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Background: The author has analyzed the success of the puncture in the treatment of the chronic purulent maxillary sinusitis in 43 patients, aged from 19 to 51, previously diagnosed (RTG PNS, CT, NMR) and treated longer than 3 months without a significant improvement. Sense of pressure on the side of the affected sinus (76%), post nasal drip (71.8%), halitosis (47.9%), nasal obstruction (46.2%), impaired smell, sub febrile temperature, fatigue etc., dominated the symptomatology. The duration of symptoms varied from 6 months to two years. The intervention of sinus puncture was carried out through the lower nasal passage, during one or more sessions of secretion aspiration, sinus lavage and drug administration in the above-mentioned passage. Puncture specimens of all the patients were sent for bio gram and antibiogram analysis. No complications were noticed. The goal of this work is to evaluate the adequacy of applying the puncture as a medical procedure in the treatment of the chronic purulent inflamed maxillary sinus.
Results:healing or substantial improvement rate of the process on the maxillary sinuses after merely one puncture was 60.7% and 80% after two or over three procedures.
Conclusion:The author emphasizes the necessity of applying the puncture in certain diseases of the maxillary sinus, especially in sinus empyema when an immediate secretion removal is needed, and when the puncture can prevent the development of endo- or extracranial complications. The puncture can come to great use in all conditions where there is simultaneous presence of the sinus disease with secretion and other chronic diseases of the lower respiratory tract (asthma, chronic bronchitis).
Chronic sinusitis is the most common disease in the USA with about 37 million people affected which comprises 14.13 % of the population, meaning that every seventh person suffers from the disease. This impairment occurs more frequent than arthritis (12.4%) and hypertension (11.44%) and is defined as an inflammatory disease of the nasal mucosa with symptoms that last longer than three months. Those dominant symptoms are: sense of pressure on the side of the affected sinus, post nasal drip, bad breath, nasal obstruction, impaired smell, fatigue and sub febrile temperature. The maxillary and ethmoid sinus are most frequently affected. In over 40% of the maxillary sinus inflammations, the process also involves the front ethmoid cells. Sinusitis can present itself on one or more sinuses (polysinusitis, pansinusitis) and is classified by the course of the disease into acute, subacute and chronic sinusitis.
The seasonal character of the sinusitis in not seldom associated with an outbreak of allergens who are more present in springtime and in the fall and with a viral infection in winter period. Chronic maxillary rhinosinusitis, particularly in the state of exacerbation, could present a potential threat for the
development of the endocranial and extracranial complications. A late diagnosis and an inadequate treatment are most frequently stated as the reasons for these complications. The normal drainage of the maxillary sinus occurs through hiatus semilunaris into the middle nasal meatus. The mucosal drainage canal is 6-8 mm long, 3-5 mm wide and is located on the roof of the sinus which impedes the drainage. The capacity of the maxillary sinus and its excretory duct is often disproportionate, especially in the state of an infection. That is when a build-up of a pathological content occurs which cannot be spontaneously eliminated for two reasons: a blocked excretory canal or a dyskinesia of the epithelium. As a means of treating and faster secretion evacuation, the puncture of the sinus as a procedure was introduced in 1886. by dr. Mikulicza.
Depending of the purpose, the puncture can be classified into:
Depending of the purpose, the puncture can be classified into:
b. Prophylactic puncture
c. Therapeutic puncture
Regarding the site of performing the procedure, the puncture
is divided into:
a. Frontal (through the fossa canina)
b. Lower (under the inferior nasal concha)
c. Middle (through the natural drainage ostium)
In the case where a perforation of the lateral nasal wall is
not possible for any reason (thickness of the medial wall of the
sinus, the size of the sinus- shallow, undeveloped, septate etc.,
nasal pathologies (septum deviation, polyps, synechia, enlarged
nasal concha etc.) etc. trepanation can be carried out through
the frontal wall of the maxillary sinus, through fossa canina.
By puncturing the sinus, because of the fast elimination of
the pathological content, we can prevent the spreading of the
process into the adjacent regions.
This does not require any special patient preparation and
it is performed by ENT specialists on their surgical practice
premises. After administrating an epimucose anesthesia to the
nasal mucosa, a needle is placed on the border of two front
thirds and back third of the nasal concha, around 1 cm above
the nasal floor in the direction of the lateral eye angle on the
same side. The thin bone lamella of the medial wall of the sinus is
perforated with a needle. As a next step, aspiration is performed
and sinus lavage and, if needed, placing a medicine in the sinus.
When the condition requires a continuous drainage and sinus
ventilation, other surgical procedures are recommended.
Today’s trends suggest FESS (Functional Endoscopic Sinus
Surgery) which requires hospital treatment and demands
special and costly equipment, strictly defined indications and
the adequate training of the physicians for its performing.
Nevertheless, the rating of other surgical procedures, such as the
“antral window” procedure, is in downfall because of the FESS.
Prior to any intervention, one must determine the size and the
content of the sinus. For that purpose, we can use methods such
as CT, NMR or even a regular RTG of the paranasal cavities can
come to use. Occasionally, a clinical check up with the anamnestic
data and an RTG of the paranasal cavities is enough to make a
The maxillary sinus is piramide-shaped
a. Width 23-25mm
b. Height 30-33mm
c. Anteroposterior dimension 32-34mm
d. Volume 16-18ml (Figures 1-3)
Since the two-week antibiotics treatment (longaceph) did
not lead to healing of the process, the sinus has been punctured
The sinus puncture is considered when:
1. When the medication treatment of acute, subacute or
chronic suppurative inflammation of the maxillary sinus
didn’t produce a favorable outcome
2. With patients who have a sinus pathology and a
simultaneous pathology of the lower respiratory tract
3. When a patient is at risk of complications due to his/
her sinus disease
4. For the collection of specimens for microbiological and
5. In cases when a condition requires a direct insertion of
a drug into the sinus
6. When a surgery is contraindicated
7. Patient does not wish it (Figures 4-7)
In carefully chosen cases the procedure will prove itself to
being favorable in the treatment of mucopurulent maxillary
rhinosinusitis and should not be avoided. The evacuation of the
pathological content of the sinus will contribute greatly to the
healing and reactivating natural sinus drainage. Puncture can
be performed at the office and doesn’t require hospitalization.
If the natural opening of the maxillary sinus is shut or blocked,
a pain should occur with the injecting of a liquid into the sinus.
In that case, we pause the intervention, to insert another needle,
next to the existing one, through which the sinus content is to
be evacuated. A cause for a negative puncture can be, stuffed
needle, a needle in contact with the back wall of the sinus, needle
in a sinus polyp or tumor mass, thick, caseous content, etc.
b. Oftentimes the procedure gives temporary relief
c. Doesn’t prevent a recurrence of the disease or new
d. Must be combined with the antibiotic treatment
In the case when the puncture doesn’t prove itself
successful, other procedures should be performed. One of the
most frequently performed procedures from the group “antral
window” procedures is nasoantrostomy and meatotomy. They
imply creating an opening on the lateral wall of the nose below
the nasal concha and establishing a wider communication
between maxillary sinus and inferior nasal passage.
However, indications for this intervention as well as
curettage, that is the removal of the affected mucosa, remains
questionable. Numerous authors give priority to drainage rather
than curettage, “drainage prime le curettage”. It needs to be
mentioned, that the fenestration represents unnatural way of
drainage and sinus ventilation and facilitates the spreading of
infection from the nose to the sinus, which is attributed as a
disadvantage of the procedure. Moreover, spontaneous closure
of the opening, before the healing process has terminated, can
compromise the success and credibility of these procedures.
Postoperative course could require nasal douche and sinus
rinsing with a prescribed antibiotic therapy. These interventions
are practically without complications and are indicated in
patients who suffer from chronic maxillary rhinosinusitis with
an immobile secretion as well as in recurring and frequent
inflammations. It can also serve as a first step for the endoscopic
evaluation of the sinus cavity, doing biopsies, continuous lavage
of the sinus, dealing with headaches due to sinus disease, etc.
Finally, these procedures are legitimate in cases where we lack
results from the medial meatotomy (FESS).
The author concludes that, the puncture of the sinus is
adequate and justified in the treatment of chronic maxillary
sinusitis with the presence of suppurative secretion where the
use of medications has not solved the issue. The sinus empyema
is an absolute indication for this procedure. When the recurring
cases of chronic sinusitis are at issue, recurring sinusitis with
secretion immobility, puncture could be a temporary solution.
If the impaired sinus requires continuous drainage, advantage
has to be given to other functional operations. Furthermore,
puncture of the sinus is a method that must not be left out in
patients who have a blockage of the osteomeateal complex which
has not been resolved by FESS operation. By using the puncture,
we remove the pathological content from the sinus, perform
sinus lavage, drug insertion, and collection of the material for
analyses, etc. The evacuation of the pathological content of the
sinus will contribute greatly to the healing and reactivating
natural sinus drainage. Puncture can be performed at the office
and doesn’t require hospitalization. Sinus puncture has the
advantage as an urgent intervention in patients with endo- and
extracranial complications. Minimum trauma, absence of serious
complications, preservation of the integrity of the adjacent
regions, the simplicity of the procedure makes this intervention
unique, and in case of failure, there is always a possibility of
another surgical procedure. In correctly chosen cases there is
full medical justification for this form of treatment where the
patients, even after a short period of time after the procedure,
regained the capability in performing normal activities and fully