Modified endoscopic medial maxillectomy for chronic maxillary sinusitis

BACKGROUND: Recently, modified endoscopic medial maxillectomy (MEMM) has been described as an alternative technique to open maxillectomy for benign sinonasal neoplasms. However, few reports discuss the efficacy of MEMM for treatment of inflammatory disease of the maxillary sinus. We evaluate the efficacy of MEMM in treating chronic maxillary sinusitis. METHODS: A retrospective review of patients who underwent MEMM for refractory inflammatory disease between December 2002 and September 2004 was performed. All patients were treated with MEMM alone or as part of an endoscopic sinus surgery procedure. Standard demographic data, operative technique, and postoperative follow-up times were collected. RESULTS: Nineteen patients (average age, 57 years) underwent 24 EMMs for chronic maxillary sinusitis refractory to middle meatal antrostomy. All patients failed prior sinus surgery, including 14 Caldwell-Luc procedures. Average follow-up was 19.5 months (range, 10-27 months). One patient has persistent hyperplastic sinusitis that currently requires monthly follow-up and medical treatment. Our only complication was one nasolacrimal duct injury. CONCLUSION: MEMM is both a safe and an effective treatment for chronic maxillary sinusitis refractory to standard medical and endoscopic surgical management.     

A comparative study between endoscopic middle meatal antrostomy and caldwell-luc surgery in the treatment of chronic maxillary sinusitis

Functional endoscopic sinus surgery (FESS) has almost completely replaced the radical Caldwell-Luc approach. About 20?years after its origin of FESS a comparative study with Caldwell-Luc Surgery (C-L) definitely should be on cards to validate the previous results. To compare the effectiveness of endoscopic middle meatal antrostomy and Caldwell-Luc's surgery in the management of Chronic Maxillary Sinusitis. This is a prospective randomized comparative study based on the analysis of eighty patients who were diagnosed to have chronic, unilateral, maxillary sinusitis and underwent surgery, after a failed trial of conservative management. One year after surgery 44% of the C-L patients and 89% of the FESS patients reported distinct improvement of their symptoms. Both are effective in the management of chronic sinusitis. Endoscopic middle meatal antrostomy is superior to Caldwell-Luc in intraoperative and postoperative parameters.     

Surgical revision of the post-Caldwell-Luc maxillary sinus

BACKGROUND: Endoscopic sinus surgeons are commonly faced with the management of patients with persistent maxillary sinusitis despite previous Caldwell-Luc surgery. Given the potential for altered mucociliary clearance in the post-Caldwell-Luc maxillary sinus, the optimal approach for surgical revision has not been well characterized. The objective of this study was to review our experience in endoscopic versus repeat Caldwell-Luc approaches in patients who have failed Caldwell-Luc surgery for chronic maxillary sinusitis. METHODS: Retrospective chart review was performed on patients who had a history of a Caldwell-Luc procedure and who then underwent a surgical revision for persistent maxillary sinusitis at the Oregon Health and Science University and Medical College of Wisconsin between 1983 and 2002. RESULTS: Sixty-eight patients were identified, with a total of 156 revision procedures performed on 103 maxillary sinuses. Fifty-three percent of the sinuses underwent endoscopic maxillary antrostomy as the first surgical revision, while 47% underwent a revision Caldwell-Luc procedure. Sixty-seven percent of the sinuses in the revision endoscopic group had clinical resolution with a single surgical revision, and 60% of the sinuses in the revision Caldwell-Luc group had clinical improvement with one surgical revision (p = 0.46). The endoscopic group averaged 1.3+/-0.5 revision procedures per sinus to achieve clinical resolution, and the revision Caldwell-Luc group averaged 1.7+/-1.0 revision procedures per sinus (p = 0.3). Mean follow-up was 25 months. CONCLUSION: Endoscopic revision of the maxillary sinus yields comparable outcomes to repeat Caldwell-Luc procedure in patients with a history of previous failed Caldwell-Luc surgery. Endoscopic revision surgery is a viable alternative for surgical rehabilitation of the post-Caldwell-Luc maxillary sinus.     

Endoscopic sinus surgery for unilateral chronic sinusitis]

Functional endoscopic sinus surgery has become an increasingly popular treatment for chronic sinusitis. This approach is aimed at re-establishment of ventilation and mucociliary clearance of the sinuses. However, some otolaryngologists believe that the Caldwell-Luc procedure should be routinely used for unilateral chronic sinusitis, because it is often associated with the maxillary sinus carcinomas. To evaluate the state of endoscopic sinus surgery for the diagnosis and treatment of unilateral chronic sinusitis, we analyzed the cases of 39 patients with unilateral chronic sinusitis who underwent endoscopic sinus procedures. These patients were unresponsive to appropriate antibiotic management for more than 6 months. Generally, endoscopic ethmoidectomy and antrostomy were performed with preservation of the middle turbinate. After the ostium was enlarged, the maxillary sinus was cleaned and carefully inspected for the presence of associated neoplasms using 30 and 70 degree endoscopes. Preoperative computed tomography (CT), postoperatve pathologic diagnosis, fiberscopic findings of the maxillary sinus, and symptomatic improvement were evaluated. Three patients had CT evidence of bone destruction of the lateral nasal wall. Pathological diagnosis demonstrated that three patients had maxillary sinus mycoses caused by Aspergillus species, one patient had inverted papilloma, and the other 35 patients had chronic sinusits. No associated malignancy was found. Eighty-one percent of the patients had almost normal endoscopic findings of the maxillary sinus by postoperative fiberscopic examination 4 to 8 months following surgery. With an average follow-up of 26 months, 88% of the patients were judged as having significantly improved in their presenting complaints of mucopurulent rhinorrhea, nasal obstruction, and facial pain. The results of this series suggest that endoscopic sinus surgery is an effective procedure for the diagnosis and treatment of unilateral chronic sinusitis.     

上颌窦囊肿手术进路的选择

目的探讨鼻内镜下3种摘除上颔窦囊肿进路的选择。方法本组上颌窦囊肿共32例,术前均经鼻窦CT扫描和鼻内镜检查,明确鼻腔情况、囊肿的大小及位置。其中8例伴鼻窦炎鼻息肉者,经中鼻道自然口开放术进路行Messerkling术;19例单纯上颌窦囊肿患者,鼻内镜下经改良柯-陆进路行囊肿摘除术,另5例采用下鼻道开窗进路行囊肿摘除术。结果术后随访6个月～1年,鼻窦CT冠状位扫描或鼻内镜检查,19例经改良柯-陆进路者术后无复发;8例经中鼻道自然口开放术进路者,2例复发,1例术后窦口闭锁,中鼻甲与鼻腔外侧壁粘连;5例经下鼻道开窗进路者,1例复发,2例失访。结论3种术式各有优缺点,临床中应根据不同情况酌情选用。     

Nasal antrostomy

With chronic maxillary sinusitis the pathological changes in the diseased mucosa used to be considered irreversible, thus necessitating its radical removal, which is only possible with the Caldwell-Luc operation. The discovery of the reversibility of the pathology caused a shift from the Caldwell-Luc towards endonasal procedures, of which the inferior meatal antrostomy became the most widely used. Nasendoscopy, later combined with computed tomography, led to the development of the concept of the osteomeatal unit, and hence the functional endoscopic sinus surgery, which is concentrated round the infundibulum region. In view of possible risks and complications of that method it is propagated here to differentiate between these two techniques: When the focus of chronic sinusitis appears to be situated in the infundibulum/anterior ethmoid region, the functional endoscopic surgery seems preferable; For cases where the inflammatory process was restricted largely to the maxillary sinus a modified inferior meatal antrostomy technique proved to have a 92% success rate in 378 sinuses.     

Intra- and postoperative application of Mitomycin C in the middle meatus reduces adhesions and antrostomy stenosis after FESS

AIM: Obstruction of the osteomeatal complex is the commonest anatomic finding in revision endoscopic sinus surgery. This study assesses the efficacy of topical mitomycin C in the middle meatus, intra- and postoperatively in the prevention of adhesion formation and restenosis of the maxillary sinus antrostomy. MATERIALS AND METHODS: At the end of endoscopic surgery for chronic rhinosinusitis and four weeks postoperatively 30 patients received a pledget soaked with 1 ml of mitomycin C (0.5 mg/ml) in the middle meatus for 5 minutes while a pledget soaked in saline was placed in the contralateral side. Patients were assessed at least 6 months postoperatively by a blinded observer for the presence of synechiae and antrostomy stenosis. Medical records were reviewed for episodes of recurrent sinusitis. RESULTS: Adhesions were observed in 8 patients. All adhesions rated as moderate to severe (4 patients) were observed in the control side (p = 0.043). Restenosis was observed in 2 sides treated with mitomycin C and in 9 control sides (p = 0.032). Recurrent symptoms of sinusitis occurred in three patients on the saline side. CONCLUSION: Mitomycin C is safe and effective in the prevention of severe adhesions and antrostomy stenosis when applied twice, during surgery and the early postoperative period.     

Management of odontogenic sinusitis with persistent oro-antral fistula

Sixteen patients were treated for odontogenic sinusitis secondary to persistent oro-antral fistula. Males outnumbered females 12 to 4. Frequency of presentation increased directly with age. Chronic signs and symptoms included facial pain, swelling, tenderness and nasal and oral discharge. The clinical diagnosis of chronic sinusitis was confirmed in all cases by radiographic findings. An opacified maxillary sinus with or without ethmoid involvement was observed in all 16 patients. Surgical pathology revealed chronic mucosal thickening and/or antral polyps in 69% of the cases. Surgical treatment of the sinusitis consisted of antrostomy alone or in combination with Caldwell-Luc procedure. The oro-antral fistula was repaired with mucosal flaps from the buccal and/or palatal region. No postoperative recurrences have been noted during a follow-up period of six months to seven years. Bacterial cultures grew out pure aerobes (44%) or mixed aerobic-anaerobic bacteria (44%). None yielded pure anaerobes. The bacteriologic spectrum was notably lacking in S. pneumoniae and H. influenzae and differed from organisms commonly found in sinusitis of rhinogenous origin.     

Endoscopic partial medial maxillectomy with mucosal flap for maxillary sinus mucoceles

Purpose

To describe a technique of endoscopic medial maxillectomy with mucosal flap for postoperative maxillary sinus mucoceles and to present a case series of subjects who underwent this procedure.

Materials and methods

This case series includes four subjects with postoperative maxillary sinus mucoceles who underwent resection via endoscopic partial medial maxillectomy with a mucosal flap. We will discuss the clinical presentation, imaging characteristics, operative details, and outcomes.

Results

Four subjects are included in this study. The average age at the time of medial maxillectomy was 52 years (range 35–65 years). Three subjects (75%) were female. One subject (25%) had bilateral postoperative maxillary sinus mucoceles. Two subjects (50%) had unilateral right sided mucoceles, and the remaining subject had a unilateral left sided mucocele.All subjects had a history of multiple sinus procedures for chronic sinusitis including Caldwell–Luc procedures ipsilateral to the postoperative mucocele. All subjects underwent endoscopic medial maxillectomy without complication and were symptom free at the last follow up appointment, average 24 months (range 3–71 months) after medial maxillectomy.

Conclusions

For postoperative maxillary sinus mucoceles in locations that are difficult to access via the middle meatus antrostomy, we recommend endoscopic medial maxillectomy with mucosal flap. Our preliminary experience with four subjects demonstrates complete resolution of symptoms after this procedure.     

Endoscopic transnasal surgery in antrochoanal polyp

The current treatment of antrochoanal polyp is simple avulsion of the nasal part with or without removal of the antral part. The antral part is removed through a Caldwell-Luc antrostomy, inferior meatal antrostomy, or middle meatal antrostomy. In this study, endoscopic surgery was performed in 22 cases of antrochoanal polyps where the antral part was removed through the middle meatus. Two new instruments were designed to help complete removal of the antral part of the polyp through the maxillary ostium. Some points of controversy concerning the antrochoanal polyp are discussed according to the diagnostic and therapeutic endoscopic findings. Endoscopic follow-up of these cases for periods ranging between 6 and 30 months, with an average of 20 months, showed no recurrence. It was concluded that endoscopic surgery of the antrochoanal polyp through the middle meatus could be performed as an outpatient procedure, and is safe and reliable.     

A proposal for endonasal middle meatal antrostomy

With increase of cases with mild chronic sinusitis, especially the cases combined with nasal allergy, endonasal sinus surgery has been substituted for Caldwell-Luc or some other modified sinus surgery in recent years. The classical inferior meatal antrostomy for maxillary sinusitis is one of the treatments of choice, though this opening is easily closed and is somewhat different from normal sinus physiology. In the middle meatal antrostomy, the opening was made via the inferior turbinate or the middle meatal wall perforated with nasal forceps. Reported here is a new technique for middle meatal antrostomy which can be easily and safely performed. At the beginning, mucosal incision is made from the agger nasi to the anterior of the inferior turbinate, dividing the mucous membrane inferomedially. Then the mucous membrane of the inferior turbinate is cut along the upper margin of it and reflected downwards. With this procedure, the frontal process of the maxilla, lacrimal bone and inferior turbinate are well exposed and well oriented in the surgical field. The pars membranacea is then cut from anterior to inferior, and removed with the uncinate process, thus entering the maxillary antrum. The antrostomy opening is made at least 1 by 1.5 cm wide. Then, the intranasal ethmoidectomy is usually done and the reflected mucous membrane of the inferior turbinate returned to its normal position. This surgery was applied to 34 patients (7 children, 27 adults), (2 antrochoanal polyps, 5 optic neuritis, 3 maxillary sinusitis, 17 pansinusitis, and 7 pansinusitis associated with nasal allergy). We have not experienced surgical complications and none of them also had closure of the antrostomy opening.(ABSTRACT TRUNCATED AT 250 WORDS)     

内窥镜鼻窦手术治疗儿童慢性鼻窦炎

儿童鼻窦的解剖特点决定了在儿童的慢性鼻窦炎中，上颌窦炎最常见，自１９９０年以来，我院对５１例（９７侧）经药物和上颌窦穿刺冲洗失败患儿行内窥镜下鼻窦手术。其中大部分（５０例）有慢性上颌窦炎，１０冽有中鼻甲水肿和息肉样变，６例有筛窦炎。行上颌窦中鼻道开窗术１００侧次，筛窦开放术１２侧次，中鼻甲部分或全部切除术３２侧次，手术后２０例头痛消失，４３例鼻呼吸通畅，３７例黄脓涕消失，疗效满意，故内窥镜鼻窦手术是目前治疗儿童慢性上颌窦炎较为理想的方法。     

鼻窦传统手术的转归

目的：通过询问病史、ＣＴ扫描及鼻内窥镜检查观察上颌窦根治术后鼻窦炎复发患者的面部症状、鼻窦骨及软组织,从病理生理学角度分析探讨上颌窦根治术后局部组织病理学变化对术后转归的影响,并以此观察分析作为基础,建议合理掌握传统手术及鼻内窥镜手术适应证范围。方法：对２８７例（３８２侧）既往曾行上颌窦根治术（Ｃａｌｄｗｅｌｌ－Ｌｕｃ）后鼻息肉复发患者进行再手术前鼻窦ＣＴ扫描,并观察前期手术后患者面部感觉,上颌窦骨质增生及窦腔容积缩小程度及中鼻道或下鼻道自然口或人工开窗口情况。结果：术后出现慢性鼻窦炎症状的全部被观察患者,２７．５％出现面部症状,４３．６％出现骨质增生引起窦腔容积变小甚至消失。此外还出现上颌窦自然口或下鼻道开窗口完全瘢痕闭锁。结论：有必要重新对各种传统鼻窦手术的适应证重新定义,对手术适应证的概念进行调整修正,以达到在彻底清除病变的基础上减低并发症、控制复发率。     

Implications of endoscopic endonasal surgery for the treatment of postoperative maxillary mucoceles

Recently, endoscopic endonasal surgery has been widely used to treat chronic sinusitis with good results being reported by many investigators. Endoscopic endonasal surgery is a technique available not only for chronic sinusitis but also for other sinus diseases including postoperative maxillary mucoceles. In this report, the indications and limitations of endoscopic endonasal surgery for the treatment of postoperative maxillary mucoceles are discussed based on our experience treating 26 such mucoceles at our clinic. The indications for endoscopic endonasal surgery include mucoceles in close contact with the lateral wall of the inferior nasal meatus and those mucoceles that can be widely opened to the middle nasal meatus. The following cases could not be treated by endoscopic endonasal surgery: mucoceles that were localized in areas distant from the nasal cavity, mucoceles in which the lateral wall of the inferior nasal meatus was bony and intensely thickened, and mucoceles that could not be sufficiently opened to the middle nasal meatus.     

What are the advantages of the endoscopic canine fossa approach in treating maxillary sinus aspergillomas?

Aspergilloma of the maxillary sinus is a non-invasive mycotic infection of the immunocompetent host. Nowadays its treatment remains surgical removal, and endoscopic endonasal middle meatus antrostomy is retained as the most popular approach. In our experience, a complementary endoscopic canine fossa approach is often needed to achieve a complete resection of the fungus ball. This fact led us to ask ourselves if an isolated endoscopic canine fossa approach had any advantages over the endonasal middle meatus antrostomy. In this paper we retrospectively analyse the results of the surgical treatment of 31 patients presenting maxillary sinus aspergillomas. These patients were all operated between January 1997 and January 2003 in our Otolaryngology Department. They were divided in three groups. Group A included 10 patients operated through an endonasal middle meatotomy only, group B included 9 patients who were operated through a combined approach (endonasal middle meatus antrostomy and endoscopic canine fossa approach), and group C included 12 patients who were operated through an endoscopic canine fossa approach alone. No recurrences were noted in any group, but in group B three patients presented mild complications like persistent purulent discharge through the meatotomy and nasal crusting. The endoscopic canine fossa approach offers several advantages over other techniques. These include an optimal visualization of all maxillary sinus walls and recesses, the possibility of performing the procedure under local anaesthesia and on an outpatient basis, the preservation of the anatomy and physiology of the natural maxillary ostium and an easy removal of the eventual foreign bodies of dental origin in the sinusal cavity that could favourite the development of an aspergilloma.     

A comparison between middle and inferior meatal antrostomy in the treatment of chronic maxillary sinus infection

Intranasal antrostomy has been performed in a series of 38 adult patients with either bilateral chronic or recurrent acute maxillary sinusitis which had failed to respond to medical treatment. In each patient, the antrostomy opening was made in the middle meatus of one side and in the inferior meatus of the opposite nasal cavity, laterality being randomised. A points' system was employed for comparing the pre- and post-operative symptoms, clinical and roentgenological findings. Symptoms and clinical findings were significantly improved following both types of antrostomy, while the roentgenological findings were essentially unchanged. Comparison of middle and inferior meatal antrostomies revealed no significant difference.     

Maxillary sinus mucoceles: clinical presentation and long-term results of endoscopic surgical treatment.

OBJECTIVE: To describe the clinical presentation of maxillary sinus mucoceles, understand their pathogenesis, and determine the long-term efficacy of the endoscopic surgical treatment. STUDY DESIGN: Retrospective review. METHODS: Thirteen consecutive patients who presented with maxillary sinus muco(pyo) celes were studied. Subjects with history of preceding sinus/nasal surgery or facial trauma were excluded. The presenting signs and symptoms, radiological findings, and surgical management were reviewed. RESULTS: There were six women and seven men with an age range of 31 to 71 years. Two patients had environmental allergies. Nine patients complained of cheek pressure or pain, six of nasal obstruction, and eight of nasal drainage. On endoscopic nasal examination, the medial wall of maxillary sinus was bulging with prolapsed middle meatal mucosa in 10; drainage was seen in 7, but none had polyps. The sinus involvement was limited to the maxillary sinus and the ipsilateral ethmoid on computed tomographic studies in 10 cases. Patients were treated with endoscopic ethmoidectomy, middle meatal antrostomy, and marsupialization of the mucocele. Intraoperative cultures grew organisms in five patients. Postoperative follow-up ranged between 10 and 66 months. Two patients required lysis of adhesions in the middle meatus, and one, revision antrostomy. All patients had a patent middle meatal antrostomy and healthy maxillary sinus mucosa at latest follow-up. The presenting symptoms resolved or improved in 12 cases. CONCLUSIONS: The etiology of maxillary sinus mucoceles is not well understood. Mechanical obstruction or allergy or both do not seem to play an important role. An infectious origin is also not supported by the above data. Endoscopic sinus surgery is a reliable therapeutic measure with a favorable long-term outcome.     

Short and long-term treatment results in chronic maxillary sinusitis

The diagnostic criteria and the length of the observation period are essential factors influencing the results of treatment of maxillary sinusitis. In 198 patients (244 sinuses) with chronic maxillary sinusitis of either rhinogenous or dental etiology all patients were judged as cured or improved at the short-term control 1-3 months after completion of therapy. The long-term observation (mean 3.5 years) revealed different figures of healing. Satisfactory results after conservative therapy were seen in only 34% while the Caldwell-Luc operation gave good results in 80%. In sinusitis of dental origin, dental treatment combined with local sinus surgery was successful in 90%. In 78 sinuses investigated by sinoscopy, discrepancy between the symptoms and the endoscopic findings was seen in 14 cases (18%). Information obtained by questionnaire is therefore unreliable. In 30 sinuses operated upon with the Caldwell-Luc procedure, discrepancy between radiographic and endoscopic findings was seen in 3 cases (10%). Contributory factors, e.g. nasal polyps, dental infections and nasal allergy were found in 48 out of 84 sinuses not completely healed at the long-term control. Patients treated for chronic maxillary sinusitis must be followed up over a long period. A clinical control after 1-2 years, including sinoscopy or sinus radiographs, is recommended even in patients free from symptoms of sinusitis. Sinoscopy seems to be more reliable than sinus radiography and should be performed if the sinus radiographs show any pathology. The patients are also recommended to visit their dentists regularly, due to the close relationship between dental infections and chronic maxillary sinus diseases.     

Patency Rate of Endoscopic Middle Meatus Antrostomy

A series of 145 patients with chronic sinusitis were treated with functional endoscopic sinus surgery. Patency of the middle meatus was evaluated by actuarial life-table methods. After 24 months' followup, the overall patency rate of endoscopic middle meatotomy was 94.08%. Questionnaire data indicated that 91.8% of these patients were improved or asymptomatic. This preliminary study indicates that the patency rate of middle meatal antrostomy appears to be greater than that of inferior meatal antrostomy when compared to literature controls, and that a high percentage of these patients are improved by this surgery.     

Caldwell-Luc operation in the treatment of childhood bronchial asthma

A follow-up study was carried out in 15 children with severe bronchial asthma. Chronic infection of the paranasal sinuses was connected with the unfavorable course of their bronchial asthma. As adenoidectomy and intranasal antrostomy had failed to cure the sinusitis, the Caldwell-Luc operation was performed at the age of 6–16 years. The follow-up examination was done 3–12 years after the radical operation of the maxillary sinuses. The majority of the patients had normal working capacity, and the need of medical treatment was reasonable. It is concluded that the Caldwell-Luc operation is indicated in children with severe bronchial asthma, when repeated respiratory infections are associated with asthmatic attacks and adenoidectomy and intranasal antrostomy have proved ineffective.