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Clinical Crossroads |

A 48-Year-Old Man With Recurrent Sinusitis

David W. Kennedy, MD, Discussant
JAMA. 2000;283(16):2143-2150. doi:10.1001/jama.283.16.2143.
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DR PARKER: Mr S is a 48-year-old businessman plagued by recurrent sinusitis for the last 21 years. Frequent infections interfere with his quality of life. He resides near Boston and is covered by commercial insurance.

Mr S first experienced allergies and sinus infections when he moved to Oregon 21 years ago. After monthly episodes of sinusitis for more than a year, he underwent septoplasty, cauterization, and creation of "surgical windows" for improved drainage. He remained free of sinus infections for 1 year. Mr S then noted a pattern of sinus infections starting in the fall and lasting through the early spring. This coincided with his seasonal allergies, and he has received 4 series of allergy shots.

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Figure 1. The Ostiomeatal Complex
Graphic Jump Location
A, Modified coronal plane at the level of maxillary sinus ostium demonstrates the concept of the ostiomeatal complex (superior shaded area). The frontal and maxillary sinuses must drain through this narrow, easily obstructed channel. B, Following functional endoscopic sinus surgery, the maxillary sinus ostium is widened and removal of ethmoid cells clears the ostiomeatal complex.
Figure 2. Endoscopic Views of the Left Nostril
Graphic Jump Location
A, View demonstrating large polyps (P) between the nasal septum (S) and the lateral nasal wall (LNW). The normal intranasal landmarks are obscured. B, View demonstrating more subtle and difficult to visualize polypoid disease confined to the middle meatus. There is a small polyp (P) in the middle meatus superiorly adjacent to and probably obstructing the frontal sinus outflow tract (arrow) in a patient with recurrent frontal sinusitis. C, View showing an enlarged middle turbinate (MT) resulting from mucosal disease within a concha bullosa. The turbinate markedly narrows the middle meatus where mucosal edema and purulence are present (arrows) and inferiorly the turbinate has become adherent to the nasal septum (arrowhead).
Figure 3. Coronal Sinus Computed Tomographic Image of Mr S
Graphic Jump Location
Image at the level of the maxillary sinus ostium (arrowheads) and ethmoid bulla. Both inferior meatal antrostomies are visualized (large arrows). There is some suggestion of mild mucosal thickening (small arrows) in both ostiomeatal complexes; however, this may represent image averaging.



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