Reversible Endoscopic Medial Maxillectomy: Endonasal Approach to Diseases of the Maxillary Sinus

THIEME Original Research Reversible Endoscopic Medial Maxillectomy: Endonasal Approach to Diseases of the Maxillary Sinus Miguel Soares Tepedino1 Ana Clara Miotello Ferrão2 Hana Caroline Morais Higa3 Leonardo Lopes Balsalobre Filho4 Enrique Iturriaga5 Marcelo Charles Pereira6 Carlos Diogenes Pinheiro Neto7 1 Department of ENT and Skull Base Surgery at the Policlinica de Botafogo, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil 2 Department of ENT, Policlinica de Botafogo, Rio de Janeiro, RJ, Brazil 3 Department of Rhinology and Skull Base Surgery, Policlinica de Botafogo, Rio de Janeiro, RJ, Brazil 4 São Paulo ENT Center, Hospital Edmundo Vasconcelos, São Paulo, SP, Brazil 5 Department of ENT and HSN/Skull Base Program, Centro Médico Caracas, Caracas, Venezuela 6 Department of Otolaryngology, Albany Medical Center, Albany, NY, United States 7 Department of Otolaryngology and Neurosurgery, Albany Medical Center, Albany, NY, United States Address for correspondence Miguel Soares Tepedino, MD, PhD, Policlínica de Botafogo, Avenida Pasteur, 72, Botafogo, Rio de Janeiro – RJ, Brazil, 22290-240 (e-mail: ). Int Arch Otorhinolaryngol 2020;24(2):e247–e252. Abstract Keywords ► maxillary sinus ► maxillary diseases ► nasolacrimal duct ► inferior turbinate received October 4, 2019 accepted November 5, 2019 published online February 27, 2020 Introduction The endoscopic access has reduced the morbidity associated with external approaches in diseases of the maxillary sinus. A reversible endoscopic medial maxillectomy (REMM) is presented as an alternative for treatment of benign maxillary diseases. Objective To describe the REMM technique and report four cases of patients with benign maxillary sinus conditions treated through this approach. Methods The present study was divided into two parts: anatomical and case series. Two cadaveric dissections confirmed the feasibility of the REMM approach. The same technique was performed on four consecutive patients with benign maxillary sinus disease. Results The cadaveric dissections confirmed wide exposure to the maxillary cavity, preserving the anatomy of the maxillary sinus. In the patient series, one patient presented with an antrochoanal polyp, one had a silent sinus syndrome, one had a chronic maxillary sinusitis secondary to a gunshot, and the last one had an inverted papilloma in the maxillary sinus. In all of the cases, the REMM approach provided excellent access and adequate resection, as well as preservation of the inferior turbinate, nasolacrimal duct, and lateral wall of the nose (including its osteomucosal component). Finally, all of the patients had an uneventful postoperative course. 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. DOI https://doi.org/ 10.1055/s-0040-1701267. ISSN 1809-9777. Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil 247 248 Reversible Endoscopic Medial Maxillectomy Tepedino et al. 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 International Archives of Otorhinolaryngology Vol. 24 No. 2/2020 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 0degree 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 returne (...truncated)