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Penetration of the maxillary sinus floor membrane during sinus lift occasionally induces maxillary sinusitis. However, maxillary sinusitis may still develop even when its floor membrane has been kept ...intact during such procedures. The decisive factor for the occurrence of maxillary sinusitis is not the integrity of the membrane ; more important is the patency of the maxillary sinus natural ostium. The occlusion of the natural ostium presumably results from the expansive edema of the sinus membrane induced by surgical manipulations to the maxillary sinus floor. We propose a minimally invasive endoscopic sinus surgery which conceivably is useful to prevent potential occlusion of the natural ostium associated with maxillary sinus floor augmentation procedures. Although our technique is not a new concept, this is the first report to propose this kind of procedure as an adjunct to dental implantation. Our method is cost-effective and can be performed under topical anesthesia as a same-day surgery. In addition, it brings about no serious complications, such as orbital injuries or cerebrospinal fluid leakage. It aims to correct anatomical deviations, such as septal deviation, concha bullosa, hypertrophied uncinate process, and excessively pneumatized ethmoid bulla, all of which precipitate the occlusion of the natural ostium. Our method consists of a combination of resection of the uncinate process, widening of the natural ostium, and excision of the anterior and inferior edge of the middle turbinate. First, the anterior and inferoposterior segments of the uncinate process are resected with a curved rongeur, leaving the agger nasi cell intact (caution must be exercised to avoid injury to the nasolacrimal duct). This enables visualization of the maxillary natural ostium. The ostium is widened in all directions, using a forceps and/or a scalpel. The resultant widened ostium is bordered anteriorly by the nasolacrimal duct, inferiorly by the base of the inferior turbinate, posteriorly by the anterior surface of the ethmoid bulla, and superiorly by the medio-inferior angle of the orbit. Then the anterior and inferior edge of the middle turbinate is trimmed to prevent its adhesion to the lateral nasal wall or narrowing of the middle meatus. This surgery does not cause cerebrospinal fluid leakage and, at the same time, minimizes the risk for olfactory dysfunction. The antrostomy window thus formed is large enough to secure drainage and ventilation of the maxillary sinus. Moreover, the middle meatus, now deprived of the antero-inferior aspect of the middle turbinate, enables the patient to irrigate the maxillary sinus with a saline solution at home. Septal deviation can also be corrected simultaneously, if postoperative packing of bilateral nasal cavities is tolerable to the patient. Our experiences in treating over 100 patients are encouraging; although postoperative care such as irrigation of the maxillary sinus at home was mandatory and the start of dental implantation was delayed for 2-6 months, no patient who underwent surgery at our clinic developed maxillary sinusitis during the following course of dental implantation. We believe that collaboration between the otorhinolaryngologist and the dentist/oral surgeon is required to minimize the risk of maxillary sinusitis associated with dental implantation in the maxilla.
上顎のインプラント治療の合併症として最も頻度が高いのは上顎洞炎である．インプラント治療によって上顎洞底の粘膜に穿孔が生じても必ずしも上顎洞炎が生じる訳ではない．逆に，上顎洞底粘膜に穿孔が生じなくとも上顎洞炎が起きることがある．上顎のインプラント治療後に上顎洞炎が生じるかどうかを決定するのは，上顎洞自然孔である．上顎洞底挙上術などによって生じる洞内の粘膜の浮腫が自然孔にまで及び，自然孔が閉塞されたならば上顎洞炎が生じる．上顎洞自然孔の鼻腔側は鈎状突起や篩骨胞に挟まれており，軽度の粘膜浮腫によっても閉塞されやすい．鈎状突起の過剰発育，篩骨胞の過剰な含気化，中甲介の含気化や外側への彎曲などが認められる患者では，上顎洞自然孔周囲の粘膜浮腫によって一層，自然孔が閉塞されやすい．したがって上顎洞底挙上術を行う場合には，あらかじめこれらのリスクファクターを除去しておくのが好ましい．今回我々は，日帰り手術が可能な保存的な内視鏡下手術を提案する．鈎状突起の下方から後方を切除して上顎洞自然孔を明視下に置き，上顎洞自然孔を四方に広げる．このようにして開大されたウィンドウの前縁は鼻涙管隆起の後縁，上縁は眼窩下壁・内側壁移行部，後縁は篩骨胞の前面，そして下縁は下甲介の付着部になる．次いで，中鼻道前端付近のスペースを確保するために中甲介の前縁〜前下方をトリミングする．本術式は重篤な合併症が生じにくい．手術侵襲も少なく，上顎洞内に高度の病変が認められない症例では，上顎洞底挙上術を行う前の上顎洞炎予防処置として優れた術式と考えられる．ただし，高度の鼻中隔彎曲症がある症例には本手術は適さない．show more
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