ORIGINAL ARTICLE
Uncinatotomy: Performing Endoscopic Sinus Surgery Without an Uncinectomy Haşmet Yazici,* Fatih Kemal Soy, MD,† Erkan Kulduk, MD,† Sedat Doğan,‡ Rıza Dündar, MD,† and Ilknur Haberal Can§ Background: The results of endoscopic sinus surgery performed for chronic rhinosinusitis are controversial. For a better surgical outcome, different surgical techniques involving an uncinectomy as the primary step of the operation have been proposed. The surgery should resolve the pathophysiologic problems caused by the disease and preserve the normal anatomy and physiology. We developed a technique to remove the pathology localized to isolated maxillary and anterior ethmoid cells, without excising the uncinate process. The infundibular area was exposed with medialization of the uncinate with a bipedicle flap prepared 1.5 cm from the insertion of the uncinate to the nasal wall, and then the sinus pathology was removed. At the end of the surgery, the uncinate was returned to its original position. Methods: We performed this new technique to 3 patients and evaluated postoperative results. Results: Primary disease was eradicated, and no complication was noted. Conclusions: With this technique, it is possible to perform all steps of sinus surgery without excising any anatomic structure. Key Words: Uncinatotomy, minimal invasive endoscopic sinus surgery, uncinectomy (J Craniofac Surg 2014;26: 52–54)
W
ith the developments in endoscopy, sinus surgery has become popular in cases that are resistant to medical treatment. Although different surgical techniques have been proposed, an uncinectomy is usually the first step in these procedures.1 Considering the etiopathogenesis of chronic sinusitis and normal nasal
physiology, the need for an uncinectomy to achieve exposure and increase the ostium size is questionable. This article presents a new sinus surgical technique that does not involve excising the uncinate process (UP), which might better preserve the normal nasal anatomy and physiology.
Technique After local anesthesia and bleeding control using cotton soaked in 2% pantocaine and adrenalin, 1% lidocaine with 1:100,000 epinephrine solution was injected into the lateral nasal wall near the UP using a 2-mL syringe with a slightly bent 26gauge needle to facilitate the injection process. A vertical incision was made 1.5 cm anterior to the insertion of the UP and 1 cm superior to the superior border of the inferior turbinate (Fig. 1). Then, in the subperiosteal plane, a superior and inferior based bipedicle flap was elevated upward of the insertion of the UP. Together with the bipedicle flap, the UP was removed from the junction of the nasolacrimal canal using a 90-degree sharp elevator, and the surgical area was visualized (Fig. 2). To maintain the continuity of the vascular supply to ensure the postoperative viability and stability of the UP, it is important to protect the superior and inferior pedicles of the flap. Following medialization of the UP, the maxillary sinus content was removed, and a maxillary sinus osteoplasty and, if necessary, an anterior ethmoidectomy were performed without difficulty. At the end of the operation, absorbable sponges were placed over the maxillary sinus ostium and UP to prevent possible synechiae. Finally, the UP with the bipedicle flap was returned to its original position, and sponges were placed over the flap. The patients were seen in the second and 14th days and ninth month (Fig. 3). Presence of epiphora, bleeding, pain, or feeling of fullness on the face were asked in the follow-up. Anatomic structures position, nasal secretion status, ostium obstruction, and synechiae formation were examined with endoscopy. In addition, the viability of
What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Balikesir University, Faculty of Medicine, Ear Nose Throat Clinic, Balikesir; †Mardin State Hospital, Ear Nose Throat Clinic, Mardin; ‡Adiyaman University, Faculty of Medicine, Ear Nose Throat Clinic, Balikesir; and §Bagcilar Medipol University, Faculty of Medicine, Ear Nose Throat Clinic, Istanbul, Turkey. Received March 8, 2014. Accepted for publication June 20, 2014. Address correspondence and reprint requests to Fatih Kemal Soy, MD, Mardin State Hospital, Mardin, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001179
52
FIGURE 1. Location of the incision. BE indicates bulla ethmoidalis; MT, middle turbinate; IT, inferior turbinate.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
FIGURE 2. The maxillary ostium and infundibulum were visualized using a 30-degree endoscope after elevating the flap. MO indicates maxillary ostium.
FIGURE 3. Postoperative image. IT indicates inferior turbinate; MT, middle turbinate.
UP was examined by screening the color changes of UP in normal situation and after the topical adrenalin-soaked cotton administration. Occurrence of paleness after administration was accepted as a proof for viability. Patients’ data are presented in Table 1.
DISCUSSION Sinus ostium obstruction, mucociliary clearance deficiency, and bacterial overgrowth have all been blamed for the pathophysiology of chronic sinusitis. In cases resistant to medical treatment, a surgical approach has become popularized because of the advances in endoscopic techniques.1,2 In the standard endoscopic sinus surgery (ESS) procedure, an uncinectomy is the first step to improve surgical exposure and facilitate instrumentation. The UP acts as a shield by directing the inspiratory air to the nasopharynx, rather than the ostium of the sinuses, and prevents unfiltered, unhumidified, cold-inspired air from contacting the paranasal sinuses. Based on Bernoulli’s principle, turbulent inspiratory air in the nasal cavity can create a vacuum effect on the paranasal
Sinus Surgery Without Uncinectomy
sinuses. This mechanism might also affect mucociliary clearance. The contents of the frontal, maxillary, and anterior ethmoid sinuses drain to the medial part of the uncinate, and the presence of the uncinate facilitates the removal of these contents to the nasopharynx with the aid of mucociliary clearance and the Bernoulli effect.3 Berger et al4 assessed the histology and morphology of the UP, as compared with the inferior and middle turbinates. They reported significantly high numbers of submucosal serous and mucous glands and relatively lower vascularization in the UP compared with the inferior and middle turbinate. This rich glandular structure facilitates the drainage and ventilation of the sinuses. The vascularization of the inferior turbinate is significantly greater than that of the UP, which might be related to the regulation of the air temperature by the inferior turbinate. The UP humidifies the nasal airflow, prevents the inspired air from reaching the sinuses, and contributes to turbulent airflow, increasing contact between the air and the inferior turbinate and allowing more effective warming of the air. Consequently, Berger et al4 suggested that in order to maintain normal physiology, it is important to preserve the UP, especially in chronic sinusitis. Similarly, Xiong et al5 compared the nasal airflow in routine ESS and ESS with preservation of the UP in a computational fluid dynamics study of a human cadaver head. They studied the airflow velocity and pathway with and without preservation of the uncinate before and after intervention. When the UP was protected, the postoperative nasal airflow speed was faster, especially in the middle meatus, superior meatus, ethmoid sinus, and maxillary sinus areas. With the preserved UP, expulsion of the sinus contents via the vacuum effect was more effective. When the UP was resected, the airflow path and volume were located more posteriorly than preoperatively. These findings show that the UP both directs the airflow to facilitate mucociliary clearance and controls sinus aeration. Opposed to these findings, some studies claimed that uncinectomy does not affect the ventilation of the sinuses and outcomes of ESS.6 Kutluhan et al6 studied the maxillary sinus CO2 tension levels and inspiration and expiration pressure inside maxillary sinus before and after and compared the effect of uncinectomy versus natural ostial dilatation surgery. They reported that both techniques have equal effect for the decrement of maxillary sinus CO2 tension levels. Although inspiration pressure was decreased in uncinectomy group, there was no significant difference for inspiration and expiration maxillary sinus pressure levels in natural ostial dilatation. In addition, in the uncinectomy group, they found increased expiratory pressure levels after uncinectomy that conflicts with the classic knowledge and claimed that UP does not have any significant effect on ventilation of maxillary sinus at the expiration. As they also mentioned in the article, the reference range of maxillary sinus pressure levels during respiration was not documented in healthy subjects yet. Therefore, it would be assertive to claim that UP has no function in ventilation of sinuses according to the acute intraoperative measurements. Furthermore, inspiratory maxillary pressure is not the only factor that affects the nasal physiology. As we mentioned before, airflow pattern, velocity, and the structural components of the nose have major roles in achieving nasal physiology.
TABLE 1. Patient Demographics, Diseases, and Clinical Findings Name, Age, Sex
Pathology
Operation
Follow-up
S.A., 36 y, female
Maxillary pathology -Maxillary pathology -Bilateral concha bullosa -Septal deviation -Maxillary pathology -Polyp formation in ethmoid bulla
-Maxillary cyst excision -Maxillary cyst excision -Lateral middle concha excision+ -Endoscopic septoplasty -Anterior ethmoidectomy, Maxillary cyst excision
-No complications -No complications
F.S. 38, male
Ö.B., 18 y, male
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
-No complications
53
Yazici et al
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Similarly, Balasubramanian and Thiagarajan7 encountered the incomplete uncinate resection as a cause of failure in endoscopic surgery. The authors suggested performing total uncinectomy to enlarge natural maxillary ostium to eliminate the risk of UP contribution to chronic inflammation. However, in our present technique, all steps of the sinus surgery were successfully performed easily, and antrostomy might be assessed without the need of uncinate removal. After the improvement of mucociliary clearance and mucosal damage by sinus surgery was demonstrated, surgeons targeted to obtain better physiologic results by conserving nasal anatomy with minimally invasive sinus surgery rather than extensive manipulations.8,9 According to our opinion, there will be no tendency to inflammation if there are ventilation of sinuses and normal physiology of the nose as in all of our 3 cases. Although routine ESS includes uncinectomy, and some previous studies claims that removal of UP does not affect the outcomes of chronic sinusitis, preserving the normal anatomy with minimal harm to surrounding is still the main objective of the surgeries. Beyond the physiologic importance of the UP, an uncinectomy has a risk of complications because of close proximity with the nasolacrimal canal and orbital tissues.10 In our technique, ESS was performed without excising any tissue to achieve the optimal nasal physiology and anatomy. Considering the UP as a door located in front of the middle turbinate, instead of removing the door and leaving it open, this method lets us detach the door, clean the sinuses, and return the door to its normal location. The bipedicle flap was elevated in the subperiosteal plane, and the UP was incised from the junction of the nasolacrimal canal, where the bony cover over the canal is very thick. This sparing move minimizes the risk of nasolacrimal canal injury. In addition, the pedicles of the flap ensure the continuity of the vascular supply of UP from the anterior ethmoid artery superiorly and the sphenopalatine artery inferiorly. In conclusion, this new technique is appropriate for ESS in some recurrent sinusitis cases with respecting the normal anatomy and physiology.
54
Ethics committee approval was obtained from Balıkesir University, and a study comparing our technique and routine ESS procedure is ongoing. ACKNOWLEDGMENTS The authors thank Prof. Dr. Derya Umit Talas for his encouragement and valuable advice.
REFERENCES 1. Stammberger H. Endoscopic endonasal surgery—concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and pathophysiologic considerations. Otolaryngol Head Neck Surg 1986;94:143–147 2. Messerklinger W. Endoscopy of the Nose. Munich, Germany: Urban and Schwarzenberg, 1978 3. Stammberger H. An endoscopic study of tubal function and the diseased ethmoid sinus. Arch Otorhinolaryngol 1986;243:254–259 4. Berger G, Eviatar E, Kogan T, et al. The normal uncinate process: histology and clinical relevance. Eur Arch Otorhinolaryngol 2013;270:959–964 5. Xiong GX, Zhan JM, Zuo KJ, et al. Use of computational fluid dynamics to study the influence of the uncinate process on nasal airflow. J Laryngol Otol 2011;125:30–37 6. Kutluhan A, Şalvız M, Bozdemir K, et al. The effects of uncinectomy and natural ostial dilatation on maxillary sinus ventilation: a clinical experimental study. Eur Arch Otorhinolaryngol 2011;268:569–573 7. Balasubramanian Thiagarajan. Maxillary sinus antrostomy Pitfalls. Online J Otolaryngol 2012;2:3–8 8. Katsuhisa I, Takeshi O, Masayuki F, et al. Restoration of the mucociliary clearance of the maxillary sinus after endoscopic sinus surgery. J Allergy Clin Immunol 1997;99:48–52 9. Catalano PJ. Minimally invasive sinus technique: what is it? Should we consider it? Curr Opin Otolaryngol Head Neck Surg 2004;12:34–37 10. May M, Levine HL, Mester SJ, et al. Complications of endoscopic sinus surgery: analysis of 2108 patients—incidence and prevention. Laryngoscope 1994;104:1080–1083
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Uncinatotomy: Performing Endoscopic Sinus Surgery Without an Uncinectomy Haşmet Yazici,* Fatih Kemal Soy, MD,† Erkan Kulduk, MD,† Sedat Doğan,‡ Rıza Dündar, MD,† and Ilknur Haberal Can§ Background: The results of endoscopic sinus surgery performed for chronic rhinosinusitis are controversial. For a better surgical outcome, different surgical techniques involving an uncinectomy as the primary step of the operation have been proposed. The surgery should resolve the pathophysiologic problems caused by the disease and preserve the normal anatomy and physiology. We developed a technique to remove the pathology localized to isolated maxillary and anterior ethmoid cells, without excising the uncinate process. The infundibular area was exposed with medialization of the uncinate with a bipedicle flap prepared 1.5 cm from the insertion of the uncinate to the nasal wall, and then the sinus pathology was removed. At the end of the surgery, the uncinate was returned to its original position. Methods: We performed this new technique to 3 patients and evaluated postoperative results. Results: Primary disease was eradicated, and no complication was noted. Conclusions: With this technique, it is possible to perform all steps of sinus surgery without excising any anatomic structure. Key Words: Uncinatotomy, minimal invasive endoscopic sinus surgery, uncinectomy (J Craniofac Surg 2014;26: 52–54)
W
ith the developments in endoscopy, sinus surgery has become popular in cases that are resistant to medical treatment. Although different surgical techniques have been proposed, an uncinectomy is usually the first step in these procedures.1 Considering the etiopathogenesis of chronic sinusitis and normal nasal
physiology, the need for an uncinectomy to achieve exposure and increase the ostium size is questionable. This article presents a new sinus surgical technique that does not involve excising the uncinate process (UP), which might better preserve the normal nasal anatomy and physiology.
Technique After local anesthesia and bleeding control using cotton soaked in 2% pantocaine and adrenalin, 1% lidocaine with 1:100,000 epinephrine solution was injected into the lateral nasal wall near the UP using a 2-mL syringe with a slightly bent 26gauge needle to facilitate the injection process. A vertical incision was made 1.5 cm anterior to the insertion of the UP and 1 cm superior to the superior border of the inferior turbinate (Fig. 1). Then, in the subperiosteal plane, a superior and inferior based bipedicle flap was elevated upward of the insertion of the UP. Together with the bipedicle flap, the UP was removed from the junction of the nasolacrimal canal using a 90-degree sharp elevator, and the surgical area was visualized (Fig. 2). To maintain the continuity of the vascular supply to ensure the postoperative viability and stability of the UP, it is important to protect the superior and inferior pedicles of the flap. Following medialization of the UP, the maxillary sinus content was removed, and a maxillary sinus osteoplasty and, if necessary, an anterior ethmoidectomy were performed without difficulty. At the end of the operation, absorbable sponges were placed over the maxillary sinus ostium and UP to prevent possible synechiae. Finally, the UP with the bipedicle flap was returned to its original position, and sponges were placed over the flap. The patients were seen in the second and 14th days and ninth month (Fig. 3). Presence of epiphora, bleeding, pain, or feeling of fullness on the face were asked in the follow-up. Anatomic structures position, nasal secretion status, ostium obstruction, and synechiae formation were examined with endoscopy. In addition, the viability of
What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Balikesir University, Faculty of Medicine, Ear Nose Throat Clinic, Balikesir; †Mardin State Hospital, Ear Nose Throat Clinic, Mardin; ‡Adiyaman University, Faculty of Medicine, Ear Nose Throat Clinic, Balikesir; and §Bagcilar Medipol University, Faculty of Medicine, Ear Nose Throat Clinic, Istanbul, Turkey. Received March 8, 2014. Accepted for publication June 20, 2014. Address correspondence and reprint requests to Fatih Kemal Soy, MD, Mardin State Hospital, Mardin, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001179
52
FIGURE 1. Location of the incision. BE indicates bulla ethmoidalis; MT, middle turbinate; IT, inferior turbinate.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
FIGURE 2. The maxillary ostium and infundibulum were visualized using a 30-degree endoscope after elevating the flap. MO indicates maxillary ostium.
FIGURE 3. Postoperative image. IT indicates inferior turbinate; MT, middle turbinate.
UP was examined by screening the color changes of UP in normal situation and after the topical adrenalin-soaked cotton administration. Occurrence of paleness after administration was accepted as a proof for viability. Patients’ data are presented in Table 1.
DISCUSSION Sinus ostium obstruction, mucociliary clearance deficiency, and bacterial overgrowth have all been blamed for the pathophysiology of chronic sinusitis. In cases resistant to medical treatment, a surgical approach has become popularized because of the advances in endoscopic techniques.1,2 In the standard endoscopic sinus surgery (ESS) procedure, an uncinectomy is the first step to improve surgical exposure and facilitate instrumentation. The UP acts as a shield by directing the inspiratory air to the nasopharynx, rather than the ostium of the sinuses, and prevents unfiltered, unhumidified, cold-inspired air from contacting the paranasal sinuses. Based on Bernoulli’s principle, turbulent inspiratory air in the nasal cavity can create a vacuum effect on the paranasal
Sinus Surgery Without Uncinectomy
sinuses. This mechanism might also affect mucociliary clearance. The contents of the frontal, maxillary, and anterior ethmoid sinuses drain to the medial part of the uncinate, and the presence of the uncinate facilitates the removal of these contents to the nasopharynx with the aid of mucociliary clearance and the Bernoulli effect.3 Berger et al4 assessed the histology and morphology of the UP, as compared with the inferior and middle turbinates. They reported significantly high numbers of submucosal serous and mucous glands and relatively lower vascularization in the UP compared with the inferior and middle turbinate. This rich glandular structure facilitates the drainage and ventilation of the sinuses. The vascularization of the inferior turbinate is significantly greater than that of the UP, which might be related to the regulation of the air temperature by the inferior turbinate. The UP humidifies the nasal airflow, prevents the inspired air from reaching the sinuses, and contributes to turbulent airflow, increasing contact between the air and the inferior turbinate and allowing more effective warming of the air. Consequently, Berger et al4 suggested that in order to maintain normal physiology, it is important to preserve the UP, especially in chronic sinusitis. Similarly, Xiong et al5 compared the nasal airflow in routine ESS and ESS with preservation of the UP in a computational fluid dynamics study of a human cadaver head. They studied the airflow velocity and pathway with and without preservation of the uncinate before and after intervention. When the UP was protected, the postoperative nasal airflow speed was faster, especially in the middle meatus, superior meatus, ethmoid sinus, and maxillary sinus areas. With the preserved UP, expulsion of the sinus contents via the vacuum effect was more effective. When the UP was resected, the airflow path and volume were located more posteriorly than preoperatively. These findings show that the UP both directs the airflow to facilitate mucociliary clearance and controls sinus aeration. Opposed to these findings, some studies claimed that uncinectomy does not affect the ventilation of the sinuses and outcomes of ESS.6 Kutluhan et al6 studied the maxillary sinus CO2 tension levels and inspiration and expiration pressure inside maxillary sinus before and after and compared the effect of uncinectomy versus natural ostial dilatation surgery. They reported that both techniques have equal effect for the decrement of maxillary sinus CO2 tension levels. Although inspiration pressure was decreased in uncinectomy group, there was no significant difference for inspiration and expiration maxillary sinus pressure levels in natural ostial dilatation. In addition, in the uncinectomy group, they found increased expiratory pressure levels after uncinectomy that conflicts with the classic knowledge and claimed that UP does not have any significant effect on ventilation of maxillary sinus at the expiration. As they also mentioned in the article, the reference range of maxillary sinus pressure levels during respiration was not documented in healthy subjects yet. Therefore, it would be assertive to claim that UP has no function in ventilation of sinuses according to the acute intraoperative measurements. Furthermore, inspiratory maxillary pressure is not the only factor that affects the nasal physiology. As we mentioned before, airflow pattern, velocity, and the structural components of the nose have major roles in achieving nasal physiology.
TABLE 1. Patient Demographics, Diseases, and Clinical Findings Name, Age, Sex
Pathology
Operation
Follow-up
S.A., 36 y, female
Maxillary pathology -Maxillary pathology -Bilateral concha bullosa -Septal deviation -Maxillary pathology -Polyp formation in ethmoid bulla
-Maxillary cyst excision -Maxillary cyst excision -Lateral middle concha excision+ -Endoscopic septoplasty -Anterior ethmoidectomy, Maxillary cyst excision
-No complications -No complications
F.S. 38, male
Ö.B., 18 y, male
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
-No complications
53
Yazici et al
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Similarly, Balasubramanian and Thiagarajan7 encountered the incomplete uncinate resection as a cause of failure in endoscopic surgery. The authors suggested performing total uncinectomy to enlarge natural maxillary ostium to eliminate the risk of UP contribution to chronic inflammation. However, in our present technique, all steps of the sinus surgery were successfully performed easily, and antrostomy might be assessed without the need of uncinate removal. After the improvement of mucociliary clearance and mucosal damage by sinus surgery was demonstrated, surgeons targeted to obtain better physiologic results by conserving nasal anatomy with minimally invasive sinus surgery rather than extensive manipulations.8,9 According to our opinion, there will be no tendency to inflammation if there are ventilation of sinuses and normal physiology of the nose as in all of our 3 cases. Although routine ESS includes uncinectomy, and some previous studies claims that removal of UP does not affect the outcomes of chronic sinusitis, preserving the normal anatomy with minimal harm to surrounding is still the main objective of the surgeries. Beyond the physiologic importance of the UP, an uncinectomy has a risk of complications because of close proximity with the nasolacrimal canal and orbital tissues.10 In our technique, ESS was performed without excising any tissue to achieve the optimal nasal physiology and anatomy. Considering the UP as a door located in front of the middle turbinate, instead of removing the door and leaving it open, this method lets us detach the door, clean the sinuses, and return the door to its normal location. The bipedicle flap was elevated in the subperiosteal plane, and the UP was incised from the junction of the nasolacrimal canal, where the bony cover over the canal is very thick. This sparing move minimizes the risk of nasolacrimal canal injury. In addition, the pedicles of the flap ensure the continuity of the vascular supply of UP from the anterior ethmoid artery superiorly and the sphenopalatine artery inferiorly. In conclusion, this new technique is appropriate for ESS in some recurrent sinusitis cases with respecting the normal anatomy and physiology.
54
Ethics committee approval was obtained from Balıkesir University, and a study comparing our technique and routine ESS procedure is ongoing. ACKNOWLEDGMENTS The authors thank Prof. Dr. Derya Umit Talas for his encouragement and valuable advice.
REFERENCES 1. Stammberger H. Endoscopic endonasal surgery—concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and pathophysiologic considerations. Otolaryngol Head Neck Surg 1986;94:143–147 2. Messerklinger W. Endoscopy of the Nose. Munich, Germany: Urban and Schwarzenberg, 1978 3. Stammberger H. An endoscopic study of tubal function and the diseased ethmoid sinus. Arch Otorhinolaryngol 1986;243:254–259 4. Berger G, Eviatar E, Kogan T, et al. The normal uncinate process: histology and clinical relevance. Eur Arch Otorhinolaryngol 2013;270:959–964 5. Xiong GX, Zhan JM, Zuo KJ, et al. Use of computational fluid dynamics to study the influence of the uncinate process on nasal airflow. J Laryngol Otol 2011;125:30–37 6. Kutluhan A, Şalvız M, Bozdemir K, et al. The effects of uncinectomy and natural ostial dilatation on maxillary sinus ventilation: a clinical experimental study. Eur Arch Otorhinolaryngol 2011;268:569–573 7. Balasubramanian Thiagarajan. Maxillary sinus antrostomy Pitfalls. Online J Otolaryngol 2012;2:3–8 8. Katsuhisa I, Takeshi O, Masayuki F, et al. Restoration of the mucociliary clearance of the maxillary sinus after endoscopic sinus surgery. J Allergy Clin Immunol 1997;99:48–52 9. Catalano PJ. Minimally invasive sinus technique: what is it? Should we consider it? Curr Opin Otolaryngol Head Neck Surg 2004;12:34–37 10. May M, Levine HL, Mester SJ, et al. Complications of endoscopic sinus surgery: analysis of 2108 patients—incidence and prevention. Laryngoscope 1994;104:1080–1083
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
