Lund–Mackay score
The association between accessory ostia of left and right maxillary
sinus in the superior meatus and the Lund–Mackay score is shown in
Figure 3. The Lund–Mackay score distribution in patients with accessory
maxillary sinus ostia in superior meatus was similar to the score
distribution in patients without accessory ostia. However, the mean and
standard deviation of scores in patients without accessory ostia was
approximately two points higher than in patients with accessory ostia in
both the left and the right maxillary sinus. There was a statistically
significant higher tendency for rhinosinusitis in patients without
versus with accessory maxillary sinus ostia in superior meatus (P
< 0.001) (Table 3).
DISCUSSION
Chronic rhinosinusitis is a commonly observed condition and has
significantly contributed to healthcare consumption and productivity
loss, affecting 5%–12% of the global
population.13,14 The obstructed drainage and
ventilation of paranasal sinuses increase the risk of long-term
inflammation.3 Theoretically, the presence of
accessory ostia implies disturbance in mucociliary clearance and the
mucus circulation of the associated maxillary sinus, which may sustain
chronic inflammation.11
We examined the incidence and associations of accessory maxillary sinus
ostia in the superior meatus with the presence of chronic rhinosinusitis
in a single-centre patient sample using HRCT and 3D simulation images.
The results revealed that 41.5% (66) of the patients exhibited
accessory maxillary sinus ostia in the superior meatus, irrespective of
gender. Several studies conducting cadaver and live endoscopic
examinations have reported 0–43% of humans have accessory maxillary
ostia.7,15 Mahajan et al. showed that accessory
maxillary sinus ostia were observed in 42 out of 200 (21%) half
heads,7 and Mladina et al. reported a prevalence of
19.3% for accessory maxillary ostia, with 68% being
bilateral.9 Bani-Ata et al. showed that both maxillary
and ethmoid sinusitis were significantly associated with male
individuals, but the presence of a right or left accessory ostium had no
correlation with gender or age.8
Our study showed a significant association between the absence of
accessory maxillary sinus ostia in the superior meatus and the
Lund–Mackay score. Accessory maxillary sinus ostia present in the
superior meatus were associated with less severe chronic sinusitis. Our
study is the first to identify and evaluate accessory maxillary sinus
ostia in the superior meatus. Previous studies have shown that in
patients who have experienced multiple episodes of maxillary sinusitis,
the greater frequency of accessory maxillary
sinus ostia can be attributed to pathology.1,3,7 Ghosh
et al. investigated the correlation between accessory maxillary ostia
and chronic sinusitis and recommended that middle meatal antrostomy
should include the posterior and anterior fontanelle to reduce mucus
circulation.3 If accessory maxillary ostia were
present, there was an associated increased incidence of mucus retention
cysts by three-fold and the frequency of findings of mucosal thickening
and maxillary sinusitis doubled, as shown by Yenigun et
al.12 According to Capelli et al., a maxillary mucosa
thickness ≥ 2 mm and obstructed natural drainage of maxillary sinus were
significantly correlated with chronic rhinosinusitis; however, they
found no association between accessory maxillary ostia and chronic
rhinosinusitis.16
Genc et al. examined 10 rabbits in New Zealand and found the development
of accessory maxillary ostia after inducing
sinusitis.17 Accessory ostia can develop when mucosal
oedema obstruct main ostia and when chronic sinusitis or other
anatomical or pathological factors in the middle meatus disrupt ciliary
movement, rupturing membranes in the lateral nasal
wall.7 The formation of accessory ostia could sustain
sinus mucosa inflammation by enabling the recirculation of mucus between
adjacent openings, leading to the chronic recurrence of
sinusitis.18 This study showed that patients with
accessory maxillary sinus ostia in the superior meatus did not have a
higher Lund–Mackay score compared with patients without accessory
ostia. A possible inference is that accessory maxillary sinus ostia in
the superior meatus are a congenital anatomical variation that do not
obstruct the mucociliary clearance of the maxillary sinus. In fact, they
may improve the mucus circulation of the maxillary sinus. Our results
suggest that patients with accessory maxillary sinus ostia in the
superior meatus may have an advantage in not being susceptible to
chronic rhinosinusitis. For a surgeon, this information may indicate
that patients with this anatomy will have better disease outcomes.
However, as accessory maxillary sinus ostia may alternatively be
individual anatomic variations of no clinical importance, it is
essential to further investigate accessory maxillary sinus ostia in the
superior meatus of healthy subjects and in those with chronic maxillary
sinusitis.
This study is subject to certain limitations given its retrospective
nature and use of radiographic data. The research design does not
examine the exact causal relationship between sinusitis and accessory
maxillary sinus ostia in the superior meatus. In addition, the study is
based on a small sample size and a single-centre design. However, the
sample size is large enough to demonstrate statistical significance.
While there are several studies that have explored maxillary sinus
anatomy and its variations, no clinical research has been conducted on
accessory maxillary sinus ostia in the superior meatus. This study is
the first to investigate the accessory maxillary sinus ostia in the
superior meatus and their incidence in patients with clinical and
radiological signs of maxillary sinusitis.