Extended endoscopic approaches to the maxillary sinus

Management of the Nasolacrimal Duct in Expanded Endoscopic Approaches to the Maxillary Sinus: A Systematic Review with Evidence-based Recommendations

BACKGROUND

Utilizing expanded endoscopic approaches to the maxillary sinus for the endonasal management of a variety of tumors is increasing in popularity. The nasolacrimal duct (NLD) may be injured inadvertantly or need to be removed during tumor resection or to augment visualization. Management of the NLD can take the form of transection alone, transection with stenting, or performing a formal dacryocystorhinostomy to avoid postoperative sequelae of injury. The purpose of this study was to review the literature and determine the optimal management of the NLD during expanded maxillary sinus approaches.

METHODS

A systematic review of Ovid, Embase, Medline, and Cochrane databases was performed to identify studies involving expanded approaches to the maxillary sinus and that explicitly reported the status of the NLD and postoperative outcomes.

RESULTS

Nineteen studies were included in the analysis and divided into two groups: NLD-preserving (n = 9 studies; n = 191 patients in aggregate) and NLD-involving (n = 10 studies; n = 296 patients in aggregate). In the NLD-preserving subgroup, one patient out of a subgroup aggregate of 191 patients (0.5%) developed epiphora. In the NLD-involving subgroup, sharp transection alone was the most common method of NLD removal and was associated with a low rate of epiphora (study rates: 0 to 18.2%; aggregated subgroup rate: 7.0%, 21 / 296). Spontaneous resolution of symptoms was common (60%-100% cases).

CONCLUSIONS

The NLD should be preserved when feasible from an exposure and tumor-control perspective. When pathology or approach requires the removal of the NLD, rates of persistent epiphora are very low, regardless of surgical technique. When expanded maxillary approaches are employed, particularly for benign tumors, and require removal of the NLD, sharp transection is the simplest method of removal, provides a low rate of postoperative epiphora, and is supported by the available literature.

Chronic Maxillary Sinusitis: A comparison of osteological and CT methods of diagnosis

OBJECTIVE

To assess the differences between endoscopic and radiological methods of analysis for diagnosing chronic maxillary sinusitis (CMS) in archaeological skeletal remains.

MATERIALS

32 crania from a Dutch post-medieval rural population.

METHODS

We assessed the presence of bone changes indicative of CMS (i.e., bone growth and bone resorption) both endoscopically and through computed tomography (CT), and then compared results.

RESULTS

We observed moderate agreement between bone growth scores obtained through endoscopy and CT, and fair agreement when assessing bone resorption.

CONCLUSIONS

CMS prevalence rates observed through CT may be comparable to rates assessed endoscopically, although caution is needed when making direct comparisons.

SIGNIFICANCE

This is the first study comparing data obtained through endoscopy and radiological methods in the study of CMS, informing paleopathologists about potential biases in data comparison.

LIMITATIONS

Our small sample size likely impacted results.

SUGGESTIONS FOR FURTHER RESEARCH

Further research is advised to fully explore the comparability of endoscopic and radiological method of analysis in the study of sinusitis.

DATA AVAILABILITY

The datasets generated and analyzed during the current study are available upon request.

The impact of maxillary dimensions on determining surgical approach of fungal ball in the maxillary sinus

Endoscopic middle meatal antrostomy (MMA) is commonly used for maxillary sinus (MS) fungal ball removal. For challenging cases involving anterior or inferior recess, an additional inferior meatal approach (IMA) might be needed. We analyzed the differences in MS dimensions on CT scans according to the surgical approach to suggest preoperative variables that could facilitate an additional IMA. CT scans of 281 adult patients who underwent ESS for the MS fungal ball (139 MMA, 62 MMA & IMA) were evaluated for comparative analysis of 8 MS measurements based on the surgical approach. Complete removal was achieved in all cases. Age and sex didn't differ significantly (p > 0.05). The maximum distances between the anterior-posterior walls, the inferior ostium border to the lateral recess, and the ostium to the inferior wall of the MS were statistically greater in the MMA & IMA group compared to the MMA group (p = 0.003, p = 0.005, and p = 0.010, respectively), especially among females. This study underscores the clinical importance of specific measurements-anterior to posterior wall, medial wall to lateral recess, and ostium to inferior wall of the maxillary sinus-for guiding optimal surgical approaches in MS lesions.

How I do it:- Endoscopic Reverse Denker's Approach

Introduction: Endoscopic Denker's approach involves complete exposure of the anterior, inferior and lateral walls of the maxillary sinus providing access to both infratemporal and pterygopalatine fossa. Open approaches to maxillary sinus may lead to a high chance of cranial nerve dysfunction, trismus and wound healing issues. Surgical methods differ based on pathology, exposure, visualization and extent of clearance of the pathology. Method: The technique and surgical steps of Endoscopic Reverse Denker's approach are presented. Results: Critical steps include inferior turbinectomy, uncinectomy, followed by mega middle meatal antrostomy. For exposure drilling is started from the anterior margin of middle meatal antrostomy up to the pyriform aperture anteriorly till the anterior wall of the maxilla is visualized and the nasolacrimal duct can be visualized and transected. This method preserves the pyriform aperture and anterior wall similar to inside-out mastoidectomy tracing the pathology with less bone removal, faster and less morbidity. Conclusion: Endoscopic Reverse Denker's is a 2-handed or 4-handed endoscopic technique for proper exposure, visualization and clearance of the maxillary pathology of the anterolateral and anterior wall. Olfaction is preserved and crusting is less as there is less bone removal with no atrophic nasal changes. It preserves the pyriform aperture thereby preventing alar collapse.

Transnasal endoscopy-guided percutaneous access to the sphenopalatine ganglion for neurostimulation in the treatment of primary headache: operative technique and feasibility

OBJECTIVES

Cluster headache is considered a trigeminal autonomic cephalalgia and may present with characteristic symptoms of sympathetic/parasympathetic activation on the affected side of the face, such as nasal discharge, tearing, and conjunctival injection. Invasive therapies targeting the sphenopalatine ganglion have been performed in these headache syndromes and can have a medication-sparing effect, especially in refractory, difficult-to-manage cases. The gate control theory of pain suggests that electric pulses delivered to nerve tissues can modulate neuronal activity, thus aiding in management of nociceptive or neuropathic pain, and studies have demonstrated the efficacy and safety of sphenopalatine ganglion neurostimulation. Within this context, we sought to assess the feasibility of a new surgical technique for neurostimulation of the sphenopalatine ganglion in a cadaver dissection model.

METHODS

The technique was developed through dissection of two cadaver heads. We divided the procedure into two stages: an endonasal endoscopic approach to expose the sphenopalatine ganglion and confirm electrode placement, and a cervicofacial approach to introduce the electrode array and position the internal pulse-generator unit. Computed tomography was performed to confirm implant placement at the end of the procedure.

RESULTS

The pulse-generator unit was successfully placed through a retroauricular incision, as is already standard for cochlear implant placement. This should reduce the incidence of perioperative sequelae, especially pain and swelling in the oral region, which are a common complication of previous approaches used for this purpose. Control imaging confirmed proper electrode placement. The device used in this study allows the patient to modulate the intensity of the stimulus, reducing or even obviating the need for drug therapy.

CONCLUSION

The novel technique described herein, based on percutaneous access guided by transmaxillary endoscopy, can provide great precision in electrode array positioning and decreased perioperative morbidity, combining the advantages of endoscopic approaches with those of the retroauricular route.

LEVEL OF EVIDENCE: 3

Temporal and Permanent Changes Induced by Maxillary Sinus Lifting with Bone Grafts and Maxillary Functional Endoscopic Sinus Surgery in the Voice Characteristics-Systematic Review

Sinus surgery procedures such as sinus lifting with bone grafting or maxillary functional endoscopy surgery (FESS) can present different complications. The aims of this systematic review are to compile the post-operatory complications of sinus elevation with bone grafting and FESS including voice changes, and to elucidate if those changes are either permanent or temporary. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used, and the literature was exhaustively searched without time restrictions for randomized and non-randomized clinical studies, cohort studies (prospective and retrospective), and clinical case reports with ≥4 cases focused on sinus lift procedures with bone grafts and functional endoscopic maxillary sinus surgery. A total of 435 manuscripts were identified. After reading the abstracts, 101 articles were selected to be read in full. Twenty articles that fulfilled the inclusion criteria were included for analysis. Within the limitations of this systematic review, complications are frequent after sinus lifting with bone grafts and after FEES. Voice parameters are scarcely evaluated after sinus lifting with bone grafts and no voice changes are reported. The voice changes that occur after FESS include a decreased fundamental frequency, increased nasality, and nasalance, all of which are transitory.

The role of endoscopic medial maxillectomy in sinus disease

PURPOSE OF REVIEW

The endoscopic medial maxillectomy (EMM) has remained a relevant procedure for certain sinus diseases and at the same time reemerged as a salvage technique or even as a primary procedure for other diseases. Several mucosal-sparing techniques have also been described and the outcome of the surgeries is available for review.

RECENT FINDINGS

Modifications of the EMM technique in the last two decades, aimed at mucosal preservation of the inferior turbinate, nasolacrimal duct, and medial maxillary wall have been successful in addressing a multitude of diseases. There are also evidences to support adjunct procedures/methods to improve access, healing, and to address associated dysfunction such as impaired mucociliary clearance. Tailored approaches have shown favourable outcomes with a low rate of adverse effects.

SUMMARY

The EMM is appropriate for selected indications, in particular lesions causing medial wall destruction or extensive tumour involving the anterior wall or the prelacrimal recess. As for other maxillary sinus diseases including those identified to a limited site, a modified EMM is a reasonable consideration. The choice is appropriate provided instrument access, visualization, the ability for complete resection, postoperative care, and the requirement for surveillance is not compromised. A tailored approach with or without adjunct procedures is recommended.