Endoscopic inferior meatal antrostomy

The nose is decongested preoperatively with 2 to 3 sprays of oxymetazoline per nostril. After intubation, a throat pack is placed. The inferior turbinates and septum are then injected with 1% lidocaine with 1:100,000 epinephrine, taking care to aspirate before injection. Four percent cocaine pledgets are then placed along the nasal floor while the operative field is prepared.

Under 0° rigid endoscopic visualization, a Freer elevator is passed into the inferior meatus and the inferior turbinate is up fractured, mobilizing the turbinate so it is perpendicular to the nasal floor (Fig. 1). This maneuver is key to adequate visualization, greatly simplifying the remainder of the procedure. At this point, Hasner's valve, located at the junction of the anterior and middle third of the lateral nasal wall, is identified (Figs. 2 and 3). A 90° curved J-curette is used to puncture the lateral nasal wall approximately 1 cm posterior to Hasner's valve, midway between the nasal floor and the genu of the inferior turbinate (Figs. 4 and 5). After an adequate opening has been created, a universal downbiter is introduced and the antrostomy is extended inferiorly, down to the nasal floor (Figs. 6 and 7). The antrostomy may be enlarged in an anterior–posterior plane with a variety of cutting instruments or punch forceps. A curved suction is then introduced into the antrostomy and the maxillary sinus and its contents are easily visualized with a 30° rigid endoscope (Figs. 8 and 9). If the inferior meatal antrostomy has been performed only to facilitate removal of maxillary sinus contents (ie, mycetoma or inspissated secretions), then the antrostomy is enlarged as necessary to allow safe removal (Fig. 10). If a middle antrostomy is performed, a 30°, 45°, or 70° scope can be introduced into the middle antrostomy, while a 40° microdebrider is introduced into the inferior meatal antrostomy, providing excellent endoscopic exposure and allowing debridement or removal of the maxillary sinus contents or vigorous irrigation. For patients requiring gravity-dependent drainage, we typically remove the portion of inferior turbinate opposing the antrostomy to prevent subsequent closure. If a middle antrostomy has been performed during a previous surgery, joining the middle and inferior antrostomy prevents recirculation phenomenon (Figs. 11 and 12). Blood loss for the procedure is typically minimal and postoperative packing is typically unnecessary. At the completion of the case, absorbable oxidized cellulose soaked in triamcinolone is laid across the wound bed to encourage hemostasis. An inferior medial based flap extending to the floor of the nose can be fashioned endoscopically prior to making the antrostomy. This flap is folded into the antrostomy at the end of surgery enhancing healing and patency. Figure 10 outlines area of flap creation as well.

While rare, indications for an inferior meatal antrostomy continue to exist, despite the widespread application of functional endoscopic sinus surgery. Indications include mucocilliary dysfunction, maxillary sinus disease not easily addressed with a middle antrostomy, and improved visualization of the anterior maxillary wall and floor. The procedure is safe and relatively simple to perform.An inferior medial based flap extending to the floor of the nose can be fashioned endoscopically prior to making the antrostomy. This flap is folded into the antrostomy at the end of surgery enhancing healing and patency. Figure 10 outlines area of flap creation as well.