What is the recommended treatment for severe chronic maxillary sinusitis using mega antrostomy?

Mega Antrostomy for Severe Chronic Maxillary Sinusitis

Endoscopic maxillary mega-antrostomy (EMMA) is the recommended treatment for severe chronic maxillary sinusitis that has failed conventional medical therapy and standard surgical interventions. 1

Patient Selection Criteria

• Mega antrostomy should be performed in patients with recalcitrant maxillary sinusitis who have:

  • Failed previous maxillary sinus surgeries (typically after 2 or more procedures) 1
  • Poor mucociliary clearance resulting from long-standing inflammation or scarring 1
  • Persistent symptoms despite adequate standard antrostomy and medical therapy 1

• Common comorbidities that may indicate need for mega antrostomy include:

  • History of Caldwell-Luc or maxillofacial surgery 1
  • Cystic fibrosis 1
  • Asthma 1
  • Immunodeficiencies 1, 2

Surgical Technique

• EMMA involves extending a standard middle meatal antrostomy through the posterior half of the inferior turbinate down to the floor of the nose, creating a significantly enlarged opening 1

• The procedure should include:

  1. Full exposure of the sinus cavity (lumen)
  2. Removal of diseased tissue
  3. Not just balloon or manual ostial dilation 2

• For advanced CRS with features like nasal polyps, osteitis, or allergic fungal disease, wide sinus openings are necessary to:

  • Facilitate sinus drainage
  • Permit effective delivery of topical therapies 2

Contraindications

• Absolute contraindications include:

  • Serious deformities and posttraumatic/postsurgical scarring on nasal-sinus walls
  • Reoccurring chronic sinusitis associated with congenital mucociliary clearance alterations
  • Nasal-sinus manifestations of systemic granulomatous diseases
  • Locally aggressive benign tumors or malignant tumors 2

• Relative contraindications (requiring treatment before sinus surgery):

  • Stenosis of drainage-ventilation pathways
  • Acute viral or bacterial rhinosinusitis
  • Allergy-related rhinosinusitis
  • Mycotic sinusitis 2

Expected Outcomes

• Clinical efficacy of EMMA shows:

  • Complete resolution of symptoms in approximately 74% of patients
  • Partial symptomatic improvement in the remaining 26%
  • Low revision rate (0% in published studies)
  • No significant complications when performed by experienced surgeons 1

• Most common symptoms improved include:

  • Facial pain/pressure
  • Purulent rhinorrhea
  • Nasal obstruction 1, 3

Advantages Over Other Techniques

• EMMA is superior to standard middle meatal antrostomy (MMA) for severely diseased maxillary sinuses:

  • Better subjective improvement in symptoms
  • Significantly reduced mucosal thickening
  • Improved drainage and ventilation 3

• Unlike the historical Caldwell-Luc procedure, EMMA:

  • Is mucosal-sparing (preserves sinus mucosa)
  • Has shorter recovery time
  • Has fewer complications
  • Can be performed endoscopically 1, 4

Postoperative Management

• Postoperative care should include:
  • Nasal saline irrigations to improve mucociliary clearance 5
  • Appropriate pain management 5
  • Continued medical therapy to maintain sinus patency 5
  • Regular follow-up to assess ostium patency 6

Potential Complications

• Major complications of extensive sinus surgery are rare (0.36-1.5% of cases) 2
• Potential complications include:
  • Mild epistaxis
  • Adhesions
  • Infection
  • Rarely: hemorrhage, injury to skull base, CSF leak, meningitis, orbital injury 2

Special Considerations

• For patients with anatomic variations like sinus septa, surgical planning should be modified:

  • Preparation of two windows/antrostomies
  • Extending the window over the septum 2
  • Using preoperative 3D imaging for planning 2

• When maxillary sinusitis is of dental origin, contemporary treatment of the odontogenic source should be performed alongside the endoscopic sinus surgery 7