Transnasal Endoscopic Medial Maxillary Sinus Wall Transposition with Preservation of the Inferior Turbinate and Nasolacrimal Duct

Objective: This study aims to evaluate the increase in access to the maxillary sinus with transnasal endoscopic medial maxillary sinus wall transposition (TEMMT).

Background: The medial maxillectomy approach provides good access to the maxillary sinus (MS); however, a large antrostomy may result in permanent drying and disruption in mucociliary clearance. The Caldwell-Luc approach also requires an external incision. Therefore, we propose the TEMMT approach as an alternative for benign disease, to decrease morbidity by preserving the inferior turbinate and nasolacrimal duct to maintain anatomy and sinonasal physiology.

Methods: The study was divided into the following two parts: anatomical and case series. Five heads were dissected (total of 10 sides) to confirm the feasibility of the TEMMT approach. Following, the procedure was performed in four consecutive patients with benign MS disease. In all cases, a vertical cut at the head of the inferior turbinate was performed. This allowed mobilization upward and exposure of the inferior meatus. Needle tip bovie was used to make an incision from the tail of the turbinate to the septum, crossing the floor of the nasal cavity. Then, the incision was carried anteriorly along the transition between the septum and the floor until the level of the head of the inferior turbinate. Finally, a cut was made from the septum, crossing the nasal floor toward the head of the inferior turbinate. The mucosa was elevated upward together with the inferior turbinate, allowing exposure of the nasal floor and the medial wall of the inferior meatus. A drill was used to open the maxillary sinus through the inferior meatus. A standard middle meatus maxillary antrostomy was also performed in all cases.

Results: The anatomical study showed feasibility of the TEMMT approach in all specimens with good exposure. In the patient series, patient 1 was a 52-year-old male patient who presented with a bony cyst of the right MS with complaints of recurrent sinusitis and retro-orbital pain. Patient 2 was a 51-year-old male patient with left sinus pressure and pain, found to have a large dentigerous cyst extending into the MS. Patient 3 was a 72-year-old female patient with a large right-sided antrochoanal polyp with insertion at the anterior wall of the MS. Patient 4 was a 50-year-old female patient with recurrent right facial cellulitis and a bony cyst arising from the inferior and anterior wall of the MS. The cyst wall and antrochoanal polyp were completely excised, except the inferior wall extending to the sinus floor to avoid risk of fistula. Excellent access into the MS, as well as preservation of the nasolacrimal duct and inferior turbinate were achieved in all cases. Finally, the mucosal flap was sufficient to cover the inferior meatal antrostomy.

Conclusion: TEMMT provides excellent access into the MS, especially the inferior and anterior wall, without the morbidities of Caldwell-Luc or medial maxillectomy approach. In addition, the transposition of the inferior turbinate and the mucosal flap provides coverage of the medial wall with preservation of the nasolacrimal duct and inferior turbinate for patients with benign MS disease.