Quantification of maxillary sinus accessibility via a middle meatal antrostomy

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.

The choice of endoscopic surgical approach and four steps of operation of inverted papilloma of the maxillary sinus

OBJECTIVE

The aim of this study was to determine the long-term efficacy of four steps of operation on the treatment of maxillary sinus (MS) inverted papilloma (IP).

METHODS

83 patients who were diagnosed with IP that originated from the MS, underwent four step procedure of attachment sites, including mucosal stripping, periosteum ablation, bone drilling and bone ablation and had postoperative follow-up of 3 years were enrolled.

RESULTS

Of the 83 patients, 59 (71.1%) patients were primary surgery and revision surgery in 24 (28.9%), single attachment was in 31(37.3%) patients and multifocal attachments in 52 (62.7%).When the numbers were not mutually exclusive, the most common origin sites of IPs were the medial wall in 54 (37.2%), lateral wall in 29 (20.0%), anterior wall in 18 (12.4%), inferior wall in 22 (15.2%), posterior in 15 (10.3%), and superior wall in 7 (4.8%). Large MMA alone was performed in 5 (6.0%), MMA combined with medial maxillectomy 76 (91.6%), and MMA combined with Caldwell-Luc approach in 2 (2.4%). No major intra- or postoperative complications were observed. The average follow-up was 41 months (range, 37-61 months). CT and endoscope showed that tumor and symptom recurrence occurred in 2 patients (2.41%). In addition, although the opening of antrostomy was closed and CT revealed the uniform soft tissue shadow and hyperostosis of MS in 11(13.3%) patients, they didn't report any symptoms and showed well epithelization of middle meatus mucosa.

CONCLUSION

The four steps of operations of attachment sites of MS IP, including mucosal stripping, periosteum ablation, bone drilling and bone ablation, may effectively prevent the recurrence of MS IP.

Human maxillary sinus size, shape, and surface area: Implications for structural and functional hypotheses

OBJECTIVES

Although research into human maxillary sinus (MS) morphology has overwhelmingly focused on sinus volume, other aspects of morphology (e.g., overall shape, mucosal surface area) factor prominently in hypotheses regarding MS form and function. Here, we investigate MS volume in conjunction with measures of MS shape and surface area in a large, diverse sample of modern humans. We test whether variation in MS volume is associated with predictable changes in MS shape (i.e., allometry) and investigate the influence of MS size-shape scaling on mucosal surface area dynamics.

MATERIALS AND METHODS

Measures of MS volume and surface area were obtained from computed tomographic (CT) scans of 162 modern human crania from three ancestral backgrounds-Equatorial Africa, Europe, and East Asia. 3D coordinate landmarks and linear measurements were also collected. Multivariate analyses were employed to test for associations between MS volume and other morphological variables.

RESULTS

Significant associations between MS volume and 3D shape were identified both across and within the subsamples. Variation in MS volume was found to predominantly relate to differences in MS height and width dimensions relative to MS length. This pattern of allometric scaling was found to differentially influence total mucosal surface area and the SAV ratio.

CONCLUSION

This study suggests that variation in MS volume is disproportionately mediated by MS width and height dimensions. This finding has implications for hypotheses which structurally link MS morphology to craniofacial ontogeny and those which suggest that MS morphology may perform adaptive physiological functions.

Surgical outcomes between two endoscopic approaches for maxillary cysts

OBJECTIVE

To compare recurrence rates and symptomatic relief in symptomatic maxillary sinus Retention Cysts (RCs) between Middle Meatus Antrostomy (MMA) alone and Inferior Meatus Antrostomy (IMA) with basal mucosa electrocoagulation.

METHODS

Patients with symptomatic unilateral maxillary RCs were randomly allocated to MMA (n=54) and IMA combined with mucosa electrocoagulation (n=53) groups. Symptomatic relief, cyst recurrence, and closure of the antrostomy opening were compared at 12-months postoperatively.

RESULTS

Symptomatic failure occurred in 13 (12.1%) patients, including 9 (16.7%) MMA and 4 (7.5%) IMA patients; this difference was not statistically significant (p=0.251). Postoperative cyst recurrence occurred in 16 (29.7%) and 1 (1.9%) patient in the MMA and IMA groups, respectively (p<0.0001). Closure of the opening occurred in 7 (13.0%) and 17 (32.1%) patients in the MMA and IMA groups, respectively (p=0.032). However, there were no significant pairwise correlations between closure of the opening and symptomatic failure or cyst recurrence.

CONCLUSION

IMA combined with basal mucosa electrocoagulation and MMA alone provided similar symptomatic relief for symptomatic maxillary RCs, but IMA had shorter operation times and lower postoperative recurrence rates of RCs.

LEVEL OF EVIDENCE

Level 1b.

Mini-Invasive Endoscopic Approaches to the Maxillary Sinus Floor: A Comparative Anatomical Study

BACKGROUND

While middle antrostomy (MA) is the most common approach to the maxillary sinus (MS), it is known for not allowing to fully inspect the whole MS, especially in its inferior and anterior portions. To overcome this limitation, alternative approaches have been proposed, such as inferior antrotomy (IA) and canine fossa accesses (CFA).

OBJECTIVE

Given the lack of studies on the MS floor visualization with different accesses, our study aims, in a cadaver lab setting, to systematically compare three different approaches (MA, IA and CFA) in these regards.

METHODS

Eight cadaver heads, previously submitted to CTscan, were prepared inserting fixtures corresponding to teeth 2, 4, 6, 11, 13 and 15 and into the canine fossae. Three approaches were prepared: a wide MA, an IM and a CFA. We endoscopically evaluated, for each specimen, side, access type and scope angle (0°, 30°, 45°, and 70°), which fixtures were visible on the maxillary sinus floor and whether the canine fossa fixture was visible (MA and IA only).

RESULTS

IA allowed to visualize all fixtures in nearly all cases (14/16 with 70° endoscope), while MA showed poor visualization results (3/16 with 70° endoscope); CFA failed to gain full visualization in most specimens (7/16 with 70°endoscope). Such difference was statistically significant. MA proved unable to visualize the canine fossa fixture in most cases while IA showed excellent possibilities. All differences were statistically significant (p < .001, Mcnemar's test).

CONCLUSIONS

Our data show that the IA grants a statistically significant superior surgical field vision when compared to MA and CFA, though in vivo validation of these results is still required.

[Radicality of maxillary sinus surgery and size of the maxillary sinus ostium]

Until the 1990s, radical sinus surgery was considered a standard procedure for maxillary sinus diseases, but it is no longer favored due to the high morbidity. Today, functional endoscopic sinus surgery (FESS) is considered the gold standard in sinus surgery. Modifications of surgical approaches also allow access to regions of the maxillary sinus that were previously difficult to reach. Depending on anatomy and pathology, different methods for widening the maxillary ostium can be selected. In type I sinusotomy, the natural ostium is widened dorsally by a maximum of 1 cm. Sinusotomy type II involves widening the natural ostium up to a maximum diameter of 2 cm. In sinusotomy type III, the natural ostium is widened dorsally to the posterior wall of the maxillary sinus and caudally to the base of the inferior turbinate. Beside the prelacrimal approach, more invasive approaches are the medial maxillectomy, in which the dorsal part of the inferior turbinate and the adjacent medial wall of the maxillary sinus is resected, as well as its modifications "mega antrostomy" and "extended maxillary antrostomy." Correct selection of the size of the maxillary sinus window is prerequisite for successful treatment and long-term postoperative success. Isolated purulent maxillary sinusitis can usually be treated by a type I sinusotomy. Sinusotomy type II addresses nasal polyps with involvement of the mucosa of the ostium, recurrent stenosis after previous surgery, chronic maxillary sinusitis due to cystic fibrosis, and purulent maxillary sinusitis with involvement of other adjacent sinuses. Sinusotomy type III is required for choanal polyps with attachment to the floor of the maxillary sinus, for extensive polyposis and fungal sinusitis, and for inverted papilloma. Particularly for (recurrent) disease and extensive interventions in the maxillary sinus, medial maxillectomy or a modification thereof may be required.

[Surgical anatomy of the maxillary sinus]

BACKGROUND

Improved understanding of the microanatomy of the paranasal sinuses, including its individual variations, makes a substantial contribution to current progress in endonasal endoscopic microsurgery. Microanatomy of the sinuses is an active field of present scientific investitations.

MATERIALS AND METHODS

A comprehensive review on microanatomy of the maxillary sinus is presented from the perspective of contemporary endonasal endoscopic microsurgery.

RESULTS

The range of variation of the individual microanatomy of all sections of the maxillary sinus is presented, in particular to minimize secondary sugical tissue trauma, to avoid complications (e.g. on orbital tissues) and as a basis for the prelacrimal access to the maxillary sinus.

CONCLUSION

Improved understanding of the range of microanatomical variations reduced the burden on the patient while opimizing the effectiveness of the necessary surgical manipulations.

Extent of maxillary sinus surgery and its effect on instrument access, irrigation penetration, and disease clearance

BACKGROUND

Middle meatal antrostomy (MMA) provides limited access to the anteromedial and inferior aspect of the maxillary sinus (MS) often resulting in residual disease and inflammatory burden. Newer extended procedures, such as mega-antrostomy (Mega-A) and extended modified mega-antrostomy (EMMA), have been developed to address this limitation. This study assesses the effect of varying extent of MS surgery on irrigation penetration and access of instrumentation.

METHODS

The MS of 5 fresh-frozen cadavers were sequentially dissected. Irrigation was evaluated with a squeeze bottle (SB) in different head positions and using different volumes of fluid. Surgical reach and visualization were examined using common sinus instruments and different angled endoscopes. A disease simulation was also performed to check for residual debris after instrumentation and irrigations.

RESULTS

Irrigation penetration improved as antrostomy size increased (p < 0.0001), with a significant difference observed between the extended procedures and MMA. The effect of the volume was significant for SB (p < 0.0001) but head positions appeared irrelevant (p = 0.613). Overall visualization improved for Mega-A and EMMA. A similar trend was seen for the reach of the instruments to all sinus wall subsites. EMMA facilitated the most removal of "sinus disease" in the disease simulation model when compared with both MMA and Mega-A, due to its reach of the anteroinferior aspects of the maxillary sinus.

CONCLUSIONS

High-volume irrigation using SB achieved good sinus penetration, irrespective of head position. Extended MS procedures appear to further increase irrigation penetration as well as surgical access.

Advances in Microdebrider Technology: Improving Functionality and Expanding Utility

Since its application in nasal surgery, the microdebrider has revolutionized the practice of endoscopic sinus surgery. As the demands and breadth of procedures performed endoscopically have increased, so has the need for improvement in the microdebrider and related technologies. This article addresses how use of the microdebrider has impacted endonasal surgery and discusses current advances, which include creation of specialty hand pieces and blades, increases in instrument rotational speed, incorporation of navigation and energy, adaptation for intracranial use, and disposable instrumentation designed for in office use. Advances in microdebrider technology have improved functionality and expanded the utility of these devices.

Canine fossa puncture in endoscopic sinus surgery: report of two cases

Introduction

Chronic rhinosinusitis with nasal polyposis is a common chronic disease that often affects maxillary sinus. Endoscopic sinus surgery is the most common procedure for treating the majority of maxillary sinus lesions.

Objective

To demonstrate the role of canine fossa puncture during endoscopic sinus surgery procedure in patients with severe maxillary sinus disease.

Methods

We present 2 cases where canine fossa puncture has been performed as method to obtain a complete access to the maxillary antrum.

Results

According our experience, 2 cases on 296 endoscopic sinus surgery (0.6%) where antrostomy and used of angled microdebrider were not sufficient, canine fossa puncture has been performed as an alternative method to obtain a complete access to the maxillary antrum.

Conclusion

Although the advent of endoscopic sinus surgery, our cases support the fact that actually canine fossa puncture is a minimally invasive technique useful in selected cases.