Cadaveric Assessment of the Efficacy of Sinus Irrigation After Staged Clearance of the Medial Maxillary Wall

Abstract

Background Nasal irrigation is a significant component of effective medical management in patients with chronic rhinosinusitis (CRS). Irrigations facilitate distribution of topical medical therapies to affected mucosal surfaces and lavage of hypersecretory mucin and inflammatory products. Objective To compare the effectiveness of cadaveric nasal irrigation distribution and force following different surgical techniques commonly used to open the maxillary sinus. Methods Fresh human cadaver heads were dissected sequentially with uncinectomy, maxillary antrostomy, endoscopic maxillary mega-antrostomy, and modified endoscopic medial maxillectomy. After each surgical technique was performed, the corresponding nasal cavity was irrigated with 240 mL irrigation bottles containing 1/1000 10% fluroscein-labeled free water. A nasal endoscope passed through the canine fossa into a fixed position in the maxillary sinus recorded the extent of sinus irrigation. These videos then underwent blinded assessment by 2 observers assessing for irrigation sinus penetration (scored as 0–4) and force (0–2). Ordinal correlation scores were assessed using Kendall’s tau-B. Results A total of 17 sinuses (age 53.4 ± 12.6, 36.4% female) were assessed. There was a statistically significant positive correlation between increasing extent of maxillary sinus dissection and both sinus penetration and force as assessed by both observers (Kendall’s tau-B P < .0001). Conclusion Increasing the extent of surgical dissection appears to improve penetration and force of the nasal irrigation into the maxillary sinus. This study suggests that while a standard maxillary antrostomy may be sufficient to achieve good topical therapy distribution, more extensive surgery such as a modified medial maxillectomy may be required for sufficient force of sinus lavage.

Clinically relevant phenotypes in chronic rhinosinusitis

“…In a double blind, randomized controlled trial, it was noted that corticosteroid irrigation provided better overall symptom control that corticosteroid nasal spray [18]. Studies have also shown that wide openings in the frontal [19], maxillary [20], and sphenoid [21] sinuses allow for improved irrigant penetration and lavage of the sinus cavity (Fig. 5).…”

Topical corticosteroid irrigations in chronic rhinosinusitis

“…Previous studies have shown improved penetration in sinuses that have been opened widely, compared with those that have been incompletely opened or have not undergone surgical intervention, particularly so for the frontal and sphenoid sinuses . Three cadaveric model studies and 1 computational dynamics study have shown improved penetration, force, and lavage of a widely open surgical cavity in the frontal, maxillary, and sphenoid sinuses . In a study by Harvey et al, all patients underwent a very similar complete sinus surgery with the only difference being surgical management of the frontal sinus.…”

Use of Off-Label Nasal Steroid Irrigations in Long-Term Management of Chronic Rhinosinusitis

“…Prior cadaveric and computational dynamic studies have shown increased delivery and absorption of topical steroids following frontal, maxillary, and sphenoid sinusotomy. [39][40][41] Left unopen, the paranasal sinuses receive limited distribution of topical agents regardless of head position, delivery device, or volume. 20,[42][43][44][45] With the exception of Harvey et al, 37 the studies reviewed here did not completely describe their surgical interventions or included nonsurgical patients in their study cohort.…”