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A Study on the Presence of Accessory Maxillary Ostium

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A Study on the Presence of Accessory Maxillary Ostium A Dsertatio A STUDY ON THE PRESENCE OF ACCESSORY MAXILLARY OSTIUM Submit th THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY I me t uireme F th M.S.BRANCH IV (OTORHINOLARYNGOLOGY) GOVERNMENT STANLEY MEDICAL COLLEGE & HOSPITAL THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY, CHENNAI, TAMILNADU APRIL 2015 DECLARATION I, Dr. VRINDA .B. NAIR, solem h issertati, titl “A Study On The Presence Of Accessory Maxillary Ostium” i nafi n m h Jnuar 2013 J 2014 Gvernmen Snle Mica Colle Hospital, Chenna unde upervisio o PROF. DR. T. BALASUBRAMANIAN, M.S., D.L.O., Pess n H, Dme O Olaryngology, Governmen Stanl Mdic Colleg an hospital, Chennai. Thi dissertati i submitt T Tam N D. M.G.R. M Uit ia men o h gulation th M.S. xamination Orhinolaryngolo hel A 2015. P: Cenn-1 DR.VRINDA .B. NAIR D: CERTIFICATE Thi i t certif tha th dissertati -“A Study On The Presence Of Accessory Maxillary Ostium” presente BY DR.VRINDA .B. NAIR , i a origina wor don i th Departmen o Olaryngology, Gve Snle M C n Hital, Chenna i partia fulfillmen o regulation o th Tami Nad Dr. M.G.R. Mica Unive M.S. (Olaryngology) Banc IV, m supervisio d th academi 2012-2015. THE DEAN, PROF.DR.T.BALASUBRAMANIAN G. Snle medica PROFESSOR AND HEAD OF THE DEPARTMENT college, G. Snle M Clleg n Hi Cenn-1. Chennai-1 P : Chenna D : ACKNOWLEDGEMENTS I i sincer ank Prof. Dr.AL. MEENAKSHI SUNDARAM, MD, DEAN, Gvernmen Stanl Medic Colleg Hita mit aciliti th ita o conductin h stud. M heartfel gratitu Prof.Dr.T. BALASUBRAMANIAN, M.S., D.L.O., P n H Dtmen, D Oinolaryngology, Governme Stanle Mdica Cg n Hita nstan motivation, valuabl uggestion, e upervisio durin th rs thi dy. I ex m wh- gratitu Prof.Dr.N. SEETHALAKSHMI M.S.,D.L.O.,D.N.B, Professo an Chie o ENT UNIT II Oorhinolaryngology, PROF. DR. F.ANTHONY IRUDHAYA RAJAN M.S.,D.L.O, Pess, f suppo, guidin an ncouragin thi udy. I s th m Assistant Professors DR.K.ATHIYAMAN M.S, DR.C.KARUPPASAMY M.S.,D.L.O., DR.M.P.CHANDRAMOULI M.S., DR.SARAVANA SELVAN M.S., DR.C.BHARANIDHARAN D.L.O. th aluabl uidan. I gratefu t al th othe post-raduate wh os willingl hel m ud perio. I als than th staf nurses, theatr personnel, OPD staff, Departmen Oorhinolaryngology, Governmen Sl Hospit f th -operati assistan th ndu thi dy. I wi exten m t statisticia fo hi exper assistan. Las bu no th least, I a indebte an gratefu t al th Patients and Normal volunteers h constitut th backbon o thi , wh m willing elfless themselv thi stud fo th sak o th benefi o thei communit an withou who thi wo av possibl. TABL 1. ABSTRA 1 2. OBJECTIV 3 3. INTRODUC 5 4. REVI O LITERATU 7 5. MATERI 38 6. RESULT 51 7. DISCUSSI 64 8. CONCL 109 9. ANN 111 A.BIBLIOGR B. FORM . THI COMMI PP LETTE . ATIEN NFORMATIO EE . INFORME CONSEN F F. LAGIAR . STE 1. ABSTRACT The association between accessory ostium and chronic sinusitis is still a subject of controversy as various studies have given a wide range of variable results. The prevalence of accessory ostium varies between 2 – 44 %. Objective To study the prevalence of Accessory ostium in those with Chronic Sinusitis and those without the disease. Methods 83 patients with chronic sinusitis and 83 subjects without the disease were studied by nasal endoscopy for the presence of accessory ostium. Results 30 % of those with chronic sinusitis had an accessory ostium , whereas only 10 % without the disease had it ( p value <0.001 ). Majority of the accessory ostia were on the left and in the posterior nasal fontanelle , in both the groups. 6 (24 %) patients and 1 (13 %) unexposed subject had bilateral accessory ostia.Only 2% of the diseased individuals had double ostia. Only 12 % showed circular phenomenon. However symptoms like headache , facial pain , post nasal drip and halitosis , and purulence on examination (Rhinosinusitis Task Force Criteria) were not found to have any specific association with the presence of accessory ostia. Conclusion To conclude we would say that the presence of an accessory ostium can be considered as an indicator of maxillary sinus disease, along with the other criteria for chronic sinusitis and that it can help surgeons in their decision making as to whether a surgery is required or not. Key words : accessory ostium , maxillary sinusitis Page | 2 2. OBJECTIVE To study, · The prevalence of accessory maxillary ostium in chronic sinusitis and that in normal subjects by nasal endoscopy. Page | 3 INCLUSION CRITERIA: 1. Age:15-45 years. 2. Patients with clinical symptoms of chronic maxillary sinusitis. 3. Radiological diagnosis of chronic maxillary sinusitis. 4. Persistence of symptoms for more than 12 weeks even after medical line of treatment. EXCLUSION CRITERIA: 1. <15 or>45 years of age. 2. History of previous maxillary sinus surgeries. 3. Patients with sinonasal neoplasms. 4. Patients with sinonasal encephaloceles. 5. Patients with known ciliary dysfunction such as primary ciliary dyskinesia and Kartagener Syndrome . 6. Patients with sinonasal polyposis. 7. Patients with fungal sinusitis. 8. Patients with Cystic Fibrosis . 9. Patients who are immunocompromised (with the exception of diabetics) . Page | 4 3. INTRODUCTION Chronic sinusitis is a group of disorders characterized by the inflammation of nasal and paranasal sinus mucosa which is now extremely prevalent, affecting 32 million adults , or 16.3 % of the adult population[9]. Its diagnosis is mainly based on clinical symptoms and signs, supported by diagnostic nasal endoscopy and CT scan. Maxillary sinusitis is the side effect of evolution as a result of which man acquired an erect posture. The secretions of the maxillary sinuses have to be transported against gravity by the mucociliary action. Hence the normal functioning of a sinus depends on – patency of the ostium , normal mucociliary transport and the normal quality and quantity of secretions. Accessory ostia also known as Giralde’s orificeare defects in the lateral nasal wall, in the region of fontanelles, which communicate with the maxillary sinus , in addition to the natural ostium. They are thought to develop as a consequence of damage to the fontanelles following sinus infections. This in turn becomes a reason for recurrence of infection due to mucous recirculation. Page | 5 Majority of the accessory ostia occur singly. A few multiple ostia have also been observed. They are mostly acquired and rarely congenital. However there is still a controversy over its etiology. The present study is an attempt at finding the prevalence of Accessory Ostium in those patients with Chronic Sinusitis and in those without. Here we have used Nasal Endoscopy as a tool to investigate the presence of accessory ostia. We have deliberately avoided CT PNS as a diagnostic tool as our study included normal subjects as well. Page | 6 4. REVIEW OF LITERATURE Hippocrates in the 5th century B.C itself has described sinusitis when he quoted “in a person having a painful spot in head, with intense headaches, pus or fluid running from the nose removes the disease.” Leonardo da Vinci in his period had accurately given the description of the maxillary antrum and the frontal sinus. [1] In 1869, Wertheim made a Conchoscope to examine the anterior and middle thirds of the nasal cavity. [1] In 1879, Nitze-Leiter developed the Cystoscope, and this marked the second stage in the developement of endoscopy. [1] Hirschmann is considered the Father of Endoscopy. In 1902, Hirschmann and Valentin introduced a modified cystoscope into a maxillary sinus through an enlarged dental alveolus.[1] During the period 1951 – 1956, Hopkins made improvements in the optics of endoscopy which included a separate light source , small diameter of the endoscope , large field of vision , excellent resolution , high contrast and constancy of color. [1] Page | 7 In the 1950s Messerklinger developed a systematic diagnostic approach to the lateral wall of nose. [1] HISTORY OF STUDIES ON MAXILLARY ACCESSORY OSTIUM There have been various studies in the past conducted to find the presence of Accessory Maxillary Ostia (AMO) on live subjects as well as cadavers. In 1870 , Zuckerkandl introduced the term ‘fontanelle’ for certain regions below the uncinate and above the inferior turbinate , deficient in bone covered by nasal mucous membrane medially and maxillary sinus laterally , with connective tissue sandwiched in between. Levine et al described the anterior and posterior fontanelle (ANF &PNF) in relation to the uncinate - PNF being posterosuperior to uncinate and ANF between the inferior edge of uncinate and attached margin of inferior turbinate[25]. Scheaffer (1953) discovered twin openings at the Hiatus Semilunaris and described them as Triple PMO. He preferred the term Duplicate PMO than Accessory ostium. Rice and Scheaffer (1993) used the term Accessory maxillary sinus ostia for all the extra openings other than the primary maxillary ostium irrespective of their location. Levine et al (1993) described that accessory ostia Page | 8 result from rupture of fonatanelles due to the blockage in the primary maxillary ostium. Scheaffer (1920) reported the AMO to number between 1 -3. But this is uncommon and hence there is not much in the literature regarding multiple openings. Stammberger & Kennedy (1995) came up with an incidence of 4-5 % in the general population as opposed to 25 % in those with chronic sinusitis. Incidence of AMO ranges between 2 - 44 % , lower values being obtained from in vivo studies whereas higher ones from cadaver studies. The reason for this wide variation may be that the AMO that may be covered with a mucous film and in inaccessible locations are often missed out in in vivo studies.
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