Top 10 Reasons for Endoscopic Maxillary Sinus Surgery Failure

Objective/Hypothesis Endoscopic sinus surgery has enjoyed impressive success curing chronic disease in sinuses and has virtually replaced the Caldwell‐Luc procedure for correction of problems with the maxillary sinus. Unfortunately, a significant number of patients have persistent maxillary symptoms after one or more endoscopic sinus operations. Existing reviews of this issue have identified only a few general causes for surgical failure. Methods The records of 85 patients presenting to the author over a 5‐year period with persistent maxillary sinus symptoms were reviewed. Results In reviewing the causes of persistent disease requiring revision surgery, the author identified 10 categories of reasons for failure to improve. Many patients have multiple causes that could be individually or sequentially identified. Some problems associated with surgical failure were likely present at the time of initial presentation, whereas others were undoubtedly caused by the first surgical procedure. Ten reasons for maxillary sinus surgical failure identified were clustered into the following categories: 1) obstructed natural ostia, 2) disease in the anterior ethmoid or frontal sinus, 3) resistant organisms, 4) intrasinus foreign body, 5) incurable mucosal disease, 6) noncompliant patient, 7) wrong primary diagnosis, 8) maxillary osteitis, 9) mucus maltransport, and 10) fundamental immunodeficiency. Conclusions A careful assessment of each patient with persistent maxillary sinus disease is central to understanding each specific patient and should include a careful history, a detailed endoscopic examination, repeat computed tomography imaging, culture of secretions, and possible revision surgery.     

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.     

鼻内窥镜术上颌窦自然开口的处理

目的探讨内窥镜鼻窦手术治疗慢性鼻窦炎、鼻息肉的上颌窦中鼻道开口的重要性及处理方法。方法配对研究５６例双侧鼻窦炎、鼻息肉患者，比较同一患者术中扩大或不扩大上颌窦自然开口的术后情况。结果窦口的开放率在不扩大和扩大上颌窦自然开口的术侧中分别为９２．９％和８０．４％（随访６个月时）。回顾性观察５１例施ＣａｌｄｗｅｌＬｕｃ术的患者，下鼻道造口的术后开放率仅为４０．６％。分析３８张单侧鼻窦炎或鼻息肉的鼻窦ＣＴ片，测量对照侧与病变侧的上颌窦口膜样部的上下径和前后径，差异无显著性。病变侧上颌窦口周围的中鼻甲气化、增生及钩突偏曲、筛泡骨性增生等解剖结构异常的发生率明显高于对照侧（Ｐ＜０．０５）。结论鼻内窥镜下处理上颌窦自然开口的关键是窦口周围的解剖异常因素。     

单侧上颌窦良性占位性病变手术入路临床分析与疗效

目的：探讨单侧上颌窦良性占位性病变的手术治疗方法及疗效。方法：对2005—06—2012-06接受鼻内镜手术治疗且有完整随访资料的84例单侧上二颌窦良性占位性病变患者的临床资料进行分析。其中采用单纯鼻内镜手术59例,采用鼻内镜联合改良Caldwell-Luc术式18例,采用鼻内镜联合F鼻道开窗15例,采用鼻内镜F泪前隐窝入路12例,并对术后情况进行随访。结果：全部患者随访4个月～7年,仅5例在手术后复发,其余81例在随访期内均未见复发。所有患者术前行鼻内镜、CT或MRI检查,并经术后病理检查证实。结论：上颌窦良性占位性病变以囊肿、真菌性上颌赛炎多见;根据上颌窦良性占位性病变的不同临床特点,可采用不同手术人路,既可有效治愈上颌窦病变,又可最大限度地减少手术创伤。鼻内镜手术是治疗上颌窦良性占位性病变的首选术式。     

两种术式治疗非侵袭性真菌性上颌窦炎疗效的比较

［摘要］目的：比较柯-陆氏手术和鼻内窥镜手术治疗非侵袭性上颌窦炎的疗效。方法：30例中，单纯真菌性上颌窦炎27例，真菌性上颌窦炎合并筛窦炎3例。12例行柯-陆式手术，18例行功能性鼻内窥镜手术。结果：柯-陆氏手术治愈11例，治愈率91.67%；功能性鼻内窥镜手术治愈16例，治愈率88.89%，两组差异无统计学意义（P＞0.05）。结论：柯-陆氏手术和鼻内窥镜手术治疗非侵袭性上颌窦炎效果确切，应根据患者的病情施术。     

Bilateral antrochoanal polyps originated from inferior meatal antrostomies

We present the first reported case of simultaneously occurring bilateral antrochoanal polyps in a 49-year-old female patient, originated from previously performed inferior antrostomies as a treatment for chronic maxillary sinusitis. The antrochoanal polyps were removed by endoscopic surgery with combined approach through the inferior and middle meatal antrostomies. Microscopic analysis of the specimens showed benign inflammatory antrochoanal polyps. Follow-up appointment 6 months postoperatively showed patent antrostomies and no recurrence of the disease. Endoscopic treatment with middle meatal antrostomy is the recommended technique in most cases of antrochoanal polyps as the greater portion of the antral part of the polyp can be removed with the healthy antral mucosa left intact promoting epithelialization and mucociliary clearance of the antrum. Inferior antrostomy can be an additional part of the operation in selected cases.     

两种不同的手术方式治疗真菌性鼻-鼻窦炎

目的：比较鼻内镜下上颌窦开放术和鼻内镜下上颌窦开放术+柯-陆(Caldwell Luc)手术治疗真菌性鼻-鼻窦炎的疗效。方法:将30例随机分成两组，A组15例，采用鼻内镜下上颌窦开放术（简称开放式手术）；B组15例，采用开放术联合柯-陆手术（简称联合式手术），术后用1%H202及生理盐水冲洗,不用抗真菌药。结果:随访1～3 年,开放式手术组15例中治愈5例，术腔完全上皮化，症状消退；好转4例，局部有迁延性炎症,少量脓性引流,开口缩小；复发6例,窦口闭塞,窦腔内再次出现真菌样沉积物堆积。联合式手术组15例中治愈12例，好转3例，无真菌性炎症复发，两组比较差异有统计学意义（P＜0.01)。两种术式均无并发症发生。结论:本研究结果表明,采用尖牙窝、上颌窦自然开口双径路治疗真菌性上颌窦炎的优势在于清除病变彻底,使鼻窦建立足够的通气引流通道，彻底改变了真菌生存的低氧环境,且能保存上颌窦黏膜的正常生理功能，可避免传统方法引起的狭窄、闭锁、引流不畅以及上颌窦通气不良、功能恢复不佳等缺点。此术式创伤小,能真正达到根治、微创目的。     

Caldwell—Luc进路联合鼻内镜治疗上颌窦病变

目的 探讨治疗上颌窦良性病变较好的手术方法。方法 采用传统的Caldwell—Luc手术进路与鼻内镜手术联合治疗39例上颌窦病变。上颌窦息肉12例，其中伴鼻腔筛窦息肉7例，出血坏死性息肉3例，上颌窦后鼻孔息肉2例；上颌窦、筛窦息肉术后复发9例；慢性上颌窦炎3倒；真菌性上颌窦炎7例；上颌窦囊肿5例；上颌蜜内翻性乳头状瘤2例；上颌窦炎性假瘤1例。结果 39例经6个月～3年的随访，治愈32例（82．1％），好转6例（15．4％）．1例炎性假瘤术后1个月复发并发眶内感染，总有效率为97．4％。结论 Caldwell—Luc手术联合鼻内镜治疗上颌窦病变。视野清楚，操作方便．既能彻底清除病变，叉保证了窦内黏膜纤毛系统功能的恢复，减少了复发率。     

Endoscopic trans-nasal-vestibular approach to the maxillary sinus--application for mucoceles of the maxillary sinus.

Endoscopic endonasal surgery has been applied to the treatment of paranasal mucoceles. The approach is, however, hard to be adopted for maxillary mucoceles when the cyst is situated in the anterior and/or lateral portion of the maxillary sinus, has a thick bony lateral wall of the inferior nasal meatus, and when the patients develop compartmentalized cysts following facial trauma or sinus operation. We devised an endoscopic approach via the vestibule of the nose to reach any part of the maxillary sinus and applied it for the treatment of postoperative maxillary mucoceles, which could not be opened following the usual endoscopic approach with favorable outcomes.     

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.     

Diagnosis and pathology of unilateral maxillary sinus opacification with or without evidence of contralateral disease

OBJECTIVE: Determine the diagnostic criteria and etiology of complete unilateral maxillary sinus opacification. METHODS: A prospective analysis was performed on patients presenting to a tertiary care rhinology practice with complaints of chronic rhinosinusitis or acute exacerbation. Sixty-four consecutive patients were identified with unilateral maxillary sinus opacification on computed tomography (CT) scan after at least a 3-week medical therapy for rhinosinusitis. The study population comprised 30 men and 34 women with a mean age of 47.0 years. All patients completed a symptom score questionnaire, received nasal endoscopy, and CT imaging. Patient symptoms and endoscopic and radiographic findings were analyzed to determine patterns related to final diagnosis. RESULTS: All 64 patients underwent functional endoscopic sinus surgery. Each surgical specimen was sent for pathologic confirmation of the diagnosis. Sixteen mucoceles, 12 cases of nasal polyposis, 27 cases of acute or chronic sinusitis, 7 cases of inverting papilloma, and 2 cases of mycetoma were identified. Endoscopic and radiographic appearances were correlated with each disease process. CONCLUSION: Unilateral maxillary sinus opacification is a relatively common finding. Early identification of inverting papillomas and mucoceles may avoid delay in surgical intervention, whereas acute/chronic rhinosinusitis and nasal polyposis can initially be managed medically. Careful history, endoscopic examination, and radiographic studies can often determine the responsible disease process.     

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.     

Efficacy of endoscopic sinus surgery for paranasal sinus mucocele including modified endoscopic Lothrop procedure for frontal sinus mucocele

This study evaluated the efficacy of the modified endoscopic Lothrop procedure (MELP) for complicated frontal mucoceles and endoscopic marsupialization for other paranasal sinus mucoceles. It was a retrospective, consecutive case review of sinus mucoceles treated endoscopically by a single surgeon over a four-year period (1998-2002). There were 41 mucoceles in 28 patients, including 24 frontal, eight frontoethmoidal, three ethmoidal, five maxillary and one frontal mucocele. Twenty-one patients underwent the modified Lothrop procedure for frontal mucoceles, and seven underwent simple drainage and marsupialization for frontoethmoidal, ethmoidal and maxillary mucoceles. At median follow-up of 16 months, all patients had a patent mucocele opening. Patients treated by drainage and marsupialization did not have any complications or mucocele recurrence. All patients treated by the modified endoscopic Lothrop procedure had improvement in symptoms and signs. Four patients had minor complications including epistaxis and adhesions and five required further surgery. The average hospital in-patient stay was 2 +/- 1.4 days. Endoscopic techniques, including MELP are effective in the short term for the management of complex and simple paranasal sinus mucoceles. MELP has a useful place in the management of mucoceles with a significant bony partition from an adjacent sinus or nasal cavity. It is also indicated when the mucocele is associated with loss of lateral support in the sinus with risk of medial-wall collapse of the orbital contents obstructing drainage.     

复发性鼻息肉的鼻内窥镜修正术

目的：探讨鼻内窥镜修正术治疗复发性鼻息肉的疗效和手术体会。方法：回顾分析１９９７年７月－１９９８年１０月间２１例因鼻息肉复发在我院行鼻内窥镜修正术的患者,２１例均双侧同时手术,根据ＣＴ所见及术中情况,采用筛窦全切或次全切,上颌窦自然窦口扩大,尖牙窝径路上颌窦病变组织清除等手术方式。结果：随访６－１２个月评定疗效,治愈７傅,好转８例,无效６例,总有效率７１．４％,无一例出现严重并发症。结论：鼻内窥镜     

Maxillary Sinus Retention Cysts Protruding Into the Inferior Meatus

Although most of the maxillary sinus retention cysts are asymptomatic, a few of them increase in size and cause symptoms. However, they rarely erode bony walls nor protrude into the inferior meatus. I present 2 cases with maxillary sinus retention cysts protruding into the inferior meatus by making a large defect on the medial wall of the maxillary sinus.     

鼻内镜下鼻泪管前径路和后径路切除上颌窦良性病变

目的 探讨鼻内镜下上颌窦内侧壁入路切除上颌窦良性病变的手术径路及手术方法的可行性及疗效.方法 2003年6月至2010年8月,采用鼻内镜下经鼻腔鼻泪管前径路和鼻泪管后径路的多种方式切除上颌窦良性病变139例,其中内翻性乳头状瘤43例、真菌性上颌窦炎63例、上颌窦囊肿28例、出血坏死性息肉3例、骨瘤2例.所有病例术前行CT检查,可疑内翻性乳头状瘤患者同步行MRI检查.鼻泪管前方径路采取3种方式:梨状孔入路、泪前隐窝入路(包括解剖鼻泪管和不解剖鼻泪管2种方式)、梨状孔鼻泪管人路,共治疗97例;鼻泪管后方径路也采取3种方式:下鼻甲翻转、双蒂下鼻甲、单蒂下鼻甲,共治疗42例.观察患者术后疗效.结果全部病例在鼻内镜下经鼻彻底清除病变,保护了鼻泪管,保留了下鼻甲,无一例发生鼻泪管损伤和下鼻甲坏死.术后鼻塞、头痛、闷胀不适、异味、牙疼和麻木感等症状逐步消失.9例感觉鼻腔干燥,经鼻腔冲洗等处理后1个月左右逐渐消失.随访6 ～79个月,骨瘤和出血坏死性息肉未见复发.所有真菌性上颌窦炎患者术中均可见窦腔黏膜明显水肿、增厚,术后3个月左右逐渐消失,无一例复发.2例上颌窦囊肿患者术后10个月和18个月在上颌窦其他部位再发,但囊肿小且无临床症状未作处理.内翻性乳头状瘤患者有3例复发,1例术后17个月上颌窦口上方局限性肿物突出,病理示乳头状瘤复发,门诊予以清理后随访1年未见复发;1例于术后15个月前筛处复发,行筛窦广泛切除后随访3年未见复发;1例术后26个月上颌窦后外侧壁局部复发,二次行蒂在前方单蒂下鼻甲方式手术,术后1年再次复发,行鼻内镜下Denker手术,随访18个月未见复发征象.所有病例术后3个月上颌窦创面上皮、瘢痕覆盖,下鼻甲形态良好,下鼻道开窗者较术中明显瘢痕变小,且引流通畅无闭锁.结论鼻内镜下鼻泪管前、后径路上颌窦手术可以减小创伤,充分暴露窦腔视野,并为术后内镜复查和复发后的处理提供了视窗;保留下鼻甲避免了鼻腔外侧壁去除过多而导致的术后干燥、结痂、头痛等并发症.     

Endoscopic treatment of antrochoanal polyps

The antrochoanal polyp (Killian polyp) is an infrequent, benign neoplasm, which arises from the maxillary sinus to reach the ipsilateral choana. The treatment of this disease is essentially surgical, by means of a wide antrostomy. The aim of the study was to compare the results obtained on 23 consecutive cases of antrochoanal polyps endoscopically treated between February 1997 and January 2000 with those reported in the literature, with particular regard to the surgical technique adopted, the histological features, the patterns of its development and the clinical outcomes. The histology revealed in most of the cases a cystic aspect surrounded by edematous stroma. In all cases the polyp emerged from the middle meatus, mostly starting from the upper-lateral (zygomatic) wall of the antrum. All patients were endoscopically followed-up for an average period of 39 months (17–61). We observed two recurrences, both in pediatric cases who evidently underwent an incomplete surgical removal of antral mucosa at its inferior aspect, probably due to the fear of damaging the teeth buds. We did not observe any postsurgical complication. Our data indicate the endoscopic middle meatal antrostomy as the optimal approach, also for the revision cases and in children.     

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 management of 108 sinus mucoceles

OBJECTIVES/BACKGROUND: Traditional teaching has emphasized the need for complete removal of sinus mucoceles to achieve a cure. However, with the introduction of endoscopic sinus surgical instruments and techniques, there has been a trend toward transnasal endoscopic management of sinus mucoceles. The aim of this study is to establish the efficacy of endoscopic management of sinus mucoceles. STUDY DESIGN: Retrospective review. PATIENTS AND METHODS: Between 1988 and 2000, 103 patients with 108 paranasal sinus mucoceles were treated endoscopically. This series includes 66 frontal and frontoethmoid, 17 ethmoid, 7 sphenoethmoid, 12 sphenoid, and 6 maxillary mucoceles. Ninety patients (83.3%) had intraorbital extension and 85 of them presented with some degree of proptosis or eye displacement. Sixty patients (55.5%) had erosion of the skull base with varying degrees of intracranial extension of the mucocele. Follow- up ranged from 1 to 131/2 years with a median of 4.6 years. INTERVENTION: All patients underwent endoscopic-wide marsupialization of the mucocele cavity. Stents were used in frontal mucoceles only. RESULTS: Recurrence of a frontal mucocele was seen in 1 patient (0.9%). In 5 patients, out of 23 patients who presented with massive pansinus polyposis in addition to the mucocele, recurrent polyposis required revision surgery. However, the mucoceles did not recur in those patients. CONCLUSIONS: There is increasing evidence in the literature that endoscopic management of sinus mucoceles results in long-term control with recurrence rates at or close to 0%. Rhinologic surgeons should consider the endoscopic technique as the surgical treatment of choice.     

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。