Maxillary sinusitis

Patients with persistent maxillary sinusitis have postnasal discharge, headache which is variable in severity and location, nasal obstruction and usually general malaise. The nasal mucosa is swollen and bathed in mucopurulent secretions. Plain sinus X-rays may show a fluid level in the antrum or complete opacity (Fig. 39.19).

The most likely causative organisms are Streptococcus pneumoniae and H. influenzae. As the infection becomes chronic the likelihood of anaerobic infection increases. The consideration of a Branhamella catarrhalis as a primary pathogen and the possibility of 3-lactam-producing strains of H. influenzae will also influence the choice of antibiotic.

Adequate penetration of antibiotics into chronically inflamed sinus mucosa is doubtful, and therefore treatment may need to be given for several weeks. Topical nasal decongestants such as ephedrine nasal drops will often encourage the sinus to drain. About 10 per cent of infections of the maxillary antrum are due to dental sepsis from anaerobic organisms. The resultant mucopurulent nasal secretion has a foul smell and taste. Maxillary sinusitis from any cause may, through irritation of the superior alveolar nerve, give rise to referred upper toothache.

Antral lavage under local or general anaesthesia allows confirmation of the diagnosis and provides the opportunity to obtain samples for bacteriology. The antrum is entered through the inferior meatus below the inferior turbinate where the bone separating the antrum from the nasal fossa is extremely thin and can be penetrated by a trocar and cannula (Fig 39.20).

If infection has caused a significant degree of inflammation and fibrosis of the lining of the antrum then the natural ostium may be completely obstructed. In this situation an intranasal inferior meatal antrostomy may be fashioned to facilitate drainage from the antrum. Alternatively, intranasal endoscopic techniques may be employed to create a middle meatal antrostomy. The middle turbinate is lifted and the infundibulum is located and enlarged anteriorly, sometimes requiring the excision of the anterior end of the uncinate process under direct endoscopic control. The antrum itself can be inspected through the antrostomy using a combination of 30degree and 70degree rigid endoscopes (Fig. 39.21). For persisting disease a Caldwell—Luc radical antrostomy may be performed, whereby the entire diseased maxillary sinus mucosa is removed through an opening in the anterior wall of the antrum via an incision in the upper gum. Once the diseased antral mucosa is removed a large window is created in the lateral nasal wall allowing drainage into the inferior meatus.

Endoscopic nasal surgery allows a more functional approach to disease’s of the paranasal sinuses and the indi­cations for radical antrostomy are on the decline. Areas of chronically diseased mucosa and infected granulation tissue hinder mucociliary transport and lymphatic drainage leading to retained secretions and the perpetuation of infection. Intranasal endoscopic operations permit the precise removal of diseased mucosa with minimal trauma to adjacent tissues. By removing scar tissue from the narrow recesses within the nose, ventilation and internal drainage can he restored allowing permanent resolution of the chronically inflamed mucosa. In this way precise endoscopic surgery directed towards the middle meatus and the ethmoid system restores the normal physiological function of the paranasal sinuses with minimal mucosal resection (Fig. 39.22).

Complications of maxillary sinusitis

Untreated chronic maxillary sinusitis can lead to acute cellulitis or Osteitis and rarely, if there is a breach in the roof of the antrum, infection may spread into the orbit.

Maxillary sinusitis summary

      Commonest organisms S. pneumoniae and         H. influenzae

May result from dental sepsis

Antral lavage is diagnostic and therapeutic

lntranasal antrostomy or endoscopic middle meatal antrostomy may be needed