Keywords
maxillary sinus - maxillary diseases - nasolacrimal duct - inferior turbinate
Introduction
The advent of endoscopic sinonasal surgery has revolutionized concepts regarding the
surgical anatomy of and approaches to the nasal cavity, the paranasal sinuses, and
the skull base.[1] In conditions of the maxillary sinus, endoscopic access has reduced the morbidity
associated with external approaches, such as lateral rhinotomy, the Caldwell-Luc procedure,
and facial degloving.[2]
Endoscopic medial maxillectomy (EMM) is a radical procedure that involves removal
of the uncinate process, the bulla, the inferior turbinate, the middle turbinate,
and the medial wall of the maxilla (including the nasolacrimal duct) to provide access
to the maxillary sinus.[3] Despite having lower morbidity compared with conventional open techniques, sequelae
such as atrophic rhinitis, epiphora, and recurrent dacryocystitis may occur due to
complete removal of the inferior turbinate and of the nasolacrimal duct.
The present study proposes a transnasal endoscopic approach to the maxillary sinus
through a reversible endoscopic medial maxillectomy (REMM) as an alternative for the
treatment of benign maxillary diseases. This technique is based on an osteomucosal
flap that provides wide exposure to the maxillary cavity, while preserving the anatomy
and physiology of the maxillary sinus.
Objective
To describe the REMM technique and report four cases of patients with benign maxillary
sinus conditions treated through this approach.
Materials and Methods
The present study was divided into two parts: anatomical and case series. Two cadaveric
dissections (total of four sides) were completed to confirm the feasibility of the
REMM approach.
The REMM technique was systematically applied in four patients who underwent surgery
at the ENT service of a private general hospital in Rio de Janeiro, Brazil, from January
2018 to January 2019.
All of the patients presented with benign conditions of the maxillary sinus and were
treated exclusively by endoscopic endonasal surgery, performed under general anesthesia.
Equipment
Dissections and surgeries were performed with instruments used in endoscopic sinus
surgery, straight and angled osteotomes, 4-mm endoscopes with 0°, 30°, and 45° Hopkins
telescopes (Karl Storz, Culver City, CA, USA) and Fusion ENT Surgical Navigation (Medtronic,
Dublin, Ireland).
Cadaveric Dissection
In the cadaveric study, the dissections performed followed the same steps of the surgical
procedure.
The uncinate process was removed, the natural ostium of the maxillary sinus was identified,
and a wide maxillary antrostomy was performed, providing good visualization of the
posterior wall of the sinus. The maxillary line was identified. A fine-tipped monopolar
diathermy pencil was used to make an oblique pre-lacrimal incision, starting 0.5 cm
anterior to the superior portion of the nasolacrimal duct and moving inferiorly so
as to draw a tangent line from the head anterior portion of the inferior turbinate
to the floor of the nose, at the pyriform aperture ([Fig. 1A]). This incision extends posteriorly through the floor of the nose to the posterior
portion of the inferior turbinate. Some minor mucosal undermining was performed to
expose the frontal process of the maxilla ([Fig. 1B, C]). A straight osteotome was used to fracture the maxilla along the line of the original
incision ([Fig. 1D]). The entire medial wall of the maxilla, including the nasolacrimal duct and the
inferior turbinate, were displaced medially ([Fig. 1E]). Even with a 0-degree endoscope, ample visualization of the posterior, lateral,
and most of the anterior walls of the maxillary sinus were possible. Angled endoscopes
(30° or 45°) may be used as needed to provide additional visualization of the anterior
wall. The maxillary sinus was fully explored. Once it is disease-free, the medial
wall was returned to its original position and secured with two sutures with 3–0 Vicryl
([Fig. 1F]).
Fig. 1 Endonasal endoscopic cadaveric dissection showing the steps of the REMM on the left
side (A–F). Pictures obtained with a 0-degree scope. (A) Oblique pre-lacrimal incision. (B) Mucosal undermining was performed to expose the frontal process of the maxilla.
(C) The incision extends posteriorly through the floor of the nose to the posterior
portion of the inferior turbinate. (D) A straight osteotome was used to fracture the maxilla along the line of the original
incision. (E) The entire medial wall of the maxilla, including the nasolacrimal duct and the inferior
turbinate, were displaced medially. (F)The medial wall was returned to its original position and secured with two sutures.
IT= inferior turbinate, MT= middle turbinate, NF= nasal floor, NLD= nasolacrimal duct,
NS= nasal septum, PW= posterior wall.
Procedure
The REMM procedure was performed under general anesthesia. Cotton pledgets soaked
in 2% lidocaine with epinephrine 1:2000 were applied on the nasal mucosa. In the patients,
the surgical procedure performed followed the same steps of the cadaveric dissection.
Postoperative care
Patients were discharged on oral antibiotics 12 hours after surgery. All were instructed
to perform nasal irrigation with 0.9% saline solution. The nasal splint was removed
1 week postoperatively.
Results
A total of two adult human cadaver specimens (four sides) were dissected using the
REMM surgical approach.
Case 1
In december 2017, a 25-year-old male presented with a 3-year history of progressively
worsening nasal congestion, discharge, and hyposmia, most prominently on the left.
Nasal endoscopy revealed a left-sided polypoid lesion in the middle meatus, extending
into the nasal cavity. Computed tomography (CT) of the paranasal sinuses showed complete
opacification of the left maxillary sinus, with enlargement of the ostiomeatal complex,
and a mass lesion isodense with soft tissue suggestive of an antrochoanal polyp ([Fig. 2A]).
Fig. 2 Case 1, patient with antrochoanal polyp in the left nasal cavity and maxillary sinus
(A) Coronal plane CT scan showing enlargement of the ostiomeatal complex and a mass
lesion isodense (antrochoanal polyp) in the left maxillary sinus. (B) Endonasal approach of the left nasal fossa with a 45-degree scope. Exposure of the
posterior wall of a left maxillary sinus after a wide middle antrostomy. (C) Endoscpic view with a 70-degree scope looking for the insertion of the antrochoanal
polyp. (D, E) With a 30-degree scope, exposure of the insertion of the antrocoanal polyp, after
medial maxillectomy and cauterization of the periosteum in the anterior wall of the
maxillary sinus. (F) 2 months postoperative follow-up. AW= anterior wall, IT= inferior turbinate, LW=
lateral wall, MT= middle turbinate, MW= medial wall, NS= nasal septum, PW= posterior
wall.
Surgery was performed through an exclusively endoscopic endonasal approach. Initially,
a wide maxillary antrostomy was performed, but did not provide visualization of the
attachment of the polyp (localized to the lateral and anterior walls of the left maxillary
sinus). A left-sided REMM was then performed, which provided adequate access to the
lesion, allowing complete excision, as well as drilling and cauterization of the periosteum
([Fig. 2B, C, D, E]).
Histopathological analysis of the excised specimen confirmed the diagnosis of antrochoanal
polyp.
The patient had an uneventful postoperative course, with improvement of nasal obstruction
and hyposmia. He reported slight left-sided facial paresthesia, which resolved completely
within 3 weeks. Nasal endoscopy showed no evidence of relapse at 1-year of follow-up
([Fig. 2F]).
Case 2
In March 2018, a 30-year-old male presented with a chief complaint of chronic nasal
congestion and progressive enophthalmos with a duration of several months.
Nasal endoscopy showed a left-sided septal deviation and discharge in the middle meatus.
Computed tomography and magnetic resonance imaging (MRI) of the paranasal sinuses
were consistent with silent sinus syndrome ([Fig. 3A, B, C]). There was significant enlargement of the posterior wall of the left maxillary
sinus and of the fat pad of the ipsilateral infratemporal fossa.
Fig. 3 Case 2, Silent sinus syndrome in the left maxillary sinus - Preoperative image exams
(A-C); computed tomography (CT) scan in coronal plane (A), axial plane (B) and magnetic resonance imaging in T2 showing the compression of the lateral and
posterior wall of the maxillary sinus by the infratemporal and pterygopalatine fossa.
Postoperative CT scan, coronal plane (D, E) and axial plane (F). Observe the maxillary antrostomy and the bone integrity of the medial wall of the
left maxillary sinus.
Endoscopic endonasal surgery was performed. As in case 1, a wide maxillary antrostomy
was performed initially, which revealed significant downward displacement of the left
orbital floor and a bulging posterior wall of the maxillary sinus. A left-sided REMM
was performed to allow cauterization of the infratemporal fossa fat pad with bipolar
diathermy.
The patient had an uneventful postoperative course, with improvement of his presenting
complaints and no cosmetic or ocular sequelae. As in case 1, he reported left-sided
facial paresthesia, which improved spontaneously within 4 weeks.
A control CT of the paranasal sinuses performed at the 6-month follow-up showed improved
aeration of the left maxillary sinus and a 0.1-cm reduction in displacement of the
ipsilateral orbit ([Fig. 3D, E, F]). He continues to attend regular follow-up appointments for nasal endoscopy and
measurement of orbital displacement.
Case 3
In july 2018, a 33-year-old male presented with a complaint of recurrent sinusitis,
postnasal drip, and cacosmia secondary to a gunshot wound received 7 years previously.
Three prior attempts at surgical treatment had been unsuccessful.
Nasal endoscopy revealed a purulent secretion in the middle meatus of the right nasal
fossa and an ipsilateral oronasal fistula. The CT scan showed opacification of the
right maxillary sinus with loss of bone discontinuity, as well as a bony defect in
the floor of the nasal fossa.
Endoscopic endonasal surgery was performed, initially with a wide right antrostomy,
followed by REMM to provide access and allow drilling of the right maxillary sinus
floor. The procedure was completed by closure of the oronasal fistula with a mucosal
flap raised from the floor and septum of the right nasal fossa.
The patient had an uneventful postoperative course, with improvement of his presenting
complaints. He reported slight right-sided facial paresthesia, which improved spontaneously
within 3 weeks. He remains asymptomatic at the periodic follow-up, with evidence of
excellent healing on nasal endoscopy.
Case 4
A 50-year-old man with a history of postnasal discharge for 1 year. In September 2018,
he still complained of chronic nasal obstruction.
Nasal endoscopy showed a purulent discharge from the left middle meatus. The CT and
MRI scans showed a solid lesion occupying the left maxillary sinus, with probable
insertion in its lateral wall ([Fig. 4A]).
Fig. 4 Case 4, Inverted papilloma of the left maxillary sinus - (A) Magnetic resonance imaging showing the relation between the tumor and the anterior
and lateral walls of the maxillary sinus. (B-F) Intraoperative photos from the left nasal cavity to show the REMM approach. (B) Endonasal view with a 45-degree scope, it is possible to observe the tumor occupying
the left maxillary sinus after a wide middle antrostomy. (C) A 0-degree scope view of a REMM approach. (D) Endoscopic aspect with a 45-degree scope after tumor removal. (E) The limits of the osteotomy (dotted line) and the nasolacrimal duct ostium (arrow).
(F) Suture of the incision anterior to the inferior turbinate. AW= anterior wall, IT=
inferior turbinate, LW= lateral wall, MT= middle turbinate, MW= medial wall, NS= nasal
septum, PW= posterior wall, SW= superior wall of the maxillary sinus, T= tumor.
Initially, a large medium antrostomy was performed and an intraoperative frozen section
biopsy indicated the diagnosis of an inverted papilloma. It was not possible to identify
the insertion of the lesion in the maxillary sinus wall, even with a 70-degree endoscope
view. Therefore, we chose to perform REMM for better access and visualization. The
tumor was inserted in the transition of the lateral and anterior wall of the left
maxillary sinus, being resected with subsequent periosteum drilling of this region
with a diamond burr ([Fig. 4B, C, D, E, F]).
The patient had a good evolution and was discharged on the same day. The anatomopathological
study confirmed the diagnosis.
The two-month control nasal endoscopy shows optimal condition of the cavity, without
nasal complications or patient complaints
Discussion
Open approaches to medial maxillectomy, such as the Caldwell-Luc procedure, lateral
rhinotomy, and midfacial degloving, can provide wide access to the maxillary sinus.
However, these techniques are associated with substantial morbidity. Complications,
including epiphora, dacryocystitis, diplopia, mucocele, cerebrospinal fluid leak,
epistaxis, and external scarring, are reported in ∼ 30% of the cases.[4]
The conventional endoscopic approach to medial maxillectomy consists of complete removal
of the lateral nasal wall, including the inferior turbinate and the nasolacrimal duct.[5] Although this approach provides satisfactory access to maxillary sinus lesions,
excision of the medial wall of this sinus may result in dry nose, with massive postoperative
crusting and mucociliary clearance disorders.
Subsequently, modified medial endoscopic maxillectomy techniques were developed in
an attempt to preserve the sinonasal anatomy and physiology. Weber et al described
a procedure that preserved the inferior turbinate but sacrificed the nasolacrimal
duct,[6] while Gras-Cabrerizo et al designed a technique which preserved both structures.[7]
Alternative endoscopic medial maxillectomy techniques, such as those described by
Suzuki et al and by Maxfield et al, involve preservation of the inferior turbinate
and nasolacrimal duct by displacing these structures medially to expose the bony medial
wall of the maxillary sinus. A drill or osteotome is then used to remove the medial
wall in the region of the inferior meatus. The original lateral nasal mucosa is replaced,
or a mucous flap is raised from the nasal floor to cover the bone defect where access
was obtained.[8]
[9]
The REMM technique provided wide access to maxillary sinus lesions just as well as
the other endoscopic techniques described above. One of its advantages is maintenance
of the sinonasal anatomy and physiology by preserving the inferior turbinate, the
nasolacrimal duct, and the lateral wall of the nose (including its osteomucosal component).
Unlike the other endoscopic approaches described previously, REMM does not necessitate
removal of the bony component of the medial wall of the maxillary sinus. Thus, there
is minimal risk of postoperative fistula formation on the lateral wall of the nose.
Furthermore, this technique minimizes postoperative crusting because the surgical
wound bed is not exposed to inspired airflow.
Facial paresthesia is a frequent postoperative complication of all medial maxillectomy
techniques, and is often persistent, which causes patient discomfort.[10] In the present case series, this symptom resolved completely and spontaneously within
4 weeks of surgery.
One aspect that must be assessed during preoperative planning of REMM is maxillary
sinus pneumatization and, consequently, the distance between the nasolacrimal duct
and the pyriform sinus ([Fig. 5 A, B, C, D]). A poorly pneumatized maxillary sinus, with only a narrow space between the nasolacrimal
duct and the pyriform aperture, will make osteotomy difficult and cause the procedure
to be more challenging. Sieskiewicz et al analyzed the course of the nasolacrimal
duct and assessed the distance between the nasolacrimal duct and the anterior wall
of the maxillary sinus to determine the capability of performing a minimally invasive
approach to the maxillary sinus. They demonstrated that in ∼ 30% of the cases, the
lacrimal recess is so narrow that this type of approach might be difficult to perform
without damaging the piriform aperture rim or the bony framework of the nasolacrimal
duct.[11] The same analysis needs to be done on patients who will be approached by REMM. This
does not contraindicate this technique, but does require greater operator skill.
Fig. 5 Endonasal dissection with a 0-degree scope of the left nasal fossa with neuronavigation
based on the computed tomography scan. Axial plane (A), coronal plane (B) and sagittal plane (C). It's possible to observe the distance between the nasolacrimal duct and the anterior
wall of the maxillary sinus (A, yellow arrow). After electrocautery incision, correlation
between the neuronavigation suction tip and the anatomy (D). AW= anterior wall, FPM=
frontal process of maxilla, NLD= nasolacrimal duct.
Conclusion
The REMM technique is an excellent surgical approach to benign conditions of the maxillary
sinus. It has few limitations and appears to be associated with less morbidity than
conventional techniques.
