Ostiomeatal Complex Research Articles

The Nose and Paranasal Sinuses

The airways should be considered as a functional unit. Indeed, disorders involving the upper respiratory tract (URT) spread to the lower respiratory tract (LRT). Modern functional anatomy divides URT in three, mutually dependent, “junction boxes”: i) the ostio-meatal complex (OMC), ii) the spheno-ethmoidal recess (SER), and iii) the rhinopharynx (RP). The first is the most interesting as it joins the anterior paranasal sinuses with the nose. The correct ventilation and the effective mucociliary clearance of these “three pathophysiologic junction boxes” condition the healthy physiology of the entire respiratory system. The OMC, SER and RP obstruction is the first pathogenic step in the inflammatory cascade of the rhino-sinusal-pharyngeal disorders. The inflammation of the respiratory mucosa is the main pathogenic factor for “airway obstruction” that may be generically defined as a heterogeneous group of pathologies. Moreover, the bacterial biofilms are an important local cause of recurrent diseases: they are a strategic modality of survival set up by bacteria and the main cause of their resistance to systemic antibiotic therapy.

Antrolith in the maxillary sinus: an unusual complication of endoscopic sinus surgery.

Antrolith of the paranasal sinuses are rare entity which are usually asymptomatic, caused by calcification of a nidus and are detected incidentally on radiological examinations. We report a case which presented to us with features of pansinusitis six months after endoscopic sinus surgery. Radiological examination revealed a discrete bony density in the maxillary sinus blocking the ostiomeatal complex. The bony mass was removed endoscopically from the maxillary sinus with drainage of discharge and debris from the sinuses. Histopathological examination revealed an antrolith with bony nidus and calcium deposited around it. We present the imaging and review the present world literature on this rare complication of endoscopic sinus surgery.

CT scan evaluation of the anatomical variations of the ostiomeatal complex

Functional endoscopic sinus surgery (FESS) has revolutionized the approach and treatment of chronic rhinosinusitis. Certain anatomical variations are thought to be predisposing factors for the development of sinus disease and it is necessary, for the surgeon to be aware of these variations, especially if the patient is a candidate for FESS. The aim of the present study was to identify the various anatomical variations of the ostiomeatal complex in patients of chronic rhinosinusitis who underwent FESS. A total of 150 patients of chronic rhinosinusitis (medical treatment failures) who were subjected to FESS were CT scanned preoperatively to find any bony anatomic variation and the extent of mucosal disease. Concha bullosa was the commonest anatomic variation and was seen in 45 (30%) patients. The other anatomic variations noted included: paradoxical middle turbinate in 9.33% patients, uncinate process variations in 25% patients, agger nasi cells in 9.33%, Haller cells in 8.66% and posterior septal deviations in 25.33% patients. The mucosal disease was most commonly seen in anterior ethmoids (87.33% ), followed by maxillary sinus ostial area (70%), maxillary sinus disease (65.33%), posterior ethmoidal disease (38%), frontal sinus disease (15%) and sphenoid sinus mucosal disease (8.66%) patients. A thorough preoperative CT evaluation of the patients undergoing FESS is necessary to detect various anatomical variations in the ostiomeatal complex.

Functional endoscopic sinus surgery

The theory behind functional endoscopic sinus surgery (FESS) is to re-establish drainage from the maxillary, ethmoid, sphenoid, and frontal sinuses. In addition, allowing the ostiomeatal complex to stay patent is an important factor in re-establishing mucociliary clearance from the dependant sinuses. By achieving adequate drainage from the natural ostium, the mucosal disease and subsequent symptoms could become reversible in many cases. Many children who are considered for FESS have comorbidities that include allergies, immune deficiency, ciliary disorders or cystic fibrosis. Medical management should be maximized before FESS. There are multiple methods and techniques described to perform FESS; however, in this manuscript we will describe an anterior to posterior technique used at the University of Miami.

Transantral, Endoscopically Guided Balloon Dilatation of the Ostiomeatal Complex for Chronic Rhinosinusitis under Local Anesthesia

A multicenter study (BREATHE I - Entellus Medical, Inc.) was performed to assess the safety and outcomes of a new, less invasive system that uses direct endoscopic visualization to facilitate balloon dilation of the maxillary sinus ostia and ethmoid infundibulum. General anesthesia was avoided in most subjects to assess feasibility of performing transantral ostial dilatation in an office setting. Subjects with chronic rhinosinusitis of the maxillary sinuses alone or maxillary and anterior ethmoid sinuses underwent baseline evaluation including CT imaging and symptom assessment using the Sino-Nasal Outcome Test (SNOT 20). Subjects underwent transantral balloon dilation and follow-up evaluation at 1 week, 3 months, and 6 months post-procedure. Thirty subjects were treated at three centers. Fifty-five of 58 maxillary ostia were successfully treated for a procedural completion rate of 94.8%. Ninety-seven percent of the procedures were completed under local anesthesia with or without minimal intravenous sedation. There were no device-related serious adverse events or unanticipated adverse device effects. The mean overall SNOT 20 score at baseline was 2.9 +/- 1.0. Mean overall SNOT 20 scores at 1-week, 3-month, and 6-month follow-up were 0.8 +/- 0.8, 0.7 +/- 0.8, and 0.8 +/- 0.9 respectively. Patency at 3-months as confirmed by CT imaging was 95.8%. These results indicate that transantral balloon dilation of the ostiomeatal complex under local anesthesia appears to be a safe technique for managing isolated maxillary or maxillary and anterior ethmoid sinusitis and can potentially be performed safely in an office setting.

Analysis of clinical characteristics of chronic rhinosinusitis in patients with postirradiated nasopharyngeal carcinoma

To study the characters of chronic rhinosinusitis in patients with irradiated nasopharyngeal carcinoma. There were 65 cases of chronic rhinosinusitis after irradiated nasopharyngeal carcinoma (NPC, experimental group) and 65 cases of common chronic rhinosinusitis (CRS, control group) in the study. The visual analogue scale (VAS) was used to evaluate the intensity of subjective symptoms. Endoscopic finding was recorded and CT results were evaluated by Lund-Mackay scoring system. As to the VAS, nasal secretion was significantly more severe in experimental group (7.86+/-1.62), compared with control group (5.12+/-1.32, t=10.541, P<0.01). As to endoscopic finding, middle nasal meatus were clean in 35 (53.8%) cases in experimental group, and 23 cases (35.4%) in control group (chi2=4.483, P<0.05). CT score was (7.03+/-4.63) in experiment group, and (11.42+/-3.32) in control group (t=-6.207, P<0.05). The main reason lays in lower CT score and lower involved rate of ostiomeatal complex, frontal sinus, maxillary sinus, anterior ethmoid sinus. The characters of chronic rhinosinusitis in patients with irradiated nasopharyngeal carcinoma is quite different from the common CRS and different therapeutic measures should be taken.

United airways again: high prevalence of rhinosinusitis and nasal polyps in bronchiectasis

Although various relationships between the lower and upper airways have been found, the association of bronchiectasis with chronic rhinosinusitis and nasal polyps has not been thoroughly evaluated. This study was undertaken to examine the association of idiopathic and postinfective bronchiectasis with chronic rhinosinusitis and nasal polyposis. In a prospective study, 56 patients with idiopathic and 32 with postinfective bronchiectasis were evaluated for chronic rhinosinusitis and nasal polyposis by using EP(3)OS criteria and assessing: symptoms score, nasal endoscopy, sinonasal and chest CT scan, nasal and lung function and nasal and exhaled NO. Most bronchiectasis patients (77%) satisfied the EP(3)OS criteria for chronic rhinosinusitis, with anterior (98.5%) and posterior (91%) rhinorrhea and nasal congestion (90%) being the major symptoms. Patients presented maxillary, ethmoidal and ostiomeatal complex occupancy with a total CT score of 8.4 +/- 0.4 (0-24). Using endoscopy, nasal polyps with a moderate score of 1.6 +/- 0.1 (0-3) were found in 25% of patients. Nasal NO was significantly lower in patients with nasal polyposis (347 +/- 62 ppb) than in those without them (683 +/- 76 ppb; P < 0.001), and inversely correlated (R = -0.36; P < 0.01) with the ostiomeatal complex occupancy. In the chest CT scan, patients with chronic rhinosinusitis showed a higher bronchiectasis severity score (7.2 +/- 0.5; P < 0.001) than patients without (3.7 +/- 0.7). The prevalence of chronic rhinosinusitis, nasal polyps and other outcomes were similar in idiopathic and postinfective bronchiectasis. The frequent association of chronic rhinosinusitis and nasal polyposis with idiopathic and postinfective BQ supports the united airways concept, and it suggests that the two type of bronchiectasis share common etiopathogenic mechanisms.

Delayed presentation of silent sinus syndrome after orbital trauma

Objectives We describe the clinical presentation and management of a patient with a remote history of orbital trauma who presented with spontaneous right enophthalmos and radiographic findings consistent with silent sinus syndrome over 30 years after her initial orbital injury. Methods The patient chart and imaging results were reviewed. A literature review of silent sinus syndrome and traumatic enophthalmos was performed. Results Our patient had both clinical and radiographic findings consistent with silent sinus syndrome. Only 2 other cases of silent sinus syndrome after orbital trauma have been reported in the literature. The underlying anatomic pathology common to all cases is obstruction of the ostiomeatal complex with subsequent maxillary sinus hypoventilation and sinus collapse. Our patient underwent single stage repair with endoscopic maxillary antrostomy and had resolution of the mucosal disease at 6-month follow-up. Conclusions Posttraumatic cases of silent sinus syndrome are much less common than spontaneous cases but share similar pathophysiology and can be effectively treated using endoscopic techniques.

Maxillary mucosal cyst is not a manifestation of rhinosinusitis: Results of a prospective three‐dimensional CT study of ophthalmic patients

Mucosal cysts in the maxillary antrum (MMC) are a common finding in imaging of the paranasal sinuses. Their significance remains in doubt and their prevalence in the general nonrhinitic population is unknown. To establish the prevalence of MMCs in patients without nasal complaints and identify any association with putative causative factors. To identify any correlation between objective radiologic evidence of chronic rhinosinusitis or dental disease and the presence of cysts. Prospective case series. Computed tomography (CT) images from 257 patients undergoing scans of the orbits for ophthalmic reasons were entered into this study. Patients responded to a questionnaire prior to scanning inquiring about nasal complaints, treatment for nasal disorders, previous nasal injury, allergy, asthma, recent upper respiratory tract infection, and dental root disease of the upper jaw. Overall 35.6% of patients studied had radiologic evidence of at least one maxillary mucosal cyst. There was no association between the presence of cysts and subjective or objective evidence of sinus or dental disease. Specifically, there was no correlation between the presence of cysts and the total and ostiomeatal complex Lund-Mackay radiologic scores. Maxillary mucosal cysts are prevalent in nonrhinitic patients and do not reflect sinus or dental disease. Their presence should not be an indication for sinus surgery.

Comparative evaluation of conventional versus endoscopic septoplasty for limited septal deviation and spur

To compare the procedure, results and complications of conventional septoplasty with those of endoscopic septoplasty, in cases of limited septal deviation and septal spurs. Prospective study; interventional type; randomised block design; comparative clinical trial. We included in the study 80 patients presenting with limited septal deviation, septal spur with nasal obstruction, or deviated septum with septal correction was required in order to access the ostio-meatal complex (OMC) for functional endoscopic sinus surgery. Of these 12 were children with septal deviation producing significant nasal obstruction. All patients were divided into two groups- with one undergoing conventional and the other endoscopic septoplasty. Post-operative assessment was carried out one month, three months and one to two years after the procedure. Post-operative complications such as haemorrhage, infraorbital oedema, nasal pain and in-patient hospital was slightly more in the conventional septoplasty group. No statistically significant difference was found between the conventional and endoscopic septoplasty groups, as assessed by subjective and objective evaluation.

Bacterial Origin of Ostiomeatalcomplex after Viral Infection

Objective After a viral infection in the nasal cavity or sinus, superimposed bacteria infection is likely to occur. Therefore the carriage rate of bacterial pathogen in the nasal cavity (NC), nasopharynx (NP), and ostiomeatal complex (OMC) were determined during wellness and upper respiratory viral infection. Methods There were 2 groups in the study. The control group was well with no nasal or sinus problems. The cohort group had an upper respiratory viral infection. The NC, NP, and OMC cultures were taken from each study group. Agars cultured were used to detect S. pneumoniae, H. influenzae, and M. catarrhalis. Statistical comparison was made between the groups. The bacterial pathogens were also compared between the various sites of culture within a group. Results There were 91 subjects in the study-51 subjects with an upper respiratory viral infection and 40 control participants. 59% of participants were female. There was no statistical difference in the rate of bacterial pathogen in the NP (p=0.2) or NC (p=0.06) between the control and cohort group. There was a significant increase (p&lt;0.008) of bacterial pathogen in the OMC of viral illness group versus the control group. Bacterial pathogen present in the OMC had a similar pathogen in either the NC or NP. Conclusions This study defines the reservoir of bacteria in the NC or NP for the bacterial pathogen in the OMC during wellness and upper respiratory viral infection.

S246 – Chronic Sinusitis in Children: Which Sinuses Are Involved

Objectives 1) Learn which paranasal sinuses are involved in chronic rhinosinusitis in children. 2) Be able to customize surgical treatment based on those findings. Methods Retrospective review of children who had sinus surgery over a period of 10 years. 76 children whose age ranged between 3 and 14 years had their CT scans reviewed to determine which sinuses were diseased. All children had a CT scan because of failure of medical management and were considered for surgery. Outcome was to determine which sinuses were developed and of those, which ones were diseased and what was the severity of the disease. Results The maxillary sinuses were the most common sinuses involved in children with chronic rhinosinusits (92%). The ostiomeatal complex was next most common area involved in these children (88%). Conclusions The maxillary sinuses, followed by the ostiomeatal complex, were the most common areas involved in children with chronic rhinosinusitis. Initial surgical management of these children should then be based on those findings.

S290 – Sinonasal Pathology and Severity of Bronchiectasis

Objectives 1) To investigate the prevalence of nasal symptoms, nasal polyposis, and sinusal opacification in patients with bronchiectasis. 2) To investigate the association between the degree of sinusal opacification and the bronchiectasis extension. Methods 88 consecutive patients with stable non-cystic bronchiectasis were prospectively evaluated for nasal symptoms (RASP, 0–3), polyp size (nasal endoscopy, 0–3), sinusal occupation (CT, 0–24), and chest HRCT (0–18). Results Following EP3OS criteria, 77% of patients presented had chronic rhinosinusitis (CRS). Nasal congestion (incidence: 90%; score: 1.6±0.1) Anterior (99%; 1.9±0.1) and posterior (91%; 1.8±0.1) rhinorrhea, were reported by patients as the major complaints. Nasal polyps (NP) of a mild-moderate size (1.6±0.3) were found in 25% of patients. Sinonasal CT was abnormal in patients with CRS, with a CT score of 8.4±0.4, with predominance in maxillary sinus (2.1±0.1), anterior ethmoid sinus (1.9±0.1), and ostiomeatal complex (2.2±0.2). Patients with CRS had significantly worse scores on chest HRCT (CRS: 3.7±0.7; no CRS: 7.2±0.5). Conclusions More than 75% of patients affected with BQs fulfil EP3OS criteria of CRS and 25% of patients presented NP. Patients with CRS presented more affectation on chest HRCT scan. We conclude that patients with bronchiectasis should be evaluated to assess the presence of chronic rhinosinusitis and nasal polyposis.

Radiologic outcomes in children with chronic rhinosinusitis and ostiomeatal complex obstruction after medical management

The presence of ostiomeatal complex obstruction can be a key component in chronic rhinosinusitis, and the medical management of this condition has not been well studied, particularly in children. To compare the effectiveness of antibiotics, intranasal topical corticosteroids, and oral systemic corticosteroids on radiologic outcomes in children with chronic rhinosinusitis and ostiomeatal complex obstruction. We reviewed the reports of 1,741 computed tomography scans performed on children at Alfred I. duPont Hospital for Children, Wilmington, Delaware, from October 1, 2001, through February 28, 2007, identifying those patients who had 2 scans performed at least 2 weeks apart but no more than 6 months apart. Forty-five instances involving abnormal ostiomeatal complex anatomy documented on the initial study with obtainable treatment information were selected for further review. Of the 3 treatment modalities examined, only oral systemic corticosteroids (P = .03) and intranasal topical corticosteroids (P = .03) were found to provide significant independent contributions to predicting treatment outcome, with the former promoting a positive outcome and the latter predicting a negative outcome. The model that contained just these 2 factors also provided a significant fit to the outcome data (P = .01), producing a diminished rate of improvement expected from a combination of positive and negative influences. Neither antibiotics nor any other combination of modalities contributed to a significant improvement in model fit. The use of oral systemic corticosteroids was found to be the only beneficial intervention, with regard to radiologic improvement, in the treatment of ostiomeatal complex obstruction in children.

Silent Sinus Syndrome Presenting as Enophthalmos Long After Orbital Trauma

Late enophthalmos is a well-known consequence of large orbital floor fractures. In rare cases, late enophthalmos can occur after direct trauma to the maxillary ostiomeatal complex and present as silent sinus syndrome (SSS). We report two cases of SSS manifesting as enophthalmos years after facial trauma. The first patient developed SSS 4 years after a minimally displaced orbital floor fracture. The second patient had progressive enophthalmos as a result of atelectasis of the maxillary sinus years after facial trauma and surgical repair of nasal fractures. There have been two prior reports of SSS presenting after orbital trauma. Our patients differ from these prior reports in that the enophthalmos was discovered years after the initial facial trauma. In the first patient, surgery addressing the blockage of the ostiomeatal complex arrested the enophthalmos; in the second patient, it reversed the enophthalmos.

Konservative und chirurgische Behandlung der oberen Atemwege

Rhinitis and sinusitis usually coexist and are concurrent in most individuals; thus, the correct terminology is now rhinosinusitis. Rhinosinusitis (acute and chronic, with and without nasal polyps) is defined as an inflammation of the nose and the paranasal sinuses characterised by two or more symptoms, one of which should be either nasal blockage, obstruction, congestion or nasal discharge (anterior and posterior nasal drip). For the acute rhinosinusitis one can state that the initial antibiotic treatment does not affect the outcome of the disease, therefore a symptomatic treatment as first line is adequate. Antibiotics are indicated after a prolonged phase of the disease with increase of the symptoms mainly after a period up to 10 days. An early treatment with topical steroids is most efficient in ARS. Chronic rhinosinusitis (CRS) is a multifactorial disease. Factors contributing can be mucociliary impairment, bacterial infection, allergy, swelling of the mucosa for another reason or anatomical variations in the nasal cavity. The ostiomeatal complex, a functional unit of the paranasal sinuses plays a key role in the pathogenesis of rhinosinusitis. The first line treatment strategy is medical treatment using topical steroids, long-term macrolide therapy and in severe cases short courses of systemic steroids. The role of surgery is defined to treat the residual disease after medical treatment. Surgery is primarily aimed at improving ventilation of the sinuses and restoring paranasal clearance.

A Case of Huge Pneumatized Uncinate Process Causing Obstruction in Patient with Chronic Rhinosinusitis

Chronic rhinosinusitis is one of the most common diseases in rhinology. The importance of the ostiomeatal complex (OMC) has been known. Anatomic abnormalities and inflammatory changes lead to sinus ostial obstruction and subsequently induce chronic or recurrent sinusitis. Therefore, anatomic variations of the nasal cavity were considered as important factors in causing chronic rhinosinusitis. Whereas pneumatization of the middle and superior turbinate is a common finding, that of uncinate process is extremely rare. It can cause obstruction of the OMC by narrowing the middle meatus and infundibulum. We have recently experienced a huge pneumatized uncinate process causing obstruction in patient with chronic rhinosinusitis. We could successfully perform endoscopic sinus surgery with good results. Therefore, we present this rare case and briefly discuss the possible pathogenesis. (Korean J Otorhinolaryngol-Head Neck Surg 2008;51:931-4)

Etiology and pathogenesis of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is defined as inflammation of the nose and the paranasal sinuses characterised by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior, posterior nasal drip) + facial pain/pressure + reduction or loss of smell sensation of smell and either endoscopic signs of polyps and/or mucopurulent discharge primarily from the middle meatus and/or edema/mucosal obstruction primarily in middle meatus, and/or computerized tomography (CT) changes showing mucosal changes within the ostiomeatal complex and/or sinuses from more than 12 weeks . It is an increasingly common cause of patients visits to physicians and the principal diagnosis in nearly 2% of them . The prevalence of rhinosinusitis is estimated to be 14% of the global population . The location and extent of different rhinosinusitis pathological conditions imply a detailed knowledge of anatomic organization of paranasal sinuses, and the first and foremost of ethmoid sinuses. The structures of the lateral nasal wall and paranasal sinuses fall into two anatomically and physiologically distinct categories: the anterior and posterior ethmoid complex. The basal lamella of the middle turbinate is the distinct separation between the two ethmoid complexes. The ostiomeatal complex (OMC) is a functional entity of the anterior ethmoidal complex that represents the final common pathway for drainage and ventilation of the frontal, maxillary and anterior ethmoid cells. The sphenoethmoidal recess is a functional entity of the posterior ethmoid complex that represents the final common pathway for drainage and ventilation of the sphenoid and posterior ethmoid cells. Three clinical entities of CRS may be defined: chronic rhinitis, localized sinusitis and diffuse rhinosinusitis . Chronic rhinosinusitis is a multifactorial disease. Predisposing factors can be divided into: local host factors, general host factors and environmental or non-host factors 1, . Local host factors

内視鏡下鼻内副鼻腔手術を施行した頭痛症例の検討

Headache is a common complaint in sinus diseases. Especially in cases of acute sinusitis, headache is often associated with congestion and purulent discharge, which facilitates the diagnosis. However, cases of chronic sinusitis that involve persistent headache as a chief complaint may often cause difficulty in selecting the surgical method such as endoscopic sinus surgery (ESS). This study investigated the relationship between headache site and CT findings and evaluated the postoperative results of patients with sinus headache after ESS. Thirty-eight patients with headache underwent surgery between 2000 and 2005. The etiology of headache was chronic sinusitis in 31, fungal sinusitis in 4 and sinus cyst in 3. Twenty-seven patients complained of frontal and/or occipital headache and 3 complained of temporal headache.On CT findings, the site demonstrating clouded sinus almost corresponded to the lesion causing headache and lesion of the ostiomeatal complex seemed to be causative in frontal headache. As a result thirty-seven of 38 patients had no further headache after surgery during an average postoperative followup of 7.1 months.

Cavernous Hemangioma of the Maxillary Sinus with Bone Erosion

We report a case of cavernous hemangioma originating in the maxillary sinus. This is an unusual location for hemangioma, and this case also had a rare presentation involving bone erosion. The substantial bone destruction and resultant widening of the right ostiomeatal complex made it difficult to differentiate this cavernous hemangioma from malignant epithelial tumors.