In some patients with recurrent maxillary sinusitis, inflammatory changes at the level of the inferior part of the ethmoid infundibulum interfere with the patency of the natural ostium, but only minimal mucosal alterations are present within the sinus. Whenever, after performing an inferior uncinectomy and removing with atraumatic technique the polyps possibly present in the inferior part of the ethmoid infundibulum, the natural ostium is well evident and patent, harvesting a middle antrostomy is unnecessary. Conversely, this is required when the maxillary sinus presents extensive disease. Widening its natural ostium in an anterior direction is limited by the presence of the nasolacrimal duct; therefore, one should be very careful not to injure it, to avoid a lacrimal pathway stenosis. Therefore, we prefer to create the antrostomy by enlarging the ostium posteriorly at the expense of the posterior fontanellae, where the maxillary and nasal mucosa stick together without bony interposition (Fig. 5.5). Whenever a dehiscence at this level (accessory ostium) is present, both ostia must be included in the antrostomy to guarantee an
effective drainage, to avoid the phenomenon of mucus recirculation, and to prevent a persistent mucus discharge from the maxillary sinus.
Using angled endoscopes and curved instruments it is possible to easily work through a middle antros-tomy inside the maxillary sinus. However, some areas of the medial maxillary wall or of the alveolar recess which are hidden to a transnasal view, may be easily reached through a canine fossa approach, a transoral small opening in the anterior wall obtained with a trocar. Surgical instruments may be used through the canine fossa into the maxillary sinus under the control of an angled endoscope inserted transnasally or vice versa (Fig. 5.6).
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