Modified transnasal endoscopic medial maxillectomy with medial shift of preserved inferior turbinate and nasolacrimal duct

Authors


  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

Although transnasal endoscopic medial maxillectomy (TEMM) is effective for the treatment of inverted papilloma (IP) in maxillary sinus (MS), it involves resection of the inferior turbinate (IT). TEMM also involves resection of the nasolacrimal duct (ND) in many cases to gain better access. Therefore, we developed a novel procedure in which the preserved IT and ND are shifted medially for a complete resection of IP in the MS. Incision was made in the mucosa of the lateral wall along the anterior margin of the IT. After removal of the medial maxillary wall except the ND and the lateral nasal mucosa, the anterior lateral mucosa of the nose, including the IT and the ND, was shifted in the medial direction to allow wider access to the MS. The tumor was removed together with the attachment through the anterior side of the ND. This modified TEMM was performed in 10 patients with IP. The IT and ND were preserved in all patients. We have not observed epiphora after this surgery. The advantages of the novel approach presented herein include: 1) preservation of the IT, ND, and lateral nasal mucosa; 2) wide access to the MS by shifting the IT, ND, and lateral nasal mucosa in the medial direction; and 3) direct access to the MS through anterior space of the ND, resulting in easier operation with a straight endoscope and instruments. This approach is a safe and effective method to obtain wide and straight access to the MS and to resect IP in the MS.

INTRODUCTION

Transnasal endoscopic medial maxillectomy (TEMM) is effective for the treatment of inverted papilloma (IP) in the maxillary sinus (MS).1–3 However, it involves resection of the inferior turbinate (IT) and lateral wall of the nasal cavity, resulting in persistent crusting, lack or reduction of warming and humidifying of inhaled air, and other disadvantages. TEMM also involves resection of the nasolacrimal duct (ND) in many cases to gain better access. Even with resection of the ND, good access to the lateral and anterior walls of the MS is difficult to obtain. Therefore, we developed a novel procedure in which the preserved ND, IT, and lateral wall of the nasal cavity are shifted medially for a complete resection of IP in the MS.

SURGICAL METHOD

This modified TEMM was performed under general or local anesthesia in patients with IP in the MS. Surgical pledgets soaked in saline lidocaine and adrenaline were applied in the nasal cavity or around the tumor (Fig. 1A and 1B). The apertura piriformis and the area anterior to the uncinate process were infused with lidocaine adrenaline. A vertical incision was made in the mucosa of the lateral wall along the anterior margin of the IT to the nasal floor. The lateral nasal mucosa was separated from the medial maxillary wall bone with a suction elevator up to the unicinate process to preserve it. Osteotomy of the medial maxillary wall bone was then performed. The ND was identified and conserved. The bone around the ND was removed with care not to damage the ND. After osteotomy of the medial maxillary wall, the periosteum and mucosa in the MS was identified (Fig. 1C). Incision of the MS periosteum and mucosa allowed entry into the MS.

Figure 1.

During the operation. (A, B) The inferior turbinate (IT) was identified by adrenaline shrink and medial shift of the inverted papilloma (IP) and polyp. (C) Identification of the nasolacrimal duct (ND) and mucosa and periosteum of the maxillary sinus (MM). (D) View with medial direction shift of IT and ND. (E) Sutured IT. MS = maxillary sinus. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Osteotomy of the anterior wall of the MS was added if necessary to obtain better access to the MS (Fig. 2). After exfoliation of the apertura piriformis from the anterior margin of the IT, the anterior wall of the maxillary bone was exfoliated via the apertura piriformis with a lateral margin inside the infraorbital foramen (IF). Further exfoliation below the IF and inside the cheek bone as the lateral margin was added as necessary. Dissection of the apertura piriformis and anterior MS bone was then performed.

Figure 2.

Schema of the surgical approach. (A, B) The nasolacrimal duct (ND) and inferior turbinate (IT) are shifted in a medial direction to allow wider access to the maxillary sinus. The tumor in the maxillary sinus is seen directly. (C) The anterior wall of the maxillary bone inside the infraorbital foramen (IF) as the lateral margin is removed if necessary to obtain better access. More dissection below the IF and inside the cheek bone as the lateral margin may be added if necessary. AM = anterior wall of maxillary sinus; MS = maxillary sinus.

The uncinate process was removed. To make and enlarge an opening to the MS through the middle nasal meatus, the membranous portion of the medial wall of the MS, including the natural ostium, was then removed. The size of the opening created using the above surgical procedures was larger than that with conventional endoscopic sinus surgery techniques.

We approached the MS from anterior to the IT, and if necessary through the middle meatus. The anterior lateral mucosa of the nose, including the IT and ND, was shifted medially to allow wider access to the MS from anterior to the IT (Fig. 1D). Following confirmation of the tumor attachment, the tumor was removed together with the attachment and adequate margins of normal mucosa. If the tumor was impacted in the MS, piecemeal removal with a microdebrider may be required to find the tumor attachment. We used a microdebrider as little as possible for en bloc resection. Underlying bone was drilled with a diamond burr. At the end of the procedure, the IT was repositioned and sutured in its original position with one stitch (Fig. 1E).

RESULTS

This modified TEMM was performed in 10 patients with IP in the MS. The IT and ND were preserved in all patients after resection of IP (Fig. 3). We have not observed epiphora after this surgery.

Figure 3.

After the operation. (A) The inferior turbinate (IT) 2 weeks after the operation. (B) The IT 2 months after the operation. Computed tomography scan before (C) and after the operation (D). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

DISCUSSION

Weber et al.4 and Gras-Cabrerizo et al.5 described TEMM with preservation of the IT. The head of the IT is cut, and dissection is continued along the attachment. After removal of the tumor, the IT is repositioned and sutured in its original position. Weber et al.4 described resection of the ND. Gras-Cabrerizo et al.5 performed TEMM with preservation of the ND, in which tumor resection is managed through the posterior side of the ND. In our approach, access to the MS is achieved through the anterior side of the preserved ND, resulting in more direct and easier management.

Partial resection of IP is often carried out to get better visualization of the entire IT in TEMM. In our approach, visualization of only the anterior IT is sufficient to operate on the MS, because the MS can be accessed through the anterior side of the IT. In one of our patients, the nasal cavity was occupied by the IP, and the head of the IT could not be seen (Fig. 1A). However, the head of the IT was identified by shrinkage with adrenaline and a medial shift of the IP in the nasal cavity, without partial resection of the IP (Fig. 1B). Access to the MS was achieved anteriorly to the IT without partial resection of the IP (Fig. 1C and 1D). Thus, this method does not involve resection of the IT in most cases, even if the IP is over the IT.

The advantages of the novel approach presented herein include: 1) preservation of the IT, ND, and lateral nasal mucosa; 2) wide access to the MS by shifting the IT, ND, and lateral nasal mucosa in the medial direction; and 3) direct access to the MS through the anterior space of the ND, resulting in an easier operation with a straight endoscope and instruments.

CONCLUSION

This modified TEMM with medial shift of the preserved MD, IT, and lateral nasal wall is a safe and effective method to obtain wide and straight access to the MS and to resect an IP in the maxillary sinus.

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