Maxillary Sinus

Back To Search

Maxillary Sinus

Rhinology
Author Credentials 

Arthur W. Wu, MD
Assistant Professor
Division of Otolaryngology
Cedars-Sinai Medical Center
Los Angeles, CA

Module Summary

The maxillary sinus is the most commonly affected sinus in chronic rhinosinusitis. Maxillary antrostomy is usually the first step in the process of a more extensive sinus surgery. Over the last three decades, endoscopic techniques have been developed and refined to address the full range of maxillary sinus pathologies.

Module Learning Objectives 
  1. Describe the most common endoscopic surgical approaches to the maxillary sinus.
  2. Recognize the most common diseases that affect the maxillary sinus.
  3. Summarize the advantages and disadvantages of specific approaches and their usual application with regards to different sinus pathology.
  4. Cite the major complications involved with maxillary sinus surgery.

Embryology

Learning Objectives 
  1. Understand the possible variations in maxillary sinus development, especially with respect to surgery in the pediatric population.
References 
  1. Lawson W, Patel ZM Lin FY. The developement and pathologic processes that affect maxillary sinus pneumatization. Anat Rec (Hoboken). 2008 Nov;291(11):1554-63.
  2. Nunez-Castruita A, Lopez-Serna N, Guzman-Lopez S. Prenatal development of the maxillary sinus: a perspective for paranasal sinus surgery. Otolaryngol Head Neck Surg. 2012;146(6):997-1003.

Anatomy

Learning Objectives 

Understand the anatomic principles which affect maxillary sinus surgery.

  1. Be familiar with the uncinate process
  2. Be able to locate the natural ostium of the maxillary sinus and differentiate this from an accessory or surgical ostium in the posterior fontanelle
  3. Be able to locate the important structures adjacent to the maxillary sinus
    1. Orbit
    2. Infraorbital nerve
    3. Nasolacrimal duct
    4. Sphenopalatine foramen
    5. Pterygopalatine fossa
    6. Ethmoid bulla
    7. Haller cell
References 
  1. Stammberger H. Endoscopic endonasal surgery – concepts in treatment of recurring rhinosinusitis. Part 1: Anatomic and pathophysiological considerations. Otolaryngol Head Neck Surg. 1986;94:143-7.
  2. Wormald PJ, McDonogh M.The ‘swing-door’ technique for uncinectomy in endoscopic sinus surgery. J Laryngol Otol. 1998;112:547-51.
  3. Kim HJ, Ahn JC, Hong SN, et al. Posterior fontanelle approach for uncinectomy and middle meatual antrostomy in endoscopic sinus surgery. Laryngoscope. 2016;126:1311-14.

Pathogenesis

Learning Objectives 

Know the most common diseases affecting the maxillary sinus and how the disease may lead the surgeon to choose certain endoscopic techniques.

  1. Acute bacterial rhinosinusitis
  2. Chronic rhinosinusitis with and without polyps
  3. Allergic fungal sinusitis
  4. Mucocele
  5. Antrochoanal polyp
  6. Fungal ball
  7. Silent sinus syndrome
  8. Inverted papilloma
  9. Sinonasal malignancies
References 
  1. Chandra RK, Kern RC, Cutler JL, Welch KC, Russell PT. REMODEL larger cohort with long-term outcomes and meta-analysis of standalone balloon dilation studies. Laryngoscope. 2016;126:44-50.
  2. Halderman AA, Stokken J, Momin SR, Smith TL, Sindwani R. Attitudes on and usage of balloon catheter technology in rhinology: A survey of the American Rhinologic Society. Am J Rhinol Allergy. 2015;29:389-93.
  3. Berg O, Carenfelt C, Silversward C, Sobin A. Origin of the choanal polyp. Arch Otolaryngol Head Neck Surg. 1988;114:21270-1.
  4. Lee TJ, Huang SF. Endoscopic sinus surgery for antrochoanal polyps in children. Otolaryngol Head Neck Surg. 2006 Nov;135(5):688-92.
  5. Vander Meer JB, Harris G, Toohill RJ, Smith TL. The silent sinus syndrome: a case series and literature review. Laryngoscope. 2001;111:975-8.
  6. Healy DY Jr, Chhabra N, Metson R, Holbrook EH, Gray ST. Surgical risk factors for recurrence of inverted papilloma. Laryngoscope. 2016;126:796-801.

Patient Evaluation

Learning Objectives 

Recognize the quality of the patient’s disease state and create an appropriate surgical plan.

  1. Inflammatory vs Infectious vs Neoplastic
  2. Likelihood of recurrence
  3. Need for endoscopic monitoring
  4. Need for frequent debridements
References 
  1. DeConde AS, Suh JD, Mace JC, Alt JA, Smith TL. Outcomes of complete vs targeted approaches to endoscopic sinus surgery. Int Forum Allergy Rhinol. 2015;5:691-700.
  2. Upadhyay S, Dolci RL, et al. Effect of incremental endoscopic maxillectomy on surgical exposure of the pterygopalatine and infratemporal fossa. J Neurol Surg B Skull Base. 2016;77:66-74.

Measurement of Functional Status

Learning Objectives 

Understand frequently used measures of disease severity and quality of life in chronic rhinosinusitis.

  1. SNOT-22
  2. Lund-MacKay CT score
  3. Lund-Kennedy Endoscopy score

Imaging

Learning Objectives 
  1. Be familiar with CT and MR imaging of the paranasal sinuses.
  2. Understand how certain findings might dictate the endoscopic technique used.
References 
  1. Reddy CE, Gupta AK, Singh P, Mann S. Imaging of granulomatous and chronic invasive fungal sinusitis: comparison with allergic fungal sinusitis. Otolaryngol Head Neck Surg. 2010;143:294-300.
  2. Fang G, Lou H, Yu, W, et al. Prediction of the originating site of sinonasal inverted papilloma by preoperative magnetic resonance imaging and computed tomography. Int Forum Allergy Rhinol. 2016;6:1221-8.

Surgical Therapies

Learning Objectives 
  1. Know the indications, advantages, and disadvantages for common endoscopic approaches to the maxillary sinus
    1. Balloon sinuplasty
      1. Indications: infectious, inflammatory
      2. Advantages
        • Can be done as in office or OR procedure
        • Less perioperative morbidity and debridement requirements
      3. Disadvantages
        • Difficult to treat CRSwNP, fungal disease, or AFS
        • Cannot inspect cavity or do debridements long term if anticipated
    2. Endoscopic maxillary antrostomy
      1. Indications: infectious, inflammatory
      2. Advantages
        • Can be done as in office but, more commonly, OR procedure
        • Ability to inspect and debride cavity long term
        • Improves postoperative topical drug delivery
      3. Disadvantages
        • Size of antrostomy can vary both based on surgeon preference and on anatomy of patient which may affect later examination and delivery of topical medications
    3. Mega-antrostomy (modified endoscopic medial maxillectomy)
      1. Indications: cystic fibrosis, primary ciliary dyskinesia, or refractory disease despite routine maxillary antrostomy
      2. Advantages
        • Improved topical drug delivery
        • Allows gravity-dependent drainage of the sinus in patients with impaired mucociliary clearance (primary ciliary dyskinesia, cystic fibrosis, biofilms)
        • Improves access for in office surveillance and debridmeents
      3. Disadvantages
        • May encounter more bleeding intraoperatively
        • Can have prolonged healing if large areas of exposed bone
    4. Endoscopic medial maxillectomy
      1. Indications: inverted papilloma and other benign or malignant tumors involving the medial, posterior, inferior and superior maxillary sinus walls; recalcitrant chronic maxillary sinusitis
      2. Advantages
        • Improved visualization compared to open techniques
        • Shorter hospital stay
        • Equivalent or superior recurrence rate for inverted papilloma
      3. Disadvantages
        • May disrupt nasolacrimal system
    5. Contralateral trans-septal approach
      1. Indications: benign or malignant tumors involving the anterior or lateral maxillary sinus walls
      2. Advantages
        • Superior access to and visualization of the anterior and lateral walls
      3. Disadvantages
        • Potential for septal perforation
        • May disrupt nasolacrimal system
    6. Endoscopic Denker Approach (Sturmann-Canfield approach)
      1. Indications: benign or malignant tumors involving the anterior or lateral maxillary sinus walls
      2. Advantages
        • Superior access to and visualization of the anterior and lateral walls
      3. Disadvantages
        • May need assistant for soft tissue retraction of overlying premaxillary muscle and fat
        • May disrupt nasolacrimal system
    7. Prelacrimal duct approach
      1. Indications: benign or malignant tumors involving the anterior or lateral maxillary sinus walls
      2. Advantages
        • Preserves the nasolacrimal duct, the inferior turbinate, and the lateral nasal wall mucosa
        • Less crusting
      3. Disadvantages
        • Postoperative surveillance of the anterior and lateral wall for recurrent tumor may be hindered as only visible through normal maxillary antrostomy
        • Temporary or potentially permanent upper lip numbness
References 
  1. Chandra RK, Kern RC, Cutler JL, Welch KC, Russell PT. REMODEL larger cohort with long-term outcomes and meta-analysis of standalone balloon dilation studies. Laryngoscope. 2016;126:44-50.
  2. Wofford MR, Kimbell JS, Frank-Ito DO, et al. A computational study of functional endoscopic sinus surgery and maxillary sinus drug delivery. Rhinology. 2015;53:41-8.
  3. Cho DY, Hwang PH. Results of endoscopic maxillary mega-antrostomy in recalcitrant maxillary sinusitis. Am J Rhinol. 2008;22:658-62.
  4. Costa ML, Psaltis AJ, Nayak JV, Hwang PH. Long-term outcomes of endoscopic maxillary mega-antrostomy for refractory chronic maxillary sinusitis. Int Forum Allergy Rhinol. 2015;5:60-5.
  5. Woodworth BA, Parker RO, Schlosser RJ. Modified endoscopic medial maxillectomy for chronic maxillary sinusitis. Am J Rhinol. 2006;20:317-9.
  6. Wang EW, Gullung JL, Schlosser RJ. Modified endoscopic medial maxillectomy for recalcitrant chronic maxillary sinusitis. Int Forum Allergy Rhinol. 2011;1:493-7.
  7. Sutter NB, Cannady SB, Citardi MJ, et al. Comparison of open versus endoscopic resection of inverted papilloma. Am J Rhinol. 2007;21:320-3.
  8. Busquets JM, Hwang PH. Endoscopic resection of sinonasal inverted papilloma: a meta-analysis. Otolaryngol Head Neck Surg. 2006;134:476-82.
  9. Lawson W, Patel ZM. The evolution of management for inverted papilloma: An analysis of 200 cases. Otolaryngology-Head and Neck Surgery. 2009;140:330-335.
  10. Harvey RJ, Sheehan PO, Debnath Ni, Schlosser RJ. Transseptal approach for extended endoscopic resections of the maxillar and infratemporal fossa. Am J Rhinol Allergy. 2009;23:426-32.
  11. Harvey RJ, Gallagher RM, Sacks R. Extended endoscopic techniques for sinonasal resections. Otolaryngol Clin North Am. 2010;43:613-38.
  12. Suzuki M, Nakamura Y, Nakayama M, et al. Modified transnasal endoscopic medial maxillectomy with medial shift of preserved inferior turbinate and nasolacrimal duct. Laryngoscope. 2011;121:2399-401.
  13. Suzuki M, Nakamura Y, Yokota M, et al. Modified transnasal endoscopic medial maxillectomy through prelacrimal duct approach. Laryngoscope. 2017.
  14. http://www.american-rhinologic.org/videos (Surgical dissection videos on the ARS website, for members. ARS membership is FREE for residents.)

Staging

Learning Objectives 

Understand staging systems for sinonasal tumors:

  1. Krouse system for inverted papilloma
  2. AJCC TNM system
References 
  1. Krouse JH. Development of a staging system for inverted papilloma. Laryngoscope. 2000;110:965-8.
  2. Deschler DG, Moore MG, Smith RV, eds. Quick Reference Guide to TNM Staging of Head and Neck Cancer and Neck Dissection Classification, 4th ed. Alexandria VA:American Academy of Otolaryngology-Head and Neck Surgery Foundation, 2014.

Case Studies

  1. 30 year old F with nasal obstruction and purulent rhinorrhea for more than 2 months. Pus is seen flowing from the maxillary sinus on endoscopy and culture only shows coagulase negative Staphylococcus. She has failed a three week course of empiric amoxicillin-clavulanic acid with a steroid taper, and a CT scan only shows isolated right maxillary sinus disease.
    1. Will require endoscopic surgical management
    2. May consider both balloon sinuplasty and endoscopic maxillary antrostomy
  2. 40 year old M with unilateral nasal obstruction found to have papillomatous mass in the middle meatus. Biopsy confirms inverted papilloma. CT scan demonstrates mass filling the maxillary sinus with expansion of the maxillary sinus ostium. There is hyperostosis of the anterior maxillary sinus wall.
    1. Options include open versus endoscopic management
    2. Endoscopic access to the tumor origin may be limited unless extended techniques are used such as the trans-septal approach, the endoscopic Denker procedure, or the prelacrimal duct approach
    3. Will likely require management of the nasolacrimal system in order to gain access either with DCR or preservation of nasolacrimal duct in prelacrimal duct approach
  3. 20 year old F with primary cystic fibrosis and severe chronic rhinosinusitis. She has chronic pseudomonal infection despite maximal medical management and is awaiting improvement in her sinuses to get placed on lung transplant list
    1. Will require endoscopic sinus surgery.
    2. Should consider primary mega-antrostomy and gravity dependent drainage
    3. Postoperatively may need longer course of PO and topical antibiotics
References 
  1. Chandra RK, Kern RC, Cutler JL, Welch KC, Russell PT. REMODEL larger cohort with long-term outcomes and meta-analysis of standalone balloon dilation studies. Laryngoscope. 2016;126:44-50.
  2. Cho DY, Hwang PH. Results of endoscopic maxillary mega-antrostomy in recalcitrant maxillary sinusitis. Am J Rhinol. 2008;22:658-62.
  3. Harvey RJ, Gallagher RM, Sacks R. Extended endoscopic techniques for sinonasal resections. Otolaryngol Clin North Am. 2010;43:613-38.
  4. Dean NR, Illing EA, Woodworth BA. Endoscopic resection of anterolateral maxillary sinus inverted papillomas. Laryngoscope. 2015;125:807-12.

Complications

Learning Objectives 
  1. Understand the most common minor and major complications from maxillary sinus surgery and their management
    1. Bleeding
    2. Infection
    3. Injury to orbit (orbital hematoma, muscle injury, blindness)
    4. Injury to nasolacrimal duct
    5. Injury to infraorbital nerve
  2. Understand the leading causes of maxillary sinus surgery failures
    1. Remnant uncinate process / posterior antrostomy
    2. Scar bands
    3. Impaired mucociliary clearance
    4. Disease in adjacent sinuses
    5. Dental disease
    6. Resistant infection / Biofilms
References 
  1. Stankiewicz JA, Chow JM. Two faces of orbital hematoma in intransal (endoscocpic) sinus surgery. Otolaryngol Head Neck Surg. 1999;120:841-7.
  2. Han JK, Higgins TS. Management of orbital complications in endoscopic sinus surgery. Curr Opin Otolaryngol Head Neck Surg. 2010;18:32-6.
  3. Richtsmeier WJ. Top 10 reasons for endoscopic maxillary sinus surgery failure. Laryngoscope. 2001;111:1952-6.

Review

Review Questions 
  1. What is the differential diagnosis for an opacified maxillary sinus?
  2. What are the potential complications of maxillary sinus surgery?
  3. What is the management of an intraorbital hematoma found intraoperatively?
  4. What is the TNM staging system for cancers of the maxillary sinus?
  5. What are the most common causes of failed maxillary antrostomy for chronic rhinosinusitis?
  6. Which approach (open vs endoscopic) had better recurrence rates for inverted papilloma?
  7. What are the imaging characteristics (CT and MR) for inverted papilloma?
  8. What are the indications for a maxillary sinus mega-antrostomy?
Resources 

Learner must Sign In to access AAO-HNSF education activities.

  1. Annual Meeting Webcast (AMW):
  2. Clinical Practice Guideline (Cpg):
  3. ENT for the PA-C:
  4. Surgical Videos: