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
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
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