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British Journal of Oral and Maxillofacial Surgery 46 (2008) 128–130

Short communication
Endoscopic treatment of maxillary sinus disease
before grafting
Fabio Costa a,∗ , Enzo Emanuelli b , Massimo Robiony a , Nicoletta Zerman c , Massimo Politi a
a Department of Maxillo-Facial Surgery, Azienda Ospedaliero Universitaria, Faculty of Medicine, University of Udine, Italy
b Otosurgery Unit, Hospital of Padua, Italy
c Faculty of Dentistry, University of Ferrara, Italy

Accepted 14 October 2006

Available online 20 November 2006

Abstract

We present our experience of the treatment of four patients with maxillary sinus disease by endoscopic sinus surgery to restore the normal
physiology of the sinus before grafting.
© 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Endoscopic sinus surgery; Sinus bone graft; Chronic rhinosinusitis

Introduction Patients and methods

Maxillary sinusitis after raising of the sinus floor with autoge-
nous bone grafts is a serious complication.1 Such operations
may lead to reduction in the patency of the ostiomeatal unit
and subsequent sinusitis.2 This area has a key role in the
development of sinusitis, because it damages the mucociliar
system. Patients who are referred for preprosthetic recon-
struction of the posterior maxilla may have chronic rhinos-
inusitis, the signs and symptoms of which may be major
or minor. Major ones include facial pain, pressure, facial
swelling, nasal obstruction, paranasal drainage, hypo-osmia
and fever, and minor ones include headache, dental pain,
halitosis, fatigue, cough, and ear-ache.3 Purulent drainage
alone during endoscopic examination is diagnostic in
itself.4
∗ Corresponding author at: Clinica di Chirurgia Maxillo-Facciale, Azienda
Ospedaliero Universitaria, P.le S. Maria della Misericordia, 33100 Udine,
Italy. Tel. +39 0432559455; fax: +39 0432559868.
E-mail address: maxil2@med.uniud.it (F. Costa).
Four patients were referred to us for sinus lift with grafting
because of resorption of the posterior maxilla. They were
investigated with orthopantomography and computed tomo-
graphic digital scanning (Fig. 1). All the patients had signs
of disease on nasendoscopy. One patient had swelling of
the uncinate process with polyposis; one had polyposis in
the middle meatus; two patients had mucopurulent discharge
from the middle meatus. All patients were operated on under
general anaesthesia to open and clear the natural maxillary
ostium involved.
After decongestion of the mucosa, and using a 0◦ optic the
uncinate process was backfractured and carefully removed
with forceps to expose the natural ostium of the maxillary
sinus. The tail or posteroinferior remnant of the uncinate
was indentified and removed to expose the natural ostium
of the maxillary sinus. Care was taken to avoid removing any
mucosa from the maxillary sinus. The sinus was washed out
with an angled aspirator from the natural maxillary ostium
to help endonasal discharge of any residual mucopurulent
fluid. Follow-up ranged from 6 months to 2 years with serial
endoscopic examinations to verify the opening of the natural

0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.10.006
 F. Costa et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 128–130
Fig. 1. Preoperative computed tomographic digital scan of the right maxil-
lary sinus showing thickened mucosa in the floor of the sinus.
Fig. 2. The natural right maxillary ostium 6 months postoperatively.
maxillary ostium and the absence of mucosal degeneration
around it (Fig. 2).
Results
All the patients met the criteria for chronic sinusitis. Postop-
eratively two patients developed fungal rhinosinusitis diag-
nosed histologically by swabs taken from the maxillary sinus
during operation. None of the patients had evidence of recur-
rent sinus disease. Computed tomographic digital scanning
after 6 months showed complete aeration with no thickening
in the mucosa in the maxillary sinuses in all patients. They all
had sinus bone grafts with autologous bone harvested from
the iliac crest. Six months after reconstruction, there was no
evidence of infection and all patients were referred for place-
ment of implants and prosthetic rehabilitation.
129
Discussion
Patients with chronic sinus disease as a result of stasis and
reduced outflow should have it corrected before augmentation
of the sinus.5 Any blockage of the ostium or disruption of the
mucociliary action can lead to failure to clear secretions and
bacteria from the sinus, resulting in an infection.
Beaumont et al.6 investigated the incidence of sinus dis-
ease among patients who were to have direct augmentation
of the sinus. Of the 45 patients, 18 had sinus disease or
abnormalities, or both. The results reinforce the importance
of detailed history-taking and thorough clinical and radio-
graphic evaluation before operation.
There is a correlation between preoperative sinus disease
and the development of acute sinusitis after augmentation.7
Iturriaga and Ruiz8 evaluated morbidity of augmentation
with autogenous calvarial bone grafts, and found total loss of
the graft, massive infection of the sinuses, and an oroantral
fistula that required closure in two cases. Both patients had
chronic sinus disease that had not been diagnosed earlier
because they were evaluated only by panoramic radiography.
The signs and symptoms consistent with a diagnosis of rhi-
nosinusitis are classified as major or minor. A strong history
consistent with chronic sinusitis includes two or more major
factors or one major and two minor factors.3 The Sinus and
Allergy Health Partnership convened a multidisciplinary task
force and asserted that definite signs on physical examination
are needed to make a diagnosis.9
Purulent drainage, polyps, and polypoid changes are all
consistent with inflammation. In our series, all patients had
physical evidence of at least one major factor on endoscopic
examination and met the criteria for the diagnosis of chronic
sinusitis, so they had preoperative sinus disease that had to
be treated before augmentation. One of the treatments for
sinusitis advocated by surgeons after augmentation is nasal
decongestants and topical vasoconstrictive agents to promote
normal drainage.10 We think that this is effective if there is
normal patency of the ostium preoperatively, but it is useless
to prescribe any drugs to improve the functional drainage
of a maxillary ostium if it does not work correctly before
augmentation.
All our patients were successfully operated on to open
the natural maxillary ostium and to restore the normal phys-
iology of the maxillary sinus before the augmentation. Six
months postoperatively, clinical and radiological investiga-
tions showed that they were all free of sinus disease. Careful
history-taking and radiographic evaluation of patients before
augmentation is essential because sinus augmentation usu-
ally requires considerable investment of time and money from
both surgeon and patient.
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