646

Journal of the Royal Society of Medicine Volume 79 November 1986

Fundamental considerations of the design and function

of intranasal antrostomies

Valerie J Lund FRcs Institute of Laryngology and Otology, London WCI

Keywords: antrostomy, intranasal; inferior nasal meatus anatomy

Paper read to
Section of
Laryngology,
3 May 1985.
Awarded Downs
Travelling
Scholarship
for 1985

Summary
The natural history of intranasal antrostomy is
poorly understood despite the popularity of the procedure. Researches have been conducted to examine
this and in particular to establish factors which might
be responsible for closure. A complete appraisal ofthe
anatomy of the inferior meatus has been undertaken
to determine factors which limit the dimensions of an
antrostomy. Retrospective and prospective studies
have been performed on patients undergoing the
operation to assess patency and size. The results of
these studies demonstrate that initial size is important in determining long-term patency in adults, and if
an antrostomy is open at one year it usually remains
open in the long-term unless infection supervenes; in
children, however, antrostomies appear to close more
rapidly.

Introduction
The operation of intranasal antrostomy is becoming
increasingly popular in Great Britain1 but its natural
history remains obscure. To elucidate the rationale
for its performance in modern rhinology, the operation has been examined from a number of aspects.
It is commonly accepted that closure may occur27
but if the antrostomy closes, how does it close, how
quickly does it close, and what measurable factors
are associated with closure? Is it simply a question
of operative technique or does it depend on factors
associated with the patient, such as age, or on
individual variation? The role of the initial size
of the antrostomy particularly requires investigation
as it is regarded by many as the most important
determining factor8.

obtained from coronal CT scans and sagittal skulls.

The maximum distance between the floor ofthe sinus
and the floor of the nose ranged from 5 mm to 16 mm.
Evidently a wide range exists, but this does serve to
demonstrate that there is always a potential sump in
the fully developed adult maxillary sinus.
Examination of super-selective arteriograms have
demonstrated a constant vessel arising from the
lateral sphenopalatine artery and supplying the
lateral wall ofthe nose. It is seen entering the inferior
meatus, running superiorly to inferiorly at between
4 and 5 cm along the bony lateral wall. It then

3.
2
E
1-

Pyriform
fosa

cm Into nose

Figure 1. Height of inferior meatus (range and mean)

Anatomy
To establish the maximum inferior meatal antrostomy which could potentially be fashioned, the
anatomy of the area has been re-evaluated. Using
sagittally sectioned skulls and coronal CT scans,
the dimensions of the inferior meatus have been
established (Figure 1) showing a maximum height of
1.6-2.3 cm (average 1.92 cm) at 1.6 cm along the bony
lateral wall.
The bone constituting the inferior meatal wall has
been examined using coronal sections from midfacial
blocks, and demonstrates a change in thickness and
quality within the meatus. A gradual transformation
occurs from compact to lamellar bone, going from
superior to inferior and anterior to posterior, so that
0141-0768/86/
the
thinnest bone lies in the central superior portion
011646-04/$02.00/0
of
the
meatus (Figure 2).
01986
The height ofthe meatus in these specimens ranges
The Royal
from 6-18 mm with the highest point occurring at the
Society of
Medicine
genu of the inferior turbinate, thus confirming data

Figure 2. Coronal section (8p H&E) from adult midfacial

block

Journal of the Royal Society of Medicine Volume 79 November 1986

Figure 3. Lateral superselective arteriogram showing artery

to inferior meatus (arrowed)
Figure 4. Left inferior meatus showingpinhole antrostomy

descends below the level of the palate, rising again

very anteriorly on the lateral wall. This may be
distinguished from the leash of vessels supplying the
inferior turbinate, the descending palatine running
more posteriorly and inferiorly, and the septal artery
running down and forwards on the vomer (Figure 3).
Thus the fashioning of the maximum potential
inferior meatal antrostomy is limited by a number
of anatomical factors. Macroscopic examination of
gross dimensions of the meatus demonstrate the
attachment of the inferior turbinate which constitutes the superior limit. Inferiorly the increasing
thickness of bone makes it progressively more difflcult to cut down to the floor of the nose, whilst
discrepancy between the floor of nose and floor of
maxillary sinus results in an inevitable sump even if
the inferior margin is completely removed.
The changes in bone thickness as the anterior end
of the inferior turbinate is approached, and decreasing meatal height, preclude anterior extension and in
part explain why the inferior end ofthe nasolacrimal
duct is rarely damaged. The inferior meatal artery is
a constant feature on the 10 arteriograms examined.
Whilst the existence of the lateral conchal branch of
the lateral sphenopalatine artery is established9 - I ,
the path taken by the inferior meatal vessel has not
been previously demonstrated. This explains why, in
making an antrostomy, no significant bleeding is
encountered until 4-5 cm posteriorly. The surgeon's
desire to avoid damage to the vessel and changes in
bone thickness impose the posterior surgical limit.

Retrospective study
Method
All patients who had had intranasal antrostomies
performed during 1979-1982 were asked to attend
the outpatient department to assess patency and size
of antrostomy. This was done using a 4 mm 0' Hopkins
rod, Olympus camera with inbuilt graticule and
Xenon light source. In addition, direct measurement
of the length was possible using a custom-made
instrument. A total of 108 patients were assessed.
Results
There were 58 men and 50 women, their ages ranging
from 7 to 73 years. On initial attendance an average of
27 months had elapsed since the operation. Of 216
antrostomies performed, 45% were closed and 50%

patent. The average age of those patients in whom

the antrostomy had closed completely was 35 years
compared with 44 years in the group with patent
antrostomies, confirmingthe clinical impression that
antrostomies close more quickly in younger people.
This group included 13 of the 15 patients aged under
16 at the time of operation.
Patency was considered in relation to time elapsed
since operation and remains constant over several
years, implying that closure occurs, if at all, in the
first year; only 2 antrostomies closed during follow
up. The experience of the operator did not improve
the length of patency, with consultants having the
highest percentage closure of 540% compared to 42%
in registrars. As the initial size of the hole .is
unknown, it is difficult to assess the appearances at
follow up, but the degree of patency varied considerably from holes 2.5 x 0.8 cm to pinholes, which are
presumably a good deal smaller than originally made
(Figure 4). The other main problem with this group
is that the exact criteria for the operation are
unknown, though a review of the notes shows that
the majority had longstanding sinus problems which
could be termed 'chronic'.

Prospective study
Method
All patients undergoing intranasal antrostomy had
an accurate assessment of antrostomy size made at
the time of operation and were then followed up at
regular intervals during which closure was carefully
monitored. Factors relevant to closure such as initial
size, operative technique and postoperative care
were evaluated. All patients had proven antral infection which had failed to respond to conservative
medication and usually one or two washouts. So far
65 patients have been operated on.
Results
There were 24 men and 41 women, their ages ranging
from 11 to 73 years (mean 44). The follow up ranged
from 25 to 104 weeks (mean 58) and 65% of patients
were studied for one year or longer. All had had at
least one antral washout and 20 had had inferior
meatal antrostomies performed in the past.

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Journal of the Royal Society of Medicine Volume 79 November 1986

Table 1. Comparison of groups of different sizes by unpaired
t test

Group versus
group (cm)

2.75 x 1 v 2.5 x 1
2.75 x 1 v 2.0 x 1
2.75 x 1 v 1.5 x 1
2.75 x 1 v 1.Ox 1
2.5 xlv2.Oxl
2.5 xlvl.5xl
2.5 xlvl.0x1
2.0 x 1 v 1.5x l
2.0 x 1 v 1.0 x 1
1.5 x 1 v 1.0 x 1

Initial %
closure

-2.880
-2.980
-3.370
-6.480
-0.73

% Closure at
one year

-1.16
-4.990
-0.62
-4.640

-1.62
-1.24
-1.990
-5.370
0.76
0.64
4.520
-1.33
5.170

-3.830

-3.840

Final %
closure
-0.62
-0.44
-1.08

-3.050
0.39
0.70
3.120
-0.92

3.460
-1.51

0 Significant wherep < 0.001

Figure 5. Right inferior meatal antrostomy 6 weeks
postoperatively

Figure 7. Left large inferior meatal antrostomy with polypoid

mucosa extruding

Figure 6. Same antrostomy as shown in Figure 5, but 3 weeks

later after infection, showing contracture of the hole with pus
pouring out

One hundred and one antrostomies of various sizes

fashioned: 11 at 2.75 cm, 21 at 2.5 cm, 32 at
2.0 cm, 10 at 1.5 cm, 22 at 1.0 cm and 5 at 0.5 cm. The
superoinferior height was 1.0 cm in all cases except
for the 0.5 cm group, which were also 0.5 cm in height.
When the results are considered overall, it becomes
apparent that an initial diminution in size occurs
shortly after surgery, though an average of five
weeks elapsed before an accurate measurement was
possible. The range of early lumen diminution was
8-100%, with an average of 27%. Subsequently 73%
remained completely unchanged, 7 having undergone 100% closure by the first outpatient attendance
(Figure 5). Further gradual closure occurred in 17
antrostomies and rapid closure was observed in 10.
Rapid closure was associated with an obvious clinical infection (severe exacerbation of mucopurulent
discharge) in 9 antrostomies (Figure 6) and resulted
in complete closure in 6.
Percentage closure for each group of different
length was considered overall irrespective of follow
were

up and, if available, at one year follow up. The results

for each group were compared, and demonstrate a
significant difference between the 1 cm group and the
2.0, 2.5 and 2.75 cm groups irrespective of time after
operation (Table 1). In those 9 patients (13 antrostomies) with 100% closure during follow up, there
was 1 at 2.0 x 1.0 cm, 1 at 1.5 x 1.0 cm, 6 at 1.0 x 1.0 cm
and 5 at 0.5 x 0.5 cm, which represents 27% of the
1.0 x 1.0 cm group and 100% of the 0.5 x 0.5 cm group.
Three ofthe 1.0 x 1.0 cm patients were under 16 at the
time of operation.
Patency does not, however, guarantee success and
patients may be clinically symptomatic despite large
antrostomies from which pus or polypoid mucosa
may be seen extruding (Figure 7).

Discussion
It has been possible in the prospective study to eliminate a number of variable factors which are intrinsic
to a retrospective study. All the antrostomies were
performed by the same surgeon, employing an identical operative technique, postoperative management
and serial assessment.
The combined results of the retrospective and
prospective studies demonstrate that, as might be

Journal of the Royal Society of Medicine Volume 79 November 1986

expected, intranasal antrostomies close more quickly

in children, given the continuing growth in the
medial wall of the maxilla. They also suggest that if
an antrostomy is open at one year, then it usually
remains open in the long-term and that initial size
is important in determining long-term patency in
adults. Clearly an initial healing occurs within the
first few weeks which is of the same order (0.4 cm) in
all cases and is circumferential. The majority then
remain unchanged unless infection supervenes when
rapid closure may be observed. It is difficult to
define the degree of infection which precipitates this
change, as many patients undergo cyclical symptomatic deterioration and improvement without any
alteration in antrostomy appearance, apart from the
presence of mucopurulent discharge draining from
the sinus.
A recent survey by the author8 confirms that the
operation of intranasal antrostomy is done for widely
differing clinical indications, which is reflected in its
popularity, and using a wide variety of techniques,
which may explain the variable results particularly
with regard to long-term patency. It seems likely,
given the anatomical constraints, that a 2.0 x 1.0 cm
or greater hole is rarely achieved.
Is it possible that surgical conservatism has swung
too far, with more and more antrostomies being
performed for chronic conditions characterized by
irreversible mucosal disease? The physiology and
natural history of antrostomies are poorly understood, and whilst particles of ink can be most beautifully demonstrated streaming towards the natural
ostium in normal sinuses12, the situation with
severely damaged mucous membrane and cilia, and
thick tenacious pus, is quite different.
The critical functional size of the antrostomy in
relation to the viscosity of the secretion remains to
be determined. However, if one accepts that size is
important to the success of the operation, then careful attention to technique is required. Nevertheless,

probably the single most important area is careful

patient selection, and the present study suggests that
it is those patients with a relatively short history
of acute recurrent infection who are most likely to
benefit from the operation.
Acknowledgments: I would like to thank Mr B Kendall for
his assistance with the arteriography, Dr G Lloyd and Dr J
Palfrey for their help with the anatomy, and Professor D F N
Harrison for his invaluable advice and support.
References
1 Lund VJ. Fundamental considerations on the design
and function of intranasal antrostomies. Rhinology
1985;23:231-6
2 Hempstead B. End results for intranasal operation for
maxillary sinusitis. Arch Otolaryngol 1939;30:711-15
3 Moore P. Intranasal antrotomy in maxillary sinusitis.
Surg Clin North Am 1939;19:1243-52
4 Hilding AC. Physiologic basis of nasal operations.
California JMed 1950;72:103-7
5 Capps FCW. Observations on the treatment of infections of the maxillary antrum. J Laryngol Otol 1952;
66:199-210
6 Lavelle RJ, Spencer Harrison M. Infection of the maxillary sinus: the case for the middle meatal antrostomy.
Laryngoscope 1971;81:90-106
7 Mann W, Beck C. Inferior meatal antrostomy in
chronic maxillary sinusitis. Arch Otorhinolaryngol

1978;221:289-95
8 Lund VJ. Design and function of intranasal antrostomies. JLaryngol Otol 1986;100:35-9
9 Warwick R, Williams PL eds. Gray's anatomy. 35th ed.
London: Longman, 1973
10 Djindjian J, Merland JJ. Superselective arteriography of
the external carotid artery. Berlin: Springer Verlag, 1978
11 Lasjaunias PL. Craniofacial and upper cervical arteries.
Baltimore: Williams & Wilkins, 1982
12 Proetz AW. Essays on the applied physiology of the nose.
St Louis: Annals Publishing Co, 1941

(Accepted 16 April 1986)

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