© Borgis - New Medicine 4/2010, s. 118-121
*Lechosław P. Chmielik, Jolanta Jadczyszyn, Magdalena Frąckiewicz, Mieczysław Chmielik
Intra-operative evaluation of natural ostia of the maxillary sinuses in children with chronic rhinosinusitis
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head of Department: prof. Mieczysław Chmielik, MD, PhD
Summary
Introduction. Narrowing of the natural ostium of the sinuses is stated in the literature to be the main structural cause of chronic rhinosinusitis. Thanks to computed tomography (CT), we are able to confirm rhinosinusitis as well as to make a prognosis of its progression. CT also enables evaluation of the state of the natural ostia and any pathological lesions that may lead to chronic inflammation. The majority of authors make a diagnosis and evaluate the progression of the disease on the basis of computed tomography or magnetic resonance imaging. The need for endoscopy of the nasal cavities, with evaluation of natural ostia in the middle nasal duct, is also emphasised. Patients with chronic rhinosinusitis caused by narrowing of the natural ostia should be qualified for surgical treatment. Currently available paediatric endoscopic sinus surgery (PESS) is based on modifications of operations by Vigand or Stammberger.
Aim. The aim of this study was to analyse lesions that may influence the functioning of the paranasal sinuses, and the intra-operative image of the natural ostium, from both the nasal cavity and the lumen of the maxillary sinus, in a group of children operated on as a result of chronic rhinosinusitis.
Material and method. In the study, the intra-operative image of the natural ostia of the maxillary sinuses of children operated on for chronic rhinosinusitis in the Department of Paediatric Otolaryngology of the Medical University of Warsaw, during the period from July 2008 to December 2009, was assessed.
Results. Unilateral lesions of the natural ostia of the maxillary sinuses were found in 4 cases (3.84%) and bilateral lesions in 100 cases (96.15%). In total, 208 maxillary sinuses were evaluated. During evaluation of the ostia from the nasal cavity, normal ostia were found in 196 (94.23%) cases, inflammatory-oedematous lesions in 9 (4.32%) cases, and polyps in 3 (1.44%) cases. During evaluation of the ostia from the lumen of the maxillary sinuses, normal ostia were found in 4 (1.92%) cases, inflammatory-oedematous lesions in 191 (91.82%) cases, a diaphragm in the area of the ostium in 7 (3.36%) cases, and polyps in 6 (2.88%) cases.
Conclusions. 1. Inflammatory-oedematous lesions were found significantly more often in the ostium of the maxillary sinus from the lumen of the sinus than from the nasal cavity. 2. Defects in ventilation of the sinuses due to skeletal or mucosal deformations in the area of the ostia may cause a chronic inflammatory process in the upper respiratory tract. 3. Haller?s cells play an essential role in the pathogenesis of chronic rhinosinusitis in children.
INTRODUCTION
Chronic rhinosinusitis in children still remains a considerable diagnostic and therapeutic problem (1).
The result of treatment depends on precise determination of the factors that play a role in development of pathological changes in the patient (2). A doctor who carries out such treatment should evaluate, first, general conditions: the patient?s immunity, mobility of cilia, density of mucus, and susceptibility to allergies.
Second, local evaluation includes: nasal patency, condition of the osteomeatal complex, and co-existence of nasal polyps (3). Precise determination of the aforementioned factors allows preparation of the most efficient scheme of preservative or surgical treatment, and an estimate of the potential for complete recovery.
Particularly in patients with chronic rhinosinusitis with nasal polyps, complete recovery is very difficult (4). Early diagnosis and treatment to prevent the full development of the symptomatic departmental appearance of the disease is very important. The majority of authors state that the main structural cause of chronic rhinosinusitis is narrowing of the natural ostium of the sinuses (5). The basic examination in patients with chronic sino-nasal symptoms is currently, without doubt, based on computed tomography. Due to computed tomography we are able to confirm rhinosinusitis as well as predict its progress. CT also enables an evaluation of the state of the natural ostia and pathological lesions that may lead to chronic inflammation. The majority of authors make their diagnosis, and evaluate the progression of the disease, on the basis of computed tomography or magnetic resonance imaging (6). The necessity for endoscopy of the nasal cavities, with evaluation of the natural ostia in the middle nasal duct, is also emphasised. Patients with chronic rhinosinusitis caused by narrowing of the natural ostia should be qualified for surgical treatment. Currently available paediatric endoscopic sinus surgery (PESS) operations are modifications of Vigand?s or Stammberger?s operation (7, 8, 9, 10). In both surgical techniques, endoscopy of the nasal cavities is carried out as the first step, during which the osteomeatal complex and the natural ostia of the maxillary sinuses are examined. For an adequate prognosis, information about the condition of the osteomeatal complex from the maxillary sinus is necessary. This information is usually included in descriptions of the surgery, whereas in the available literature no research concerning such analysis has been found.
AIM
The aim of this study was to analyse lesions that may influence the functioning of the paranasal sinuses, and the intraoperative image of the natural ostium, from both the nasal cavity and the lumen of the maxillary sinus, in a group of children operated on as a result of chronic rhinosinusitis.
MATERIAL AND METHOD
In the study, the intra-operative image of the natural ostia of the maxillary sinuses of children operated on for chronic rhinosinusitis in the Department of Paediatric Otolaryngology of the Medical University of Warsaw, during the period from July 2008 to December 2009, was assessed.
Inclusion criteria: fulfilment of the criteria of chronic rhinosinusitis that lasts, in spite of proper treatment, more than 3 months, and lesions in the maxillary sinuses. Exclusion criteria: exacerbation of pathological lesions which enable assessment of the natural ostia both from the side of the nasal cavity and from the lumen of the maxillary sinus, previous operations on the maxillary sinuses, and lesions not concerning the maxillary sinuses. Patients with other than sinusal causes of disease, such as hypertrophy of the adenoids (tab. 1), were also excluded from the study. Each patient, before surgery, had CT of the sinuses. Patients were qualified for surgical treatment on the basis of CT. The natural ostium of the maxillary sinus was examined intra-operatively using an endoscope (0°, 30°). Afterwards, the endoscope was inserted below the inferior nasal turbinate through a trocar into the maxillary sinus, and its mucosa and natural ostium were examined. To assess lesions in the maxillary sinus, 0°, 30°, 70°, and 120° endoscopes were used. To assess the natural ostium from the side of the lumen of the maxillary sinus, 70° and 120° endoscopes were used (fig. 1).
Table 1. Inclusion and exclusion criteria.
| Inclusion criteria | Exclusion criteria |
| meeting the criteria of chronic rhinosinusitis that lasts, in spite of proper treatment, more than 3 months | exacerbation of pathological lesions which enables assessment of the natural ostium from both the nasal cavity and the lumen of the maxillary sinus |
| lesions in maxillary sinuses | previous operations on maxillary sinuses |
| acute rhinosinusitis |
| lesions not concerning the maxillary sinuses |
| patients with other than sinusal causes of disease - e.g.: hypertrophy of adenoid |
Fig. 1. Normal natural ostium of the right maxillary sinus seen from the lumen of the sinus.
Fig. 2. Polyp in the natural ostium of the maxillary sinus.
A ? View from the nasal cavity.
B ? View from the lumen of the sinus.
Fig. 3. Oedematous-inflammatory lesions of the natural ostium of the maxillary sinus seen from the lumen of the sinus.
Fig. 4. Membrane in the natural ostium of the maxillary sinus seen from the lumen of the sinus.
Fig. 5. Polyp in the natural ostium of the maxillary sinus seen from the lumen of the sinus.
Fig. 6. Oedematous-inflammatory lesions and a small polyp in the area of the natural ostium of the maxillary sinus seen from the lumen of the sinus.
RESULTS
Altogether, 104 operations on children, carried out in the Department of Paediatric Otolaryngology, Medical University of Warsaw, were analysed. The group included 54 (51.92%) girls and 50 (48.07%) boys.
The mean age was 12.91, the oldest child being 18 and the youngest 4. In CT, concha bullous was found in 28 (26.92%) patients, Haller?s cell in 87 (93.26%), and obstructed ostia (uni- or bilateral) in 104 (100%).
Intra-operatively, unilateral lesions in the natural ostia of the maxillary sinuses were found in 4 (3.84%), and bilateral in 100 (96.15%) children. In total, 208 maxillary sinuses were evaluated. During evaluation of ostia from the nasal cavity, normal ostia were found in 196 (94.23%) cases, inflammatory-oedematous lesions in 9 (4.32%) cases, and polyps in 3 (1.44%) cases
(fig. 2). During evaluation of the natural ostia from the lumen of the maxillary sinuses, normal ostia were found in 4 (1.92%) cases, inflammatory-oedematous lesions in 191 (91.82%) cases (fig. 3), a diaphragm in the area of the ostium in 7 (3.36%) cases (fig. 4), and polyps in 6 (2.88%) cases (tab. 2).
Table 2. Results of evaluation of the natural ostia.
| type of lesions | from the nasal cavity n = 208 | from the maxillary sinus n = 208 |
| normal ostium | 196 (94.23%) | 4 (1.92%) |
| inflammatory-oedematous lesions | 9 (4.32%) | 191 (91.82%) |
| polyps in the ostium | 3 (1.44%) | 6 (2.88%) |
| septum in the ostium area | 0 | 7 (3.6%) |
DISCUSSION
The basic examination in diagnostics of chronic rhinosinusitis is computed tomography, which shows mainly osseous elements, whereas tissue elements are less well shown. Thanks to computed tomography, we are able to confirm such pathologies as concha bullous or Haller?s cells (11). Mucous lesions are better displayed in MRI. This examination, in cases of chronic rhinosinusitis, is rarely performed, because patients are qualified for surgical treatment on the basis of computed tomography. However, neither CT nor MRI can unequivocally determine the nature of lesions in the natural ostium of the maxillary sinuses. It is necessary to complete the examination with an intra-operative endoscopic evaluation of the natural ostium of the sinuses. The majority of authors in the literature, during endoscopic surgery, evaluate the natural ostium of the maxillary sinus from the nasal cavity (12, 13), and thus evaluation from the maxillary sinus is incomplete. For the authors of this article, evaluation of the natural ostium from the nasal cavity, as well as from the maxillary sinuses, is a routine procedure. In our material, we significantly more often found inflammatory-oedematous lesions from the maxillary sinus ? in 91.82%, whereas from the nasal cavity only in 4.32%.
Polypous lesions in the natural ostium from the nasal cavity were found in 1.44% and, twice as often, in 2.88% from the lumen of the maxillary sinus (fig. 5).
A diaphragm in the area of the natural ostium was found in 3.36% and only from the maxillary sinus. Normal natural ostia, both from the maxillary sinus and from the nasal cavity, were found in 1.92% of cases. Significantly more often, inflammatory-oedematous lesions were found in the ostium of the maxillary sinus from the lumen of the sinus than from the nasal cavity (fig. 6). These findings suggest that the pathogenic process develops in the area of the natural ostium from the maxillary sinus, and then spreads to other regions. In the examined group in CT, Haller?s cells were found in 93.26%, whereas the literature states that in the general population they are present in around 10% of cases (14). Haller?s cells play an essential role in the pathogenesis of chronic rhinosinusitis in children.
CONCLUSIONS
1. Inflammatory-oedematous lesions were found significantly more often in the ostium of the maxillary sinus from the side of the lumen of the sinus than from the nasal cavity side.
2. Defects in the ventilation of the sinuses due to skeletal or mucosal deformation in the area of the ostia may cause a chronic inflammatory process in the upper respiratory tract.
3. Haller?s cells play an essential role in the pathogenesis of chronic rhinosinusitis in children.
Piśmiennictwo
1. Meltzer EO et al.: Rhinosinusitis: establishing definitions for departmental research and patient care. Otolaryngol Head Nec Surg 2004; 131, 6: 1-62. 2. Bluestone CD et al.: (ed.) Pediatric Otolaryngology. Saunders. Philadelphia 2002 1013-1021. 3. Lusk RP (ed.): Pediatric Sinusitis. Raven Press, NY 1992; 1-7. 4. Bhatt NJ (ed.): Endoscopic Sinus Surgery: New Horizons. Singular Publishing Ltd. London 1997; 140-148. 5. Bluestone CD et al.: Normalization of maxillary sinus mucosa after functional endoscopic sinus surgery in paediatric chronic sinusitis. Int J Ped Otorhinolar 2005; 69, 9: 1219-1223. 6. Kim HJ et al.: The relationship between anatomic variations of paranasal sinuses and chronic sinusitis in children. Act Oto-Laryngologica 2006; 126(10): 1067-72. 7. Bernal-Sprekelsen M, Massegur Solench H, Tomas Barberan M: Paediatric endoscopic sinus surgery (PESS) Rev Laryngol Otol Rhinol 2003; 124, 3: 145-150. 8. Stammberger H: The evolution of functional endoscopic sinus surgery. ENT Journal 1994; 73, 7: 451-455. 9. Wigand ME: Endoscopic surgery of the paranasal sinuses and interior skull base. Georg-Thieme Verlag Stuttgart 1990.10. Chmielik LP, Frackiewicz M, Chmielik M: Operating changes in the median wall of the maxillary sinus in children. New Medicine 2007; 11, 4: 91-93. 11. Chmielik M, Bielicka A, Chmielik LP: Mini-FESS in children. New Medicine 2004; 7: 62-65. 12. Bhatt NJ (ed.): Endoscopic Sinus Surgery. Singular Publishing Group, San Diego, London 1997; 84-87. 13. Bassiouny A et al.: A comparative study between ciliary count and the degree of opacity of paranasal sinus CT scans in chronic sinusitis pre- and post-FESS. Journal of Laryngology and Otology 2005; 119(12): 950-954. 14. Bhatt NJ (ed.): Endoscopic Sinus Surgery: New Horizons. Singular Publishing Group, Inc. San Diego 1997; 30.
