Antral lavage explained

Antral lavage
Specialty:	Otorhinolaryngology

Antral lavage is a surgical procedure in which a cannula is inserted into the maxillary sinus via the inferior meatus to allow irrigation and drainage of the sinus.^[1] It is also called proof puncture, as the presence of an infection can be proven during the procedure. Upon presence of infection, it can be considered as therapeutic puncture.^[2] Often, multiple repeated lavages are subsequently required to allow for full washout of infection.

In contemporary practice, endoscopic sinus surgery has largely replaced antral lavage and as such, it is rarely performed.

Medical uses

It can be used as therapeutic procedure for:

• Acute and chronic maxillary sinusitis not responding to medical treatment.^[3]
• Chronic infections not responding to treatments.^[4]
• Irrigating and washing out collected purulent secretions.^[5]
• Dental maxillary sinusitis.^[6]
• Oro-antral fistula if associated with sinusitis.^[7]
• Acute Bacterial Rhinosinusitis. Though it is indicated only in severe cases not as a regular treatment.^[8]

It can be also used as diagnostic procedure for:

• Carrying out culture and sensitivity test if the returning fluid is mucopurulent or purulent in Chronic Sinusitis.^[9]
• Exfoliative cytology of the returning fluid to rule out any malignancy.

Contraindications

Age: Below the age of 3 years, as the size of the sinus is small due to underdeveloped Maxillary Sinus.^[10]

Bleeding disorders: May lead to epistaxis.

Fracture of maxilla: Antral Lavage may result in escape of the fluid through fracture lines.

Febrile stage of acute maxillary sinusitis: May cause osteomyelitis of Maxilla.

Procedure is contraindicated in diabetic and hypertensive patients.

Acute maxillary sinusitis not resolving on medical treatment.^[1]

Instruments

The following instruments are used in the procedure:^[11]

• Tilley's Forceps
• Lichtwitz Antral Trocar Cannula
• Higginson's Rubber Syringe
• Nasal Speculum

Diagnosis of antral pathology

1. Watery, amber color fluid flowing from cannula, immediately on puncture and containing cholesterol crystals, indicates presence of cyst.
2. Blobs of mucopus in washings indicates hyperplastic sinusitis.
3. Presence of frank, foul-smelling pus, which easily mixes with irrigating fluid indicates suppuration and in such cases, antral wash may be repeated once or twice a week.^[12]
4. Plain Radiological X-rays (Water's view) of sinuses is most specific non- invasive method of diagnosing Antral pathology.^[13]

Difficulties

The following difficulties may arise during antral lavage:

• Hard Bone: The wall of the maxillary sinus may be hard, rendering the procedure difficult.
• Touching the posterior wall of the sinus by the tip of the cannula may block the cannula and the fluid may not return on pumping the higginson syringe. The cannula is slightly withdrawn and it becomes patent.
• Blocked ostium: If the ostium of the sinus is blocked, the fluid doesn't return through it. To bypass the ostium, one more trocar and cannula are inserted at the site of the first one, a fluid returns through the other cannula.

Complications

1. Vasovagal shock: Due to over stimulation of the vagus nerve, the patient may become pale, may faint and fall down and the pulse rate may decrease.
2. Bleeding may occur at the site of the puncture which stops in a short time with cotton wool plug.
3. False passages into cheek or orbit leading to emphysema or extravasation of fluid into the cheek or lower eyelid or orbit. Also may lead to cerebrospinal fluid leak and haematoma.^[14]
4. Infection in the maxillary sinus is common.
5. Anaesthetic complications may occur.
6. Air embolism.^[15]

Repetition

If the returning fluid is purulent, one repeats the puncture after a week. If more than three successive puncture shows returning fluid to be persistently purulent, the patient may require functional endoscopic sinus surgery (FESS) and occasionally may need Caldwell-Luc operation.

As antral Washout is a much simpler procedure compared to FESS, it may be done on an outpatient basis for Subacute Maxillary Sinusitis. However, FESS remains gold standard in treatment of Chronic Maxillary Sinusitis.^[16]

Post operative

1. Patient lies down for 10–15 minutes after operation and pack is removed after an hour.
2. Antibiotic should be given for 5–6 days in cases of suppuration depending upon culture and sensitivity.^[17]
3. Oral and local decongestant are given to improve the patency of ostium.^[18]
4. Analgesics may be required for post-operative headache.

Newer techniques

• Luma Wire Transillumination: This technique has a number of advantages^[19] over antral Lavage, such as:

1) Discovery of the location of the Maxillary Sinus with greater accuracy.

2) A general improvement in safety of the procedure.

3) The ability to obtain cultures at the time of lavage, when clinically warranted or indicated by CT-scan evidence.

4) Avoiding the need for exposure to radiation, as fluorescence is used in its stead.

5) Lack of interference in anatomy.

• Functional Endoscopic Sinus Surgery (FESS) is one of the newer modalities in treatment of Chronic Sinusitis. However, it is not first line of treatment as it may lead to massive bleeding. It allows ventilation and drainage of inflamed or infected sinuses and restoration of mucociliary clearances. It has proven to be very effective in treatment of acute and chronic sinusitis.^{[20] [21]}

Notes and References

1. Book: Lt Col BS Tuli. Text book of Ear, Nose & Throat. 2005. Jaypee Brothers Medical Publishers . 978-81-8061-446-0. 495, 496, 497. First.
2. Book: Maheshwari. Dr.Sharad. Kumar. Dr.Subirendra. TEXTBOOK of E.N.T.. 2003. ARYA PUBLICATIONS. 978-81-7855-128-9. 333. First.
3. Ramadan. HH. Owens. RM. Tiu. C. Wax. MK. Role of Antral Puncture in treatment of sinusitis in the intensive care unit.. Otolaryngol Head Neck Surg. 1998. 119. 4. 381–4. 9781995. 10.1016/s0194-5998(98)70083-x. 22678588 .
4. Book: Bhargava. S.K. Bhargava. K.B. Shah. T.M. A Short Textbook of ENT Diseases. 2002. Usha Publications. 978-8190098434. 183–5. 6.
5. Jibiinkoka. Nihon. Gakkai. Kaiho. Bacterial examination of sinusitis using antral puncture and irrigation. Sep 2002. 105. 9. 925–30. 12400169. 10.3950/jibiinkoka.105.925. Nihon Jibiinkoka Gakkai Kaiho. free.
6. Christensen. O. Gilhuus Moe. O. Surgical treatment of chronic hyperplastic sinusitis and maxillary sinus empyema of oral/dental origin.. International Journal of Oral Surgery. 1979. 8. 4. 276–282. 120331. 10.1016/s0300-9785(79)80049-6.
7. Web site: Elwany. Samy. Procedures and operations of nasal and Paranasal sinuses.
8. Toran . KC . Is Antral Washout really indicated in Acute Bacterial Rhino Sinusitis . Nepalese Journal of ENT Head and Neck Surgery . 2010 . 1 . 1 . 12–13 . 10.3126/njenthns.v1i1.4730 . free .
9. Greval. RS. Khurana. S. Goyal. SC. Incidence of fungal infections in chronic maxillary sinusitis. Indian Journal of Pathology & Microbiology. 1990. 33. 4. 339–343. 2132501.
10. Book: Bansal. Mohan. Diseases of ear, nose and throat : head and neck surgery. 2013. Jaypee. New Delhi. 9789350259436. 561. 1.
11. Book: De. S.K. Surgery ENT Head and Neck. 2005 . New Book Stall . 978-8187447160.
12. Adachi. M. Furuta. S. Suzuki. S. Maeda. T. Bacterial examination of sinusitis using antral puncture and irrigation. Nihon Jibiinkoka Gakkai Kaiho. Sep 2002 . 105. 9. 925–930. 12400169. 10.3950/jibiinkoka.105.925. free.
13. Ezeanolue. BC. Nwagbo. DF. Aneke. EC. Correlation of plain radiological diagnostic features with antral lavage results in chronic maxillary sinusitis. West Africa Journal of Medicine. 2000. 19. 1. 16–18. 10821080.
14. Book: Jackson. J.P.. A Practical Guide to Medicine and the Law. 1991. Springer London. London. 9781447118633. 296. 1.
15. Thomson. K.F.M. Air embolism following antral lavage. The Journal of Laryngology & Otology. 29 June 2007. 69. 12. 829–832. 10.1017/S0022215100051483. 13278643. 37334672 .
16. Muthubabu. K. Srinivasan. MK. Sakthivel. M. Kumar. Kiran. Kumar. Arvindh. Comparison of endoscopic sinus surgery and antral wash out in the management of subacute and chronic maxillary sinusitis. International Journal of Medical Research & Health Sciences. 2014. 4. 2. 302–4. 10.5958/2319-5886.2015.00056.9.
17. Axelsson. A. Chidekel. N. Grebelius. N. Treatment of acute maxillary sinusitis. A comparison of four different methods. Acta Oto-Laryngologica. 1970. 70. 1. 71–6. 4989705. 10.3109/00016487009181861.
18. Malm. L. Pharmacological background to decongesting and anti-inflammatory treatment of rhinitis and sinusitis.. Acta Oto-Laryngologica Supplementum. 1994. 515:53–5. 7520660. 515. 10.3109/00016489409124325.
19. Zeiders. JW. Dahya. ZJ. Antral lavage using the Luma transilluminaton wire and vortex irrigator--a safe and effective advance in treating pediatric sinusitis.. International Journal of Pediatric Otorhinolaryngology. 2011. 75. 4. 461–3. 10.1016/j.ijporl.2010.11.021. 21295864.
20. Stammberger. H. Endoscopic endonasal surgery--concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and pathophysiologic considerations.. Otolaryngology–Head and Neck Surgery. 1986. 94. 2. 143–7. 3083326. 10.1177/019459988609400202. 34575985.
21. Stammberger. H. Endoscopic endonasal surgery--concepts in treatment of recurring rhinosinusitis. Part II. Surgical technique. Otolaryngology–Head and Neck Surgery. 1986. 94. 2. 147–56. 3083327. 10.1177/019459988609400203. 10542945.