14 June 2017
© 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/coa Clinical Otolaryngology. 2018;43:786–788.