Pathophysiology of current odontogenic maxillary sinusitis and endoscopic sinus surgery preceding dental treatment.

OBJECTIVE: The successful management of odontogenic maxillary sinusitis (OMS) involves a combination of medical treatment with dental surgery and/or endoscopic sinus surgery (ESS). However, there is no consensus for the optimal timing of ESS. Although several studies have emphasized dental surgery as the primary treatment modality for OMS, there is recent evidence to suggest that ESS alone may be an effective treatment approach. The purpose of this study is to retrospectively investigate the pathophysiology of the current intractable OMS and the role ESS, especially ESS preceding dental treatment, plays in its pathophysiology. METHODS: Ninety-seven adults (60 males and 37 females, 48 ± 12 years) who underwent ESS for intractable OMS were retrospectively examined. RESULTS: In a great deal of the cases (85 cases, 87.6%), causative teeth of OMS were periapical lesions after root canal treatment (endodontics). The root canal procedures were not sufficient; hence, the root-canal-treated teeth had periapical lesions causing OMS. In postoperative nasal endoscopy and cone-beam CT scans for all patients, the natural ostiums and the membranous portions of the maxillary sinuses were enlarged and the ostiomeatal complexes remained widely open. The ventilation and drainage of all patients' maxillary sinuses seemed to be successfully restored. Temporary acute sinusitis recurrence after primary ESS for OMS was observed in 10 cases (11.8%) when the patients caught a cold. However, since the natural ostium and the membranous portion of the maxillary sinuses and the ostiomeatal complexes remained widely open, antibiotic administration alone without dental treatment cured the temporary acute sinusitis. Regarding the causative teeth (endodontic treated teeth), in 83 out of 85 cases (97.6%), causative teeth were able to be preserved with only antibiotic treatment and without dental retreatment. In two cases, extraction of the teeth was necessary because the teeth became mobile. Regarding the causative teeth after dental restoration, in 2 out of 2 cases (100%), causative teeth were able to be preserved with antibiotic treatment alone. CONCLUSION: ESS is highly indicated for OMS requiring surgery. The treatment results of intractable OMS are exceptionally good once the ventilation and drainage of the maxillary sinus is successfully restored after surgery. Consequently, ESS can be considered the first-line therapy for intractable OMS caused by root canal treatment (endodontics) and dental restoration, followed by close dental follow-up and dental treatment when necessary.

Fungal ball of the maxillary sinus and the risk of persistent sinus dysfunction after simple antrostomy.

BACKGROUND: Maxillary sinus fungal ball is a common cause of unilateral maxillary sinusitis. Fungal balls or mycetomas are primarily treated with surgery to remove the fungus. However, this assumes the pre-fungal ball sinus cavity was normal and post-surgery patients may suffer from mucostasis in the sinus cavity with persistent symptoms. It is proposed that fungal balls are potentially a feature of impaired mucus clearance as they are a pathology in their own right. METHODS: A case series of consecutive patients undergoing antrostomy for maxillary sinus fungal ball was performed. Patient factors including age, gender, smoking status, comorbidities (allergy, asthma, and reflux), disease specific factors including duration of symptoms, microbiology (bacterial co-infection, Gram-positive and/or Gram-negative) and preoperative radiologic findings (extent of sinus development, and neo-osteogenesis/bone thickness) were collected. The primary outcome was sinus function defined by evidence of a normal functioning maxillary sinus, with the absence of mucostasis or pooling, on endoscopic exam at three months, six months and last follow-up. Endoscopic evaluation of inflammation was also collected. RESULTS: 28 patients (age 58.5 ± 15.5 years, 64.3% female) were assessed. Mucostasis was present at three months in 39.3%, at six months in 32.1%, and 17.9% at last follow-up. There was no comorbidity or radiologic finding that was associated with failure to normalize. Those patients with mucostasis had a higher modified Lund-Mackay endoscopic score at last follow-up (5.0 ± 0.7 v 0.2 ± 0.6, p < 0.01). CONCLUSIONS: Long term post-operative mucostasis occurred in 17.9% of patients following an adequate maxillary antrostomy for treatment of a fungal ball. Patients with mucostasis had persistent mucosal inflammation and a greater need for further surgery (modified medial maxillectomy).

Challenges in diagnosing odontogenic lesions in maxillary sinuses.

<b>Objectives:</b> The study aimed to identify the patients with pathological lesions in the maxillary sinuses in which the reported symptoms might be indicative of odontogenic origin, as well as to establish specific causative risk factors promoting their development. <br><b>Methods and Materials:</b> The study covered 44 patients with suspected odontogenic maxillary sinusitis. Dental examination and Cone Beam Computed Tomography were completed. The age of patients ranged between 19 and 69 years, and the mean age was 43 (SD = 13.9) years. <br><b>Results:</b> Out of 44 patients, 22 (50%) had non-odontogenic lesions in maxillary sinuses, while in 15 (34.1%) dental origin was established. In the remaining 7 (15.9%) patients, no pathological changes were found in the sinuses. The median of reported symptoms was 10 months (Q1 = 4, Q3 = 24). The reported complaints were not associated with the actual cause of pathological lesions. <br><b>Conclusions:</b> Odontogenic cause of the lesions in the sinuses should primarily be hypothesized, especially in patients with long-term disease symptoms, also regarding any unilateral inflammations.

Clinical implications of taste thresholds in patients with odontogenic maxillary sinusitis.

Patients with odontogenic maxillary sinusitis (OMS) often complain of reduced taste sensitivity as well as nasal obstruction. The filter paper disc method (the conventional gustatory test) was applied to nine patients who underwent sinus surgery to open the inferior nasal meatus and sinus drainage, on three different days: 1day prior to surgery, 7days postoperative, and 28days postoperative. The same test was applied to nine non-clinical participants with or without clipping the nose to interfere with smooth nasal airflow on two different days. Acquired recognition thresholds for the four basic tastes of sweet, salty, sour, and bitter were assessed. In OMS patients, the recognition thresholds for all four tastes were markedly decreased at 7 and 28days postoperative, and subjective taste sensitivity and the elimination of nasal obstruction was improved. The mean recognition threshold for the four tastes correlated negatively with taste satisfaction scores. Clipping the nose in non-clinical participants induced increases in gustatory detection and recognition thresholds. Despite the small sample size and different ages and sexes of the study subjects, it was demonstrated that nasal obstruction in OMS patients and nose clipping in non-clinical subjects reduce taste reactivity, and surgical intervention to promote nasal airflow recovers impaired taste reactivity.

[Clinico-anamnestic diagnostics of chronic maxillary sinusitis associated with chlamydial infection]. / Kliniko-anamnesticheskaya diagnostika khronicheskogo verkhnechelyustnogo sinusita, assotsiirovannogo s khlamidiinym infitsirovaniem.

The present study included 201 adult patients presenting with exacerbation of chronic maxillary sinusitis. The presence of Chlamydia trachomatis and Chl. pneumoniae was verified by the direct immunofluorescencetechnique and polymerase chain reaction. The study material consisted of swipes und swabs from the mucous membrane of the middle nasal passage. The information from the patients was collected with the use of a questionnaire specially elaborated for the purpose of this study. The correlation relationships were established by means of gamma-statistics. The method is based on the calculation of the integral index characterizing the risk of development of chlamydial infection using the scoring scale for the evaluation of the clinical and anamnestic characteristics of the patients. The assessment of the risk of chlamydial colonization by the anamnestic method makes it possible to enhance the effectiveness of clinical diagnostics of chlamydial infection and thereby provides a basis for the prescription of the adequate anti-chlamydial treatment facilitating reduction of the frequency of complications and preventing dissemination of the causative factor of the disease. Moreover, this approach creates the conditions for the targeted selection of the patients to be referred to the laboratory verification of Chlamydia. Highoperating performance and effectiveness characteristics of the clinic-anamnestic diagnostics make it a method of choice for the wide application in the clinical practice.

[The influence of accessory ostia on the development and the course of the inflammatory processes in the maxillary sinuses].

The objective of the present study was to detect accessory ostia in the patients presenting with various diseases of the maxillary sinuses. We undertook the endoscopic examination of the middle meatuses in 250 patients. It was shown that accessory ostia can be especially frequently seen in the patients with chronic maxillary sinusitis and nasal septum deviation.

[The experience with the application of a lyophilized xenodermograft for the treatment of the patients suffering from frequently recurring inflammation of the maxillary sinus in combination with alveolar fistula].

The objective of the present study was to summarize the data of the special literature concerning methods of the surgical treatment of odontogenic maxillary sinusitis complicated by the alveolar fistula with the purpose of using them for the improvement of the effectiveness of the treatment of the patients presenting with this pathology. The study group was comprised of 39 patients with odontogenic diseases of paranasal sinuses and alveolar fistulas. The alveolar fistulas were closed in 20 patients by means of plastic surgery with the use of a lyophilized xenodermograft prepared from the pig's skin. Not a single case of relapse of the inflammatory process in the maxillary sinuseswas documented within one year after the treatment by means of the closure of the alveolar fistula using the lyophilizedxenodermografts.

Endoscopic sinus surgery in individuals with facial pain due to chronic maxillary sinusitis ? a functional controlled study / Cirurgia endoscópica de seio da face em indivíduos com dor facial devida a sinusite maxilar crônica ? um estudo funcional controlado

Objective: To measure the intra-sinus pressure and the maxillary sinus functional efficiency (MSFE) in individuals with chronic facial pain after conservative or conventional endoscopic maxillary surgery, as well as in controls. Method: Sinus manometry was performed 5 times during inhalation. Results: The resemblance of pressure values comparing those treated with minimally invasive surgery and controls was remarkable, while traditional surgery significantly decreased intrasinusal pressures. The MSFE was 100% in the three tested times for controls, close to that in those submitted to minimally invasive surgery (98.3%, 98.8%, and 98.0%) and significantly impaired after conventional surgery (48.8%, 52.1%, 48.5 %, p<0.01). All patients submitted to minimally invasive surgery remained pain-free after three months of surgery, relative to 46.7% of the submitted to conventional surgery (p<0.05). Conclusion: Minimally invasive sinus surgery is associated with functionality of the chambers that resemble what is found in normal individuals. .

Objetivo: Medir a pressão intrasinusal e a eficiência funcional do seio maxilar (EFSM) em indivíduos com dor facial crônica após cirurgia endoscópica maxilar conservadora ou convencional em comparação a pessoas normais. Método: A manometria do seio foi feita 5 vezes durante a inalação. Resultados: A semelhança entre os valores das pressões comparando aqueles tratados com cirurgia minimamente invasiva e os controles foi notável, enquanto que na cirurgia tradicional houve diminuição significativa das pressões intrasinusais. A EFSM foi 100% nas três vezes testadas nos controles, de modo muito semelhante ao que foi observado naqueles submetidos a cirurgia minimamente invasiva (98,3%, 98,8%, e 98,0%) e significativamente diminuída naqueles submetidos a cirurgia convencional (48,8%, 52,1%, 48,5 %, p<0,01). Todos os pacientes submetidos a cirurgia minimamente invasiva mantiveram-se sem dor três meses depois da cirurgia, comparados a 46,7% naqueles submetidos a cirurgia convencional (p<0,05). Conclusão: Cirurgia minimamente invasiva está associada a funcionalidade das câmaras sinusais que se assemelha ao que é observado em indivíduos normais. .

Endoscopic sinus surgery in individuals with facial pain due to chronic maxillary sinusitis - a functional controlled study.

OBJECTIVE: To measure the intra-sinus pressure and the maxillary sinus functional efficiency (MSFE) in individuals with chronic facial pain after conservative or conventional endoscopic maxillary surgery, as well as in controls. METHOD: Sinus manometry was performed 5 times during inhalation. RESULTS: The resemblance of pressure values comparing those treated with minimally invasive surgery and controls was remarkable, while traditional surgery significantly decreased intrasinusal pressures. The MSFE was 100% in the three tested times for controls, close to that in those submitted to minimally invasive surgery (98.3%, 98.8%, and 98.0%) and significantly impaired after conventional surgery (48.8%, 52.1%, 48.5 %, p<0.01). All patients submitted to minimally invasive surgery remained pain-free after three months of surgery, relative to 46.7% of the submitted to conventional surgery (p<0.05). CONCLUSION: Minimally invasive sinus surgery is associated with functionality of the chambers that resemble what is found in normal individuals.

Acute rhinosinusitis (ARS). Diagnosis and treatment of adults in general practice.

The idea behind this thesis is to present how ARS and especially acute maxillary sinusitis in adults is diagnosed and treated in general practice. The study extends over many years, beginning with the first survey in 1991. Based on doctors' answers, we then investigated the diagnostic values ​​of the symptoms, signs and examinations which the doctors reported using. All patients over 18 years suspected of acute maxillary sinusitis were included consecutively and only once and, after a clinical examination with the GP, they were offered the opportunity to enter into the prospective study referred to acute CT scan and by changes in the CT, immediately referred to sinus puncture. Both examinations were conducted at Aalborg Hospital. The disease was found most frequently in younger and 2/3 were women. The reason for this gender difference is unknown. We have assessed the diagnostic values of the symptoms, objective findings and investigations ​​using 3 different reference standards: sinus puncture, microbiological diagnosis and CT scan described in three articles. In all examinations, it appeared that the usual signs and symptoms of acute maxillary sinusitis occur almost equally often and with a few exceptions in patients, with and without pus in the sinus cavities. Pain in the sinus cavities occurring in 95% of patients, and only elevated levels of CRP and ESR are significantly and independently associated with pus in the sinus cavities. This finding is surprising, because they are two nonspecific markers. CRP tested by near-patient testing has, within the investigations period, been introduced in general practice, and from 1999 the doctors also get reimbursed for performing the test. We have on this background originally defined a clinical criterion with pain over the sinuses accompanied by elevated values ​​of CRP and/or ESR giving a sensitivity of 0.82, specificity 0.57, ppv 0.68 and npv 0.74. But looking at the ROC curve we suggest that a more clinical relevant diagnose will be based on use of CRP alone, as the test can be made easily and fast while the patient is in the clinic compared to the use of ESR. The disease is over-diagnosed in general practice. In only 53% of patients, who the GP suspected of having acute sinusitis, was there detected pus or mucopus at the sinus puncture, furthermore the patients' statements that they had had sinusitis was significantly negatively associated with current acute maxillary sinusitis. Almost all patients are prescribed topical treatment to the nose in the form of vasoconstrictor, and 50-70% also antibiotics. The most common bacteria that can be isolated are S. pneumoniae and H. influenzae. For many years the first drug of choice has been penicillin V, and treatment with penicillin V has followed Scandinavian recommendations. However, the resistance patterns in respect of H. influenzae have changed over the years and if the dominant flora is H. influenzae, then oral penicillin is not sufficient anymore, and should be replaced by amoxicillin with or without clavulanate. It is reported that the MIC of penicillin V is too high, such that oral dosage cannot provide sufficiently high concentrations. However, in daily clinical practice the doctor does not have the possibility to decide whether the infection is caused by either S. pneumoniae or H. influenzae, unless a sinus puncture is performed and it is not considered as a standard procedure. The recommended treatment is therefore starting with penicillin V, and at treatment failure switching to amoxicillin with or without clavulanate. It is well known that URTI's can exacerbate a chronic pulmonary disease - like asthma - in allergic patients, but this influence is also demonstrated as described in article 6 where ARS in adults without any sign of chronic lung disease or allergy is accompanied by a temporary reduction lung function. Future research should focus on the use of CRP in general practice, analysing cost-effectiveness of the use of CRP patient outcome in relation to antibiotic treatment, clarification of ARS as a female disease, and a detailed exploration of the relationship between URTI's and impaired lung function in lung-healthy patients.

Medial maxillectomy in recalcitrant sinusitis: when, why and how?

PURPOSE OF REVIEW: We reviewed all journal articles relevant to endoscopic medial maxillectomy in patients with recalcitrant chronic maxillary sinusitis in order to present all indications, the underlying pathophysiology and the developed surgical techniques. RECENT FINDINGS: Despite the high success rate of middle meatal antrostomy, cases with persistent maxillary sinus disease exist and often need a more extended endoscopic procedure for the better control of the disease. Such surgical option uses gravity for better sinus drainage and offers better saline irrigation, local application of medications and follow-up inspection. An endoscopic medial maxillectomy and its modified forms offer a wider surgical field and access to all 'difficult' areas of the maxillary sinus. SUMMARY: Patients with previous limited endoscopic sinus surgery or extended open surgery, cystic fibrosis, extensive mucoceles, allergic fungal sinusitis, odontogenic infections, foreign bodies and so on may suffer from recurrent disease requiring an endoscopic medial maxillectomy. Depending on the disease, various modifications of the procedure can be performed preserving the anterior buttress, nasolacrimal duct and inferior turbinate if possible.

Quadrupedal head position enhances recovery from chronic maxillary sinusitis.

OBJECTIVES: The position of human maxillary ostia is high on their superomedial walls, which may be suboptimal for natural drainage. Human maxillary sinuses exhibit better passive drainage through their ostia when tilted anteriorly to mimic a quadrupedal head position. We all know that sufficient drainage is very important for the treatment of chronic rhinosinusitis (CRS). Chronic maxillary sinusitis (CMS) is the high incidence of CRS. The aim of this study was to investigate the efficacy of quadrupedal head position in patients with CMS. METHODS: One hundred six patients diagnosed with CMS were enrolled. Patients were randomized to quadrupedal head position group and non-quadrupedal head position group for 6 weeks of treatment. Treatment outcomes were measured using 1) Lund-Mackay scoring system of pre-and post-treatment computer tomography (CT); and 2) Sinonasal Quality-of-Life (QoL) Survey completed at baseline and 6 weeks of therapy. RESULTS: There were statistically significant differences in QoL scores and CT scores between quadrupedal head position group and non-quadrupedal head position group. The quadrupedal head position group had much more improvements in QoL scores and CT scores than that of non-quadrupedal head position group. One patient in the quadrupedal head position group required functional endoscopic sinus surgery (ESS) due to persistent symptoms, and nine patients in non-quadrupedal head position group needed ESS. There were less patients that required ESS in the quadrupedal head position group than in the non-quadrupedal head position group. CONCLUSIONS: The improvements of QoL scores and CT scores were significantly better in the quadrupedal head position group than that in the non-quadrupedal head position group. Quadrupedal head position can be valuable adjuvant therapy for patients with CMS.

Recirculación en rinosinusitis maxilar / Mucus recirculation in maxillary rhinosinusitis

Introducción: La recirculación de moco entre el ostium natural del seno maxilar y otras aberturas en el seno, altera el transporte mucociliar normal, favorece su acumula-ción y sobreinfección, perpetuando el fenómeno inflamatorio. Objetivo: Describir nuestra experiencia en el diagnóstico y tratamiento de pacientes con rinosinusitis maxilar crónica y/o aguda recurrente cuyo estudio reveló recirculación maxilar. Material y método: Estudio retrospectivo descriptivo. Se revisaron historias clínicas, nasofibroscopías, informes radiológicos y hallazgos operatorios. Resultados: Ocho pacientes con edad promedio de 43 años. El 100%% presentó antecedente de cirugía que involucraba el seno maxilar. Todos se presentaron como rinosinusitis maxilar crónica y/o aguda con reagudizaciones frecuentes (3 episodios/ año). El diagnóstico se realizó mediante nasofibroscopía que evidenció recirculación de moco entre ostium natural y accesorio. Cinco pacientes se sometieron a cirugía endoscópica para unir el ostium accesorio (OA) al natural, disminuyendo el número de exacerbaciones. Conclusión: La recirculación maxilar se debe sospechar en pacientes con diagnóstico de rinosinusitis maxilar crónica y/o aguda recurrente con antecedente de cirugías que involucren el seno maxilar. Su diagnóstico se basa en la observación de recirculación de moco a la nasofibroscopía. El manejo es quirúrgico y dependerá de la ubicación del OA y de la permeabilidad del ostium natural.

Introduction: Recirculation of mucus between the maxillary sinus natural ostium and adjacent openings disturbs mucociliary clearence leading to secretions accumulation and persistent infection, perpetuating the inflammatory phenomenon. Aim: Describe our experience in the diagnosis and treatment ofpatients with maxillary rhinosinusitis (chronic or acute recurrent) and maxillary recirculation. Material and method: Descriptive and retrospective study. Clinical records, radiologic characteristic, nasal endoscopies and surgical findings were reviewed. Results: 8 patients, mean age of 43 years. All of them had prior history of maxillary sinus surgery. Clinical presentation was maxillary rhinosinusitis, chronic or acute, with frequent episodes ofreagudization (3 episodes/year). The diagnosis was made by endoscopic nasal examination that showed mucus recirculation between natural and accessory ostium. Endoscopic sinus surgery was done in 5patients in order to communicate the accessory to the natural ostium, leading to a decrease in the number of exacerbations. Conclusions: Maxillary recirculation must be suspected in patients with maxillary rhinosinusitis (chronic or acute recurrent) who have had prior surgical procedures that involve the maxillary sinus. The diagnosis is based on the observation of the recirculation phenomenon in the nasal endoscopy. The treatment is surgical and depends on the location of the accessory ostium and the permeability of the natural ostium.

[The efficacy of rinopront for the treatment of acute and chronic rhinitis in the children].

The objective of the present study was to estimate the therapeutic efficacy of rinopront used to treat inflammatory diseases of the nasopharynx in the children. The study included 32 patients at the age between 12 and 14 years presenting with various forms of acute and chronic rhinitis. The children with infectious inflammatory rhinitis with concomitant catarrhal maxillary sinusitis and pronounced symptoms of rhino-conjunctival syndrome recovered within 4-5 days after the initiation of rhinopront therapy. The patients presenting with vasomotor and all-the-year-round allergic rhinitis needed two courses of treatment (5 days each) to recover. The duration of treatment of mild seasonal rhinitis was 4 days whereas the moderately severe disease required the second 5-day course of therapy to be performed to arrest the disease activity.

Changes in intramaxillary sinus pressure following antrostomy, draining tubes, and YAMIK procedures in 25 patients treated for chronic paranasal sinusitis.

When conservative therapies are not effective in treating sinus infections, alternate steps can be taken to improve paranasal cavity ventilation. These measures may include surgical procedures such as intranasal endoscopic or maxillary sinus fenestration, and other procedures such as placement of a maxillary sinus tube or a YAMIK sinus catheter. We conducted a prospective study of 25 patients to investigate the effects on the nasal mucosa of improved ventilation between the nasal and paranasal cavities. We accomplished this by comparing (1) the results of simultaneously measured nasal cavity and intramaxillary sinus pressures before and after widening of ventilation openings, (2) changes in mucociliary transport function as measured by the saccharin test, and (3) changes in nasal airway resistance. Just as multiple transit routes between the nasal cavity and maxillary sinus give rise to greater fluctuations in intramaxillary sinus pressure, and just as rapid breathing gives rise to even greater pressure fluctuations than does quiet breathing, we believe that both intranasal cavity airflow velocity and the number of ventilation openings present have an effect on the state of ventilation between the nasal cavity and maxillary sinus. We also suggest that the establishment of maxillary sinus ventilation openings improves mucociliary clearance.

Endoscopic maxillary antrostomy: not just a simple procedure.

The endoscopic middle meatal maxillary antrostomy is one of the most commonly performed endoscopic procedures. Despite this, at our tertiary institution, we commonly see failed antrostomies requiring revision surgery. Accordingly, we describe in a stepwise fashion strategies helpful in creating a patent and naturally function maxillary antrostomy.

Silent sinus syndrome: a rare presentation after botulinum toxin injection.

Silent sinus syndrome is a unique diagnosis characterized by spontaneous enophthalmos and hypoglobus resulting from collapse of the orbital floor secondary to chronic subclinical sinusitis. Although reported in the ophthalmology and otolaryngology literature, there is no mention of silent sinus syndrome in the plastic surgery literature. The authors present a case report, along with a brief overview of silent sinus syndrome, so that knowledge of this rare but potentially devastating clinical entity may supplement plastic surgeons' differential to ensure proper diagnosis and treatment.

The effects of uncinectomy and natural ostial dilatation on maxillary sinus ventilation: a clinical experimental study.

The purpose of this study was to determine the effect of uncinectomy without sinusotomy and natural ostial dilatation on maxillary sinus ventilation in chronic rhinosinusitis. Twenty patients with chronic rhinosinusitis were included in this study. The patients were randomly divided into two groups. Group 1 consisted of patients with uncinectomy (n = 10), while group 2 was made up of patients treated with natural ostial dilatation (n = 10). The CO(2) tension and pressure levels of the maxillary sinus during inspiration and expiration phases were obtained and compared before and after the procedures within and between the groups. The mean CO(2) tension levels in both groups were significantly decreased after the procedures. The mean maxillary sinus pressure during inspiration was significantly decreased to a negative value after uncinectomy; however, no significant change was observed during expiration. There were no significant changes in maxillary sinus pressures after natural ostial dilatation procedure. Both uncinectomy and natural ostial dilatation seem to be equally effective in decreasing maxillary sinus pCO(2) levels. The effects of decreased maxillary sinus pressure during inspiration after uncinectomy on mucociliary clearance and development mechanisms of chronic rhinosinusitis seem to be worth investigating.

[The atypical course of subperiosteal abscess of the orbital wall].

The authors describe a clinical case of malformation of intranasal structures of the lateral wall and the middle turbinated bone of the nose (bullous middle turbinated bone, lateral position of the middle turbinated bone, hypertrophy of ethmoidal bulla and uncinate process) in combination with expressed deformation of the nasal septum. These malformations were responsible for the development of acute hemisinusitis complicated by subperiosteal abscess of the superomedial orbital wall. Conjunctival chemosis was impossible to remove by traditional medicamental therapy and surgical intervention. Hirudotherapy produced the well-apparent anti-odematous, anti-inflammatory, anti-coagulative, and thrombolytic effects that resulted in reduced conjunctival oedema and marked positive dynamics of the state of the eyeball. Subcutaneous administration of anticoagulants was used to prevent thrombosis of orbital veins and cerebral venous sinuses.