Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 5  |  Page : 606-608  

Relationship between development of accessory maxillary sinus and chronic sinusitis


1 Department of ENT Clinics, Sakarya Akyazi State Hospital, Sakarya, Turkey
2 Ankara Numune Hospital, Ankara, Turkey
3 Hitit University, Corum, Turkey

Date of Web Publication10-Sep-2015

Correspondence Address:
Caner Sahin
MD, Beratevler No: 19/1, Erenler, Sakarya
Turkey
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Source of Support: Nil., Conflict of Interest: None declared.


DOI: 10.4103/0975-2870.164978

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  Abstract 

Background: We aimed to investigate whether there is a relationship between development of accessory maxillary osmium (AMO) and chronic sinusitis. Material and Methods: A total of 100 patients who had endoscopic sinus surgery for chronic rhinosinusitis (CRS) constituted the study group while 100 patients who had septoplasty were taken as the control group. The patients were examined for the presence of AMO using rigid endoscope. Results: The prevalence of AMO was 14% in the rhinosinusitis group and 9% in the control group. The difference between the groups was statistically significant (P < 0.05). Conclusion: Our study revealed that AMO prevalence is significantly higher in patients with CRS when compared with the controls. CRS may enhance perforation of fontanelle and formation of AMO.

Keywords: Accessory ostium, maxillary sinus, sinusitis


How to cite this article:
Sahin C, Ozcan M, Unal A. Relationship between development of accessory maxillary sinus and chronic sinusitis. Med J DY Patil Univ 2015;8:606-8

How to cite this URL:
Sahin C, Ozcan M, Unal A. Relationship between development of accessory maxillary sinus and chronic sinusitis. Med J DY Patil Univ [serial online] 2015 [cited 2024 Mar 29];8:606-8. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2015/8/5/606/164978


  Introduction Top


Chronic rhinosinusitis (CRS) is one of the most frequent diseases seeking for medical attention. Anatomical variations have been suggested to play a role in the pathogenesis of CRS.

Mucociliary transport is directed through the natural ostium in the maxillary sinus, and the accessory ostium does not play a role in its physiologic drainage.[1] In contrary, drained mucus may enter into the maxillary sinus through the accessory ostium, and it may play a role in the pathogenesis of chronic maxillary rhinosinusitis.[2] This phenomenon has been known as "mucus recirculation."[3] This is why the presence of the accessory ostium may play a role in the pathogenesis of CRS.[1]

It is not clearly known whether accessory maxillary osmium (AMO) is a congenital anatomical variation or it is acquired.

We aimed to investigate the prevalence of AMO and investigate whether there is a relationship between the development of AMO and chronic sinusitis in this study.


  Material and Methods Top


The 100 patients who had endoscopic sinus surgery with a diagnosis of chronic sinusitis constituted a study group and 100 patients who had septoplasty surgery with a diagnosis of nasal septum deviation constituted a control group. The study was planned as a prospectively, randomized trial. The consent form was received from all the patients to participate in the study.

The patients that have nasal inflammatory process longer than 12 weeks with osteomeatal unit complex obstruction on paranasal sinus computerized tomography constitutes the study group. The patients that we planned septoplasty operation with the diagnosis of septum deviation constitute the control group. We investigate control group with computerized tomography of the paranasal region to eliminate any other causes of nasal obstruction preoperatively. Patients with nasal poliposis, concha bullosa or any additional nasal or paranasal pathology were excluded from the study. Patients with any paranasal sinus pathology were excluded from the control group. The patients with complaints of allergic symptoms like itching, nasal discharge, and paleness of nasal mucosa were further analyzed. The patients with allergic rhinitis were also excluded from the study to minimize possible other pathologies.

All patients were operated under general anesthesia. 0° and 30° rigid endoscopes were used to identify the AMO. The investigation was made by the same surgeon. The middle turbinate was medialized gently with an elevator, and the lateral nasal wall was inspected carefully to identify the AMO.

Written informed consent was obtained from each subject following a detailed explanation of the objectives and protocol of the study, which was conducted in accordance with the ethical principles stated in the Declaration of Helsinki and approved by the institutional ethics committee. The study was approved by the Ankara Numune Education and Research Hospital's ethical committee.

The statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 13, manufactured by SPSS Inc., Chicago. Chi-square test was used to compare the groups, accepting P < 0.05 as the level of statistical significance.


  Results Top


The study group consisted of 44 females and 56 males. There were 38 females and 62 males in the control group. The ages of study group ranges between 16 and 65 years (mean of 34) and the age-range of the control group was 19-63 years (mean of 38) years.

AMO was detected in 14/100 patients in the CRS group. Nine patients had AMO unilateral. Five of them was on the right side, 5 of them was on the left side. Four of them were bilateral. Of the cases, 65% was unilateral, and 35% of cases were bilateral. The defect was seen in posterior fontanelle in 13 patients and only 1 in anterior fontanelle. The vast majority were seen in posterior fontanelle.

In control group; 9/100 patients had AMO. Eight patients had AMO unilaterally. Four of them was on the left side, 4 of them was on the right side. One of the patient had AMO bilaterally. Of the patients, 11% of them were bilateral, and 89% were unilateral. The defect was seen in posterior fontanelle in nine patients. There was no perforation of the anterior fontanelle. The difference between the groups was statistically significant (P = 0.001) [Table 1].
Table 1: The statistical analysis of accessory maxillary sinus ostium and the configuration of the anatomical variation

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  Discussion Top


CRS is a common disorder in the otorhinolaryngologic clinic. AMO may be an anatomic or acquired anatomical cofactor in the development of chronic sinusitis. There may be visious circle between chronic sinusitis and AMO. Mucus recirculation from AMO may lead to chronic sinusitis, and chronic sinusitis may promote the formation of AMO.[1]

The term fontanelle refers to the areas of the medial wall of the maxillary sinus situated anterior and posterior to the inferior bony attachments of the uncinate process. The defects of this region in the lateral nasal wall have been named as AMO in literature.[4] Those areas do not contain bone. It is composed of two mucosal layers; maxillary sinus mucosa laterally and nasal mucosa medially, and some connective tissue in between.[5] Due to the weakness (they do not have bony support) the fontanelle may perforate with the pressure of pus and edema created by recurrent sinusitis episodes.

It is not clearly known whether AMO is congenital or acquired. Some authors suggest that AMO develops congenitally due to closure defect of the maxillary sinus fontanelles. Some others claim that it develops after recurrent infections due to perforation of the fontanelles.[2] Recurrent episodes of infections may perforate the weak fontanelle membrane. One experimental study in the literature showed that AMO may develop after acute rhinosinusitis.[6]

In our study, we found a statistically significant difference between the chronic sinusitis and the control groups for the prevalence of AMO. As previously reported animal study, the results of this study also support that AMO is an acquired anatomical variation and develops after rhinosinusitis.

There are only a few studies in the literature that investigated the prevalence of AMO in different study designs.[4] The prevalence of AMO has been reported between 4% and 43%.[7],[8] Earwaker investigated prevalence of AMO on paranasal computerized tomographies.[8] They reported its prevalence as 14% in 800 patients referred for evaluation for functional endoscopic sinus surgery. Jog and McGarry used a flexible endoscope to investigate the prevalence of AMO in patients with rhinitis/sinusitis and general ENT clinic patients as a control group. The prevalence as 4% in the control group and as 8% in the rhinosinusitis group.[9] Mladina et al. also used a fiberoptic endoscope to investigate AMO in patients with chronic sinusitis and normal healthy patients as a control group. They reported the prevalence of AMO as 19.3% in CRS population and 0.4% in control group.[10] They also declared that the AMO were all unilateral and all in posterior fontanelle in the control group. In CRS group 68% of AMO were bilateral, and 0.61% of the perforations were seen in anterior fontanelle.

Midwinter et al. reported that the rigid endoscope was superior to the flexible endoscope in the evaluation of the sinonasal structures.[11] Jog and McGarry used flexible endoscope in their study and concluded that a study performed using rigid endoscope was needed.[9] We used rigid endoscope in our study. Rigid endoscopes are superior to flexible endoscopes in identifying AMO. Because enlarged middle concha, septum deviation, any conchal hypertrophies can hide AMO and desired positioning and manipulation of endoscopes can be difficult. Also because of patients discomfort, pain the process can be hard. In our study, we used the advantage of general anesthesia with patients consent for the process to investigate AMO with rigid endoscopes.

We found the prevalence of AMO as 14% in the rhinosinusitis group and as 9% in the control group. In our study, 13 cases (92.8%) were seen in posterior fontanelle and 1 (7.2%) were seen on anterior fontanelle. 10 (65%) was unilateral, and 4 (35%) of cases were bilateral.

In control group, all of the cases were seen on posterior fontanelle. 8 (88%) of the cases were unilateral, and 1 (12%) were bilateral. Our control group has a disadvantage because septum deviation can be a risk factor for CRS. However, we cannot investigate the AMO in normal healthy people study group without any sinonasal disorder because of ethical reasons. We completed the investigation in people who somehow be operated from the mose region with patients allow. Especially we eliminate the patients of control group using paranasal computerized tomography findings and history of the patients.


  Conclusion Top


Our study has revealed that AMO prevalence is significantly higher in patients with CRS when compared to the controls. CRS may enhance perforation of fontanelle and formation of AMO. There are few investigations about the issue in the literature. Our study is a preliminary study with relatively small number of cases. There are larger series using flexible endoscopes in the literature. Our case number is limited, but we have the advantage of using rigid endoscopes under general anesthesia with making manipulations to identify the AMO Further investigations including postmortem studies need to be done to investigate the issue.

 
  References Top

1.
Gutman M, Houser S. Iatrogenic maxillary sinus recirculation and beyond. Ear Nose Throat J 2003;82:61-3.  Back to cited text no. 1
    
2.
Chung SK, Dhong HJ, Na DG. Mucus circulation between accessory ostium and natural ostium of maxillary sinus. J Laryngol Otol 1999;113:865-7.  Back to cited text no. 2
    
3.
Yanagisawa E, Yanagisawa K. Endoscopic view of recirculation phenomenon of the maxillary sinus. Ear Nose Throat J 1997;76:196-8.  Back to cited text no. 3
    
4.
Kuma RH, Choudhr YR, Kaka RS. Accessory maxillary ostia: Topography and clinical application. J Anat Soc India 2001;50:3-5.  Back to cited text no. 4
    
5.
Prasanna LC, Mamatha H. The location of maxillary sinus ostium and its clinical application. Indian J Otolaryngol Head Neck Surg 2010;62:335-7.  Back to cited text no. 5
    
6.
Genc S, Ozcan M, Titiz A, Unal A. Development of maxillary accessory ostium following sinusitis in rabbits. Rhinology 2008;46:121-4.  Back to cited text no. 6
    
7.
May M, Sobol SM, Korzec K. The location of the maxillary os and its importance to the endoscopic sinus surgeon. Laryngoscope 1990;100:1037-42.  Back to cited text no. 7
    
8.
Earwaker J. Anatomic variants in sinonasal CT. Radiographics 1993;13:381-415.  Back to cited text no. 8
    
9.
Jog M, McGarry GW. How frequent are accessory sinus ostia? J Laryngol Otol 2003;117:270-2.  Back to cited text no. 9
    
10.
Mladina R, Vukovic K, Poje G. The two holes syndrome. Am J Rhinol Allergy 2009;23:602-4.  Back to cited text no. 10
    
11.
Midwinter KI, Ahmed A, Willatt D. A randomised trial of flexible versus rigid nasendoscopy in outpatient sinonasal examination. Clin Otolaryngol Allied Sci 2001;26:281-3.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1]


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