Endonasal endoscopic medial maxillectomy with preservation of the

Endonasal endoscopic medial maxillectomy with
preservation of the inferior turbinate
Rainer K. Weber, M.D.,1 Jochen A. Werner, M.D.,2 and Tanja Hildenbrand, M.D.1
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ABSTRACT
Background: Endonasal endoscopic medial maxillectomy usually includes removal of the inferior turbinate (IT) even if it is not involved in the disease.
A surgical approach is presented in which the IT is temporarily excised and then reinserted, followed by postoperative occlusion of the nose for at least 2 weeks.
Methods: A retrospective case series of 12 patients with inverted papilloma (IP) of the maxillary sinus (Krouse II–III) and 2 patients with 3 mucoceles of
the maxillary sinus after a Caldwell-Luc operation were reviewed. After a follow-up period of 12– 80 months (28 months on average) all patients underwent
endoscopy, and in four cases, additionally, an MRI was performed.
Results: There was no recurrence of tumor or mucocele after 12– 80 months. The IT and its important function for warming and humidifying the inhaled
air could be preserved up to now in all 15 operated sides. The patients did not have any specific pain postoperatively and there was no postoperative bleeding.
They all tolerated occlusion for 2– 4 weeks. Two patients developed mucoceles due to the formation of scar tissue after endonasal tumor surgery. In three cases
of endonasal endoscopic Denker operation patients reported some degree of numbness or irritation of the ipsilateral frontal teeth.
Conclusion: The IT can be preserved in endonasal endoscopic medial maxillectomy for treatment of IP without a higher incidence of tumor recurrence.
Aftercare should specifically focus on preventing the development of mucoceles caused by scarring.
(Am J Rhinol Allergy 24, e132–e135, 2010; doi: 10.2500/ajra.2010.24.3531)
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ndoscopic surgery plays a central role in the treatment of inverted
papilloma (IP) of the nose and paranasal sinuses and both its
safety and its efficacy have been established.1–4 According to the
meta-analysis of 32 studies by Busquets and Hwang,5 patients undergoing endoscopic treatment showed significantly fewer recurrences
than nonendoscopically treated patients (12% versus 20%).
The goal of surgical treatment is complete removal of the lesion
under direct visual control with minimal morbidity. The meticulous
identification of attachment sites is crucial. The recommended procedure is to cut 8–10 mm around the tumor in the normal mucosa and
to resect the relevant bone fragment or to drill the underlying bone to
ensure complete extirpation of neoplastic mucosa.6
For tumors involving the lateral and anterior wall of the maxillary
sinus (MS) Mackle et al.7 prefer an additional transantral approach.
Landsberg et al.,6 on the other hand, perform a complete extended
endoscopic medial maxillectomy (EEMM), in these cases, including
the nasolacrimal duct, stating that all aspects of the MS can be reached
by curved instruments and burrs using a 70° endoscope.
In more extended cases, particularly involving the prelacrimal,
palatinal, alveolar, and zygomatic recess, an EEMM procedure is
performed.8–19 In all of these cases the inferior turbinate (IT) is resected, even though it is not involved in tumor growth.
The IT is an important structure in nasal physiology.20,21 It warms,
cleans, and moistens the inhaled air and regains water during exhalation. We therefore present a novel technique for performing EEMM
with preservation of the IT. In addition, this technique can be used to
gain access to mucoceles or other inflammatory conditions of the MS
that are difficult to reach otherwise, particularly in the case of a
shrunken MS after a Caldwell-Luc operation or conditions in an
inferior anterior location.
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This study was approved by the local Ethics Committee (Landesärztekammer Baden-Württemberg). It is a retrospective case series of
From the 1Department of Ear, Nose, and Throat, Hospital Karlsruhe, Karlsruhe,
Germany, and 2Department of Otolaryngology, Head and Neck Surgery, University of
Marburg, Marburg, Germany
Address correspondence and reprint requests to Rainer K. Weber, M.D., Division of
Sinus and Skull Base Surgery, Traumatology, Department of Ear, Nose, and Throat,
Hospital Karlsruhe, Moltkestr. 90, D-76133 Karlsruhe, Germany
E-mail address: [email protected]; alternative: www.rainerweber.de
Copyright © 2010, OceanSide Publications, Inc., U.S.A.
e132
• Five patients with a primary IP of the MS.
• Seven patients with a recurrent IP of the MS.
• Two patients with three mucoceles of the MS (one with bilateral
mucoceles after two previous Caldwell-Luc operations; one with a
mucocele after three previous operations elsewhere).
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MATERIALS AND METHODS
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patients who underwent endonasal endoscopic medial maxillectomy
preserving the IT. They consisted of
In all patients endonasal endoscopic medial maxillectomy was performed (15 operated sides).
Twelve patients (5 women and 7 men, aged 26–77 years) with IP
were operated on between 2002 and 2008. In all cases the tumor
extended at least into the prelacrimal recess of the MS. In seven cases
the patients presented with a recurrent IP after previous surgery
elsewhere (three times a second recurrence and one time a fourth
recurrence). All patients were asked to return for endoscopic follow-up every 3 months in the 1st year, every 6 months for 1 year, and
afterward once a year.
OPERATIVE TECHNIQUE
A 45° endoscope was used for most parts of the operation. Additionally,
a 0° and 70° telescope was used. In IP, the tumor is first debulked intranasally and then followed into the MS to look for the attachment. An uncinectomy is necessary to do this. If the tumor can not be sufficiently removed via
a middle meatal antrostomy and the IT is not involved in the tumor, the
decision to perform an EEMM with preservation of the IT is made. It
includes the following surgical steps (Fig. 1, A–H):
• Dissection of the IT just behind the anterior insertion, continuing
along the insertion at the lateral nasal wall, preserving the posterior
end and the supplying vessels from the sphenopalatine artery.
• The IT is then mobilized in a medial direction or rotated cranially
into the ethmoid cavity if some kind of ethmoidectomy was performed before.
• Then, an EEMM is performed with resection of the medial wall of
the MS including the nasolacrimal duct followed by a dacryocystorhinostomy to ensure sufficient lacrimal drainage.
• The lateral nasal wall is removed down to the base of the nose. A
medially based mucosal flap can be raised to cover the drilled bone
laterally at the end of the operation.
• The anterior portion of the medial wall of the MS (parts of the
frontal process of the maxilla) can be removed as it forms the medial
part of the prelacrimal recess.
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Figure 1. (A–H) Endonasal endoscopic maxillectomy
with preservation of the inferior turbinate (IT) in a case
of inverted papilloma. (A) Characteristic endoscopic appearance of an inverted papilloma (IP; Krouse II).
(B) Cutting of the anterior attachment of IT. (C) Dissection is continued slightly lateral along the attachment, preserving the nutrifying vessels at the posterior
end. IT is positioned medially. (D) After reinsertion of
the IT at the original attachment site. (E) Schematic
drawing of the situation at the end of the operation (1 ⫽
inferior turbinate that is reinserted with two stitches,
2 ⫽ maximally opened maxillary sinus [broken line],
3 ⫽ opened lacrimal sac [Dacryocystorhinostomy], 4 ⫽
piriform aperture [it is resected in Denker‘s operation],
and 5 ⫽ ground lamella of middle turbinate). (F) Endoscopic view (45° optic) onto a recurrent IP at the roof
of the MS, the lateral recess is free of tumor. (G) Endoscopic view (45° optic) into the alveolar recess after
tumor removal, which is free of tumor. (H) Endoscopic
view (45° optic) into the palatinal recess after tumor
removal.
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• To optimize the access to the MS, an endonasal Denker operation8
can be performed, including resection of the piriform aperture,
which can be extended laterally to the infraorbital nerve and cranially to the orbit. This was performed in six cases of IP.
• Usually, there is bleeding from dental branches of the infraorbital
artery, which can be stopped using a diamond burr.
• After complete removal of the tumor the IT is repositioned and
sutured in its original position with one to two stitches with resorbable material (Fig. 1 D).
To ensure a moist wound environment, the nose is occluded for 2–4
weeks, depending on the degree of wound healing and the wound
surface.
Occlusion is realized by taping the nose with sticking plaster,
preventing breathing through the nose that imminently dries the nose
and is harmful to the healing mucosa.22
In cases of mucoceles (Fig. 2), these were marsupialized by removing scar tissue and bone fragments to allow proper drainage into the
inferior nasal meatus.
A crucial factor to support healing of this reattachment of the IT is
the prevention of
RESULTS
• Mechanical trauma through aggressive aftercare.
• Drying, because both lead to impaired wound healing and an
increased risk of wound dehiscence.
American Journal of Rhinology & Allergy
Postoperative endoscopy revealed no recurrence of the tumor in
any of the cases after a follow-up period of 12–80 months (28 months
on average, calculated for 11 patients). One patient died of esophageal
carcinoma and was therefore only followed up for 2 months. During
e133
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irritation of the ipsilateral frontal teeth. Two patients with IP developed mucoceles in the MS caused by the formation of scar tissue.
Because they were free of symptoms, they have up to now declined
any form of surgery.
DISCUSSION
EEMM is a well-accepted surgical technique for treatment of extended cases of IP. The use of a shaver enables precise removal of the
tumor and drilling of the underlying bone.
Our technique preserves the IT, which plays an important role in
warming and humidifying the inhaled air. Temporary dislocation of
the IT enables the surgeon to resect the piriform aperture and parts of
the anterior wall of the MS (endonasal Denker operation as described
by Bros and Draf8). Reinsertion with one or two dissolving sutures led
to survival of the IT in 100% of our cases under the necessary conditions of moist wound healing. This means occlusion of the nose for at
least 2 weeks, sometime 3–4 weeks. This was well tolerated by all
patients and is the most important step to ensure successful healing of
the IT. Because occlusion was only performed on the operated side
and the patients could breathe through the other unobstructed nasal
cavity, the patients tolerated this well. Mechanical cleaning, which
was performed once a week, did not cause severe pain or bleeding
because the moist wound healing environment prevented the development of major crusting, which convinced the patients to accept
nasal occlusion.
It is important to perform intensive cleaning with removal of blood
clots and fibrin once a week postoperatively for up to 4–6 weeks, if
necessary, to prevent the development of mucoceles. In contrast, care
must be taken not to pull off the healing turbinate.
In comparison with alternative approaches such as a sublabial
transoral approach, midfacial degloving, or lateral rhinotomy, EEMM
can achieve the goal of total tumor removal with the advantage of
avoiding extranasal scars and, in addition, it does not touch the
medial palpebral ligament, it causes minimal trauma to the surrounding tissue of the sinonasal framework, it carries no risk of oroantral
fistula, und it offers lower morbidity and shorter hospitalization.7,14 A
possible recurrent tumor will not find a preformed gateway of invasion into the extranasal tissue.14,19 EEMM may have limitations in the
case of extensive involvement of the MS, especially the anterior and
lateral walls, and/or a large pneumatized MS with a deep alveolar
recess and a protruding infraorbital nerve. In these cases a transseptal
approach is a possible alternative technique for endoscopic resection
of the maxilla and infratemporal fossa.23 Our method provides the
advantage of preservation of the IT. One disadvantage is the resection
of the nasolacrimal duct, which could be preserved in a sublabial
transoral approach.
Numbness of the frontal teeth is caused by a lesion of the superior
alveolar nerve, which runs through the bone of the anterior MS wall
and can be damaged if the piriform aperture is resected (Denker
operation). It is not a complication of the procedure preserving the IT
but of the Denker operation. It is hypothesized that the same numbness would occur if a transoral approach is performed because it is
also necessary to remove bone from the anterior MS wall during this
procedure.
Figure 2. Mucocele of maxillary sinus (MS) after two previous CaldwellLuc operations.
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Figure 3. Preserved and well-healed inferior turbinate (IT) 12 months
postoperatively.
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this period the patient showed normal healing of the nasal and sinus
cavity. In four cases MRI was performed confirming the endoscopic
findings.
All ITs survived dissection and reinsertion and showed a normal
appearance endoscopically (Fig. 3). The openings to the MS via the
inferior and middle meatus were patent. There was no problem with
any MS mucus recirculation in any of the patients. Typically, there
was some extent of lateralization due to the absence of the lateral
nasal wall after EEMM. Both patients with mucoceles were free of
symptoms; the marsupialized cavities were endoscopically patent 12
months postoperatively.
Complications
The patients did not have any specific pain postoperatively and
there was no postoperative bleeding. They all tolerated occlusion for
2–4 weeks. There was only one patient with persistent crusting of the
nose that was caused by a septal perforation after septoplasty elsewhere in addition to heavy smoking and recurrent infections of the
residual MS. All other patients had normal nasal breathing without
any signs of dryness. In three of six cases of endonasal endoscopic
Denker operation patients reported some degree of numbness or
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CONCLUSIONS
In all cases of EEMM we recommend attempting to preserve the IT
by dissecting it at the anterior insertion and reinserting it after the
tumor has been completely removed or a mucocele has been drained.
With permanent occlusion for at least 2 weeks, preservation of the IT
is possible in almost all cases. Aftercare should focus on not pulling
off the healing turbinate and on the prevention of mucoceles caused
by scarring inside the MS.
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