case presentation · processes (arrows), a large left concha bullosa, bowing of the superior...

Joyce HO , Eugene WONG, Narinder SINGH Department of Otolaryngology Head and Neck Surgery, Westmead Hospital, Sydney, Australia Background • Chronic maxillary atelectasis (CMA) is an underdiagnosed condition that can occur bilaterally and may lead to significant complications. • Its aetiology has not been established. • Accessory maxillary ostium (AMO) is a defect in the fontanelle and is associated with maxillary sinus pathology. • It has not been established whether AMO is a congenital or an acquired structure. • We present a case of bilateral CMA in the presence of a unilateral (left) AMO. Case Presentation • 47-year-old male with a long history of nasal obstruction that was worse on the right. • Associated right-sided malar and periorbital facial pain and frontal headaches. • Flexible nasendoscopy demonstrated a right anterior septal deviation and marked lateralisation of both uncinate processes. • CT of paranasal sinuses (Figure 1) demonstrated findings consistent with a diagnosis of bilateral stage II CMA. An AMO could also be identified on the left. • Patient underwent septoplasty, bilateral inferior turbinoplasty, bilateral uncinectomies and maxillary antrostomies. • Intraoperatively, the left-sided AMO was identified in the posterior fontanelle (Figure 2) and incorporated into the antrostomy. • At 6 weeks follow-up, there was complete resolution of symptoms. Discussion Figure 2. Intraoperative endoscopic view of left middle meatus showing lateralisation of uncinate process and accessory maxillary ostium. POSTER NUMBER P-160 Figure 1. Coronal slice of the CT paranasal sinuses demonstrating septal deviation to the right, bilateral lateralisation of uncinate processes (arrows), a large left concha bullosa, bowing of the superior osseous walls (right more pronounced than left), opacification of the right maxillary sinus and an early retention cyst in the left maxillary sinus. • CMA has traditionally been described as a unilateral condition. • Multiple reports of bilateral pathology in the literature have challenged this traditional definition. • Main theory regarding its aetiology: • Sustained obstruction at ostiomeatal complex à mucosal resorption of sinus gas à development of negative pressure within maxillary sinuses à triggers process of remodelling and inward bowing of the maxillary sinus walls. • Study on rabbit models suggests that AMO can be acquired as a result of a pathological situation • Our patient had bilateral stage II CMA but only had maxillary sinus opacification and symptoms on the right side. • Presence of a congenital, patent AMO would have likely prevented the initial build-up of negative intra-sinus pressure. • Therefore, we postulate that the patient initially developed CMA bilaterally from obstruction of the ostiomeatal complex. The patient subsequently developed left AMO, or had a pre-existing obstructed or small AMO that became patent, which then halted the progression of the disease on the left side by equalising the negative pressure differential. • This supports that idea that some AMO may be acquired anomalies secondary to sinus pathology. Conclusion • Chronic maxillary atelectasis can occur bilaterally and cause significant sinonasal symptoms. • This case suggests that some AMO are acquired defects and supports the notion that CMA is caused by negative intra- sinus pressures. • Further research is required to establish the precise aetiology of CMA.

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Page 1: Case Presentation · processes (arrows), a large left concha bullosa, bowing of the superior osseous walls (right more pronounced than left), opacification of the right maxillary

Joyce HO, Eugene WONG, Narinder SINGH

Department of Otolaryngology Head and Neck Surgery, Westmead Hospital, Sydney, Australia

Background

•  Chronicmaxillaryatelectasis(CMA)isanunderdiagnosedconditionthatcanoccurbilaterallyandmayleadtosignificantcomplications.

•  Itsaetiologyhasnotbeenestablished.•  Accessorymaxillaryostium(AMO)isadefectinthefontanelleandisassociatedwithmaxillarysinuspathology.•  IthasnotbeenestablishedwhetherAMOisacongenitaloranacquiredstructure.•  WepresentacaseofbilateralCMAinthepresenceofaunilateral(left)AMO.

CasePresentation

•  47-year-oldmalewithalonghistoryofnasalobstructionthatwasworseontheright.

•  Associatedright-sidedmalarandperiorbitalfacialpainandfrontalheadaches.

•  Flexiblenasendoscopydemonstratedarightanteriorseptaldeviationandmarkedlateralisationofbothuncinateprocesses.

•  CTofparanasalsinuses(Figure1)demonstratedfindingsconsistentwithadiagnosisofbilateralstageIICMA.AnAMOcouldalsobeidentifiedontheleft.

•  Patientunderwentseptoplasty,bilateralinferiorturbinoplasty,bilateraluncinectomiesandmaxillaryantrostomies.•  Intraoperatively,theleft-sidedAMOwasidentifiedintheposteriorfontanelle(Figure2)andincorporatedintotheantrostomy.•  At6weeksfollow-up,therewascompleteresolutionofsymptoms.

Discussion

Figure2.Intraoperativeendoscopicviewofleftmiddlemeatusshowinglateralisationofuncinateprocessandaccessorymaxillaryostium.

POSTERNUMBER

P-160

Figure 1. CoronalsliceoftheCTparanasalsinusesdemonstratingseptaldeviationtotheright,bilaterallateralisationofuncinateprocesses(arrows),alargeleftconchabullosa,bowingofthesuperiorosseouswalls(rightmorepronouncedthanleft),opacificationoftherightmaxillarysinusandanearlyretentioncystintheleftmaxillarysinus.

•  CMAhastraditionallybeendescribedasaunilateralcondition.•  Multiplereportsofbilateralpathologyintheliteraturehave

challengedthistraditionaldefinition.•  Maintheoryregardingitsaetiology:

•  Sustainedobstructionatostiomeatalcomplexàmucosalresorptionofsinusgasàdevelopmentofnegativepressurewithinmaxillarysinusesàtriggersprocessofremodellingandinwardbowingofthemaxillarysinuswalls.

•  StudyonrabbitmodelssuggeststhatAMOcanbeacquiredasaresultofapathologicalsituation

•  OurpatienthadbilateralstageIICMAbutonlyhadmaxillarysinusopacificationandsymptomsontherightside.

•  Presenceofacongenital,patentAMOwouldhavelikelypreventedtheinitialbuild-upofnegativeintra-sinuspressure.

•  Therefore,wepostulatethatthepatientinitiallydevelopedCMAbilaterallyfromobstructionoftheostiomeatalcomplex.ThepatientsubsequentlydevelopedleftAMO,orhadapre-existingobstructedorsmallAMOthatbecamepatent,whichthenhaltedtheprogressionofthediseaseontheleftsidebyequalisingthenegativepressuredifferential.•  ThissupportsthatideathatsomeAMOmaybeacquiredanomalies

secondarytosinuspathology.

Conclusion

•  Chronicmaxillaryatelectasiscanoccurbilaterallyandcausesignificantsinonasalsymptoms.•  ThiscasesuggeststhatsomeAMOareacquireddefectsandsupportsthenotionthatCMAiscausedbynegativeintra-

sinuspressures.•  FurtherresearchisrequiredtoestablishthepreciseaetiologyofCMA.

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