Antral puncture and Lavage

Submitted by drtbalu on Tue, 11/27/2018 - 02:52
higginson syringe

This procedure is done for diagnosis as well as treatment of sinusitis.  This procedure involves introduction of a canula into the maxillary sinus cavity via an opening made in the inferior meatus.  This procedure is rather out moded these days.  One reason that could be stated for failure of this procedure is that maxillary sinus drainage is not dependent on gravity assisted drainage to drain away its secretions.  Drainage of maxillary sinus on the other hand is dependent on the ciliary beat of the cells lining the sinus mucosa.  These cilia always beat towards the natural ostium which is situated in the middle meatus.  It is this beating cilia that propels the secretions towards the middle meatus.  Even if an antrostomy opening is created in the inferior meatus still the secretions are pushed towards the natural ostium.

Components of Tilley Lichtwicz trocar and canula:

1. Sharp trocar

2. Canula which is available in three different sizes 1mm, 2mm and 3mm.  The trocar will smoothly slide into the canula.

3. Connecting adapter if antral wash bulb is preferred to propel water instead of a syringe

Diagnostic uses of antral lavage:

Proof puncture: This is done if radiological evidence points to sinusitis.  The wash material collected can be sent for culture and sensitivity.

Therapeutic uses:  The infected secretions pent up inside the maxillary sinus cavity is cleared by antral lavage.

Procedure:

The patient should be comfortably seated in a chair with back support.  Eye pad should be used to blind the patient.

It is usually done under local anesthesia.  The nerves blocked during anesthesia include:

1. Superior alveolar nerve near the inferior meatus

2. Anterior ethmoidal nerve near the roof of the nose

3. Posteriorly the sphenopalatine ganglion

Anesthesia is usually produced by introducing cotton pledgets soaked in 4% xylocaine with 1 in 100000 adrenaline in the Inferior meatus.  One more pledget can be placed under the lip on the side where the procedure is planned. 

The Tilley Lichtwitz trocar and canula is passed under the attachment of inferior turbinate and is directe towards the outer canthus of the ipsilateral eye.  With a firm turn the inferior meatus is puncturd.  While intruducing index finger of the surgeon should be placed at the junction of anterior 1/3 and posterior 2/3 of the trocar canula assembly.  This will help in ensuring the safe penetration depth.   The trocar is gently removed leaving the canula in position.  A syringe is connected to the cannula and aspiration is attempted.  If it is inside the maxillary sinus secretions could be aspirated.  If the sinus is empty then air will be aspirated.  If gross blood is aspirated then it should be construed that the canula is not inside the maxillary sinus cavity.  A higginsons syringe which contains a bulb and an one way valve is connected to the canula and the other end of the syringe is placed inside a vessel containing water at body temperature.  Flushing can be performed by squeezing the bulb of higginson syringe. Dilute potassium permanganate wash can also given.  Three successive washes should be given.  A kidney tray should be held under the patient's mouth.  The patient can be asked to hold the tray so that their mind will be diverted from the actual procedure.  When the antrum is being flushed the patient should be asked to keep the mouth open so that fluid used for irrigation will drain through the patient's mouth.

Complications:

1. Bleeding

2. Orbital damage.  Perfortion of orbital floor will cause proptosis and pain

3. Cheek swelling:  This is caused by breaching the soft tissue of the cheek and the anterior wall of the sinus.

4. Air embolism due to injury to veins

5. Infection of maxillary sinus

6. Vaso vagal shock

Contraindicatins:

1. Should not be done in children below the age of 3 because the maxillary sinus cavity is very small hence injury to orbit and unerupted teeth is quite common

2. Acute sinusitis

3. Traumatic conditions damaging the floor of orbit and maxilla

 

trocar

 

 

antral puncture

 

Image showing antral wash

 

wash

 

Antral puncture

 

 

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