Original article Intranasal endoscopic prelacrimal ...

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Original article Intranasal endoscopic prelacrimal recess approach to maxillary sinus ZHOU Bing, HAN De-min, CUI Shun-jiu, HUANG Qian and WANG Cheng-shuo Keywords: nasal endoscope; maxillary sinus; prelacrimal recess; inferior turbinate; nasolacrimal duct Background The inferior turbinate (IT) and nasolacrimal duct (NLD) are often sacrificed while managing the diffuse lesion of maxillary sinus (MS). We report a new approach to MS without ablation of NLD and IT. Methods This retrospective study enrolled 19 hospitalized patients (aged from 42 to 68 years) who underwent endoscopic sinus surgery between 2003 and 2008. Twelve patients had inverted papilloma (IP), two had nasal polyps, two had Kubo’s postoperative cyst of MS, one had recurrent bone cyst of maxilla, one had dentigerous cyst and one had bleeding of internal maxillary artery secondary to Caldwell-Luc operation respectively. Two IP patients were excluded from this group since the follow-up time was less than 12 months. The NLD was dissected after removing the anterior bony portion of nasal lateral wall. The prelacrimal recess approach (PLRA) to MS was established when IT-NLD flap was raised medially. The flap was repositioned when MS lesion was removed. Results All the 17 patients had unilateral lesions. Ten MS IP patients were at the T3 Krouse stage. The follow-up ranged from 7 to 60 months. No recurrence was seen in 16 patients. Only one IP patient had a local recurrence in MS. All of them had no any complications. Conclusion The diffuse or severe diseases of MS may be the potential indications for PLRA. Chin Med J 2013;126 (7): 1276-1280

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he Caldwell-Luc in particular has been a fundamental surgical technique for many indications in the past since the initial reports of this procedure in 1893 by George Caldwell and later by Henry Luc in France, with more than one hundred years improvements and modifies.1 Now, functional endoscopic sinus surgery (FESS) is the gold standard surgical treatment in patients with chronic rhinosinusitis (CRS). It has an 80%–90% success rate in primary surgeries;1-4 however, the rate drops to only 50%–70% in revision surgeries. Although there are documented goals of surgery such as improvement of drainage and ventilation with preservation of the mucosal lining and mucociliary transport, the approach to the severely diseased sinus, especially the maxillary sinus (MS), still has controversy. According to the anatomy of MS and the feature of diseases originated from MS assessed with multi-angulated telescopes, including 30 and 70 telescopes, with kinds of curved instruments, there are still some areas which can not be viewed and handled.5 To an extensive lesion that needs to be incised in MS, the approaches such as midfacial degloving, external or intranasal Denker approach, medial maxillectomy and or a combined approach (for example, canine fossa trephine) are still applied in clinical treatment.2-4,6-11 Though a good visualization is provided for a complete incision of the tumor, as the viewpoint of minimal invasion, the problem still remains both in the external and intranasal surgical procedures. By those procedures above, it is often unavoidable to sacrifice the inferior turbinate (IT) and The postoperative nasolacrimal duct (NLD).2 complications such as dry nose, epiphora, dacrocystitis,

mucocele, facial neuralgia and external scarring remain at high incidence. Weber et al,12 Nakamaru et al13 and Rutherford et al14 made efforts to preserve IT or NLD in their series, but there were still some limitations. This paper reports a new approach to enter the MS which is created endoscopically via prelacrimal recess (PLR) without ablation of IT and NLD. METHODS This retrospective study enrolled 19 hospitalized patients (aged from 42 to 68 years) who underwent endoscopic sinus surgery between 2003 and 2008. Fourteen patients were male and 5 were female. Twelve patients had recurrent inverted papilloma (IP) of MS by histopathology biopsy pre-operation or intraoperation. Two patients had recurrent nasal polyps of MS, 2 had DOI: 10.3760/cma.j.issn.0366-6999.20121754 Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing 100730, China (Zhou B, Han DM, Cui SJ, Huang Q and Wang CS) Correspondence to: ZHOU Bing, Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing 100730, China (Tel: 86-10-58269206. Fax: 86-10-58269258. Email: [email protected]) This work was supported by a grant for Training High-level Health Technicians of Beijing Health System to ZHOU Bing (No. 2009-3-26). None of the authors have any conflict of interest, financial or otherwise.

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Kubo’s postoperative cyst of MS, 1 had recurrent bone cyst of maxilla, 1 had dentigerous cyst and 1 had bleeding of internal maxillary artery secondary to Caldwell-Luc operation respectively. Two IP patients were excluded from this group because the follow-up time was less than 12 months. Seventeen patients were presented and analyzed at last in this study. All the patients were evaluated preoperatively in our department by nasal endoscopy, olfactory function test, 4-phase rhinomanometry and acoustic rhinometry. The patients also received skin prick test (SPT), sIgE examination for allergic assessment. They all received preoperative axial and coronal computed tomography (CT) scans. Ten IP patients had been assessed by paranasal sinus MRI as a means of radiologic evaluation (Figure 1). IP cases were classified according to the Krouse staging system.15 Visualization was facilitated by the use of 0°, 30°, and 70° rod lens endoscopes coupled to a high definition camera and monitor (Storz Endoscopy, Tuttingen, Germany). The surgical dissection was performed using paranasal sinus and skull base/neurosurgical endoscopic instruments (Explorent, Storz), BienAir drill with a diamond and cutting burrs and a high-speed microdebrider with angled hand-piece and diamond and cutting burrs (XPS System, Medtronic, USA). Surgical technique In all cases surgery was performed under general anesthesia. The 0° telescope was mainly used. Additionally, a 70° telescope was used. The lesion in the nasal cavity or middle meatus was first resected intranasally combined with frontoethmoidectomy and/or sphenoidectomy according to the extent of the lesion. Then it was followed into the MS to look for the attachment. If the lesion could not be sufficiently removed via a middle meatal antrostomy (MMA), the PLR approach (PLRA) was indicated. It included the following surgical steps. The incision was infiltrated with 1% lidocaine (Xylocaine) with 1:100 000 epinephrine solution. A curved mucosal incision on the lateral wall of the nasal cavity was made between the anterior aspect of the IT and

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inner nostril to the underlying bone. The mucoperiostium was lifted towards the attachment of the IT bone at the nasal lateral wall of the nasal cavity and then the bony attachment of IT was disconnected. The bony inferior orifice of NLD could be seen after the mucoperiostium was elevated posteriorly (Figure 2). Taking the bony attachment of IT as a landmark, we chiselled off the anterior bony portion of the medial wall of the MS (parts of the frontal process of maxilla) as it forms the medial part of the PLR (Figure 3). After chiseling the bone posteriorly, the NLD can be exposed and the IT-NLD flap was formed. The IT-NLD flap was pushed medially and the medial mucosal wall of MS was exposed (Figure 4). The anterior or the antero-medial bony wall of MS should be partially removed according to the extent of MS pneumatization or the location of lesion. The PLR was opened while removing the medial mucosal wall of the MS, thus the PRA to MS was established (Figure 5). The IT-NLD mucosal flap was repositioned and the incision was sutured at the end of the operation with or without inferior meatal antrostomy according to the nature of the lesion and the necessity of drainage (Figure 6). Merocel® or NasoPore® was used to pack the operative cavity at last. Follow-up The postoperative care was managed under a nasal endoscope at regular intervals for 3 months, which included cleaning the crust and cysts. They then followed an individualized schedule based on the progress of the condition of the sinus cavities. The nasal corticosteroid spray and nasal irrigation of 0.9% sodium saline were also prescripted for at least 6 months. The epithelization of the operative cavity or lesion recurrence was examined. The postoperative CT scan was obtained for IP patients just 1 week after the operation. To follow up, they will have a CT evaluation postoperatively 1 year later. The volume and bone remodeling of the MS were mainly observed.

Figure 1. Preoperative paranasal sinus CT and MR of recurrent IP of MS. A: A coronal CT image demonstrates opacification of the left-side maxillary sinus (arrow) involving the alveolar recess. B: A coronal T1-weighted MR image with contrast shows IP as an intermediate and irregular mixed signal intensity mass (arrow) involving the medial portion, especially the alveolar recess of the left-side MS. C: An axial CT scan shows the mass involving prelacrimal recess (arrow). D: An enhanced T1-weighted MR image shows the tumor (arrow) lies around the left-side MS, especially the prelacrimal recess.

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Figure 2. Endoscopic view (2A) and schematic diagram (2B) show the incision (dash line) of lateral wall of nasal cavity which is just between the head of IT and inner nostril. IT: inferior turbinate. Figure 3. Endoscopic view (3A) and schematic diagram (3B) show the insertion of IT to the lateral wall of nasal cavity (white arrow), which serves as the anatomic landmark for locating and dissecting NLD with a chisel. The dashed line (blue, yellow and white) indicates the extent of medial wall of MS which can be removed according to extent of lesion. IT: inferior turbinate. Figure 4. Endoscopic view (4A) and schematic diagram (4B) show mucosa (*) of MS, NLD (arrow) and IT after removing the bone around NLD and medial wall of MS. Figure 5. Endoscopic view (5A) and schematic diagram (5B) show the approach of MS while removing IT-NLD flap medially to the septum. Arrow: NLD. IT: inferior turbinate. MS: maxillary sinus. In schematic diagram, dashed line represents the projection of MS. Figure 6. Replacing the NLD-IT flap and suture the incision at the end of surgery.

RESULTS The character of a paranasal CT scan and the endoscopic findings in the operation: CT scans showed all the cases presented soft tissue mass in MS. MRI demonstrated that the lesions of IP were located mainly in the MS. They were all categorized as stage T3 according to the Krouse staging system. Among 10 cases of IP of MS, 5 cases had evidently neoostiohyperplasia where the mass was located. The same situation was also found in cases with recurrent polyps. The IP from patients was found originating from the lateral nasal wall in the operation. All of the areas of MS were extensively involved both in IP and polyposis patients. An extension to the ethmoid sinus was seen in all patients and to frontal sinus was seen in 6 cases. The results of biopsies in them were all benign. The inferior meatal antrostomy (IMA) was performed for all patients, especially for those with a cyst at the end of surgery because the middle meatal windows were closed due to scarring and ostiohyperplasia. The tooth was removed from MS for patients with dentigerous cysts. Follow-up The out-patients follow-up period was 7–60 months after surgery. A well healed mucosa (epithelialization) of nasal

and sinus operative cavity and normal inferior turbinate appearence were observed endoscopically (Figure 7C). Stenosis of the middle meatal antrostomy and scarification were observed in 9 IP and 2 polyp cases. During the follow-up period, one recurrence was observed in 1 IP patient. The recurrent tumor, which was located in the inferior meatal antrostomy, was removed with a microdebrider. This patient has been followed up for 36 months and has not had any further recurrence. No epiphora occurred in this group. Postoperative CT scan 1 year after operation revealed a shrunken MS (Figure 7D) in 12 patients. Among them, 9 were IP patients. Two were patients with cysts. No operative complications occurred. DISCUSSION In the era of endoscopic surgery, intranasal endoscopic MMA has become a standard technique to address chronic maxillary sinus disease. But for extraordinary or diffuse diseases in MS, for example, IP or recurrent polyposis can not be removed thoroughly by MMA endoscopically, even with some curved instruments and angled endoscopes, or even with a wide antrostomy.5 More aggressive procedures, such as midfacial desgloving, Denker’s or modified Denker’s operation,

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Figure 7. Pre- and postoperative paranasal sinus CT scan and endoscopic view of a patient with recurrent IP of left MS. A: Preoperative endoscopic view showed tumor of middle meatus (arrow). UP: uncinate process. B: Preoperative CT scan demonstrated a soft tissue mass in left MS with mild bone erosion of lateral nasal wall. C: Postoperative endoscopic view shows a very smooth and well epithelized mucosa of nasal cavity with wide opened middle meatal antrostomy (arrow). D: Postoperative CT scan shows a clear left MS with thickened mucosa and no tumor recurrence.

Caldwell-Luc operation, medial maxillectomy, and etc. should be selected. Endoscopic medial maxillectomy (EMM) is advocated because the main area where disease has been difficult to be completely removed endoscopically has been the anterior wall and floor of the maxillary sinus.16 With the use of 45 and 70 degree endoscopes and the technique of EMM, all areas of MS can be accessed endoscopically and diseased mucosa removed. And now, EEM has become the golden standard for management of IP of MS.17,18 But all these procedures or techniques will sacrifice IT and/ or NLD. Is it necessary even if they are not involved by the disease? As we know, EMM can reduce the rate of surgical complications compared to those external approaches, but there remains the possibility of epiphora and dacryocystiits occurring due to resection of NLD while other report thought that patients undergone EMM appeared no epiphora and suggested it was unnecessary to care about the function of nasolacrimal apparatus.19 And of course, dry nose, although it happens less did cause some physiological problems. So, some surgeons try to reserve IT or NLD while operating. Nakamura et al13 reported a method with a preservation of the nasolacrimal duct during EMM for IP. But if the tumor is attached to the bottom of MS with irregular prominences, it was difficult to manage intranasally with this method. The author indicated a transantral approach of the canine fossa to resect the lesion. However, IT was cut off without exception. Weber et al12 preferred a new method for performing EMM with preservation of IT under 45° endoscope for most parts of the operation. Thus, the nasal physiology may well be preserved. The author also indicated that there is one disadvantage of his technique which involved the resection of the nasolacrimal duct. To the aim of preservation of the function of the nasal cavity and lacrimal aperture, we designed a new approach to enter MS without ablation of IT and NLD. Anatomically, the PLR, which is a very difficult area to reach via MMA or IMA, could be a potential space to create an approach to enter MS. As we described in Figures 2 to 5, after an incision along the lateral wall of nasal cavity just between the head of IT and inner nostril,

the anterior portion of nasal cavity which form the medial wall of PLR and the bony insertion of IT and the bony insertion can be exposed. The insertion of IT should be an anatomical landmark for locating NLD. We usually dissect and expose NLD with chisel (Figure 3). When NLD was dissected and exposed clearly, the NLD-IT flap formed and pushed medially to septum. Then the PLRA is established (Figure 5). By this approach, all the area of MS should be easily reached under 0° rigid nasal endoscope (Figure 8). The 30° or 70° endoscope is occasionally used in some circumstances, for example, when the lesion is in an overpneumatized alveolar and/or zygmatic recess. By removing much more the most anterior and/or anteroinferior portion of lateral bony wall, we can gain a wider entrance to MS (Figure 3). Also, the anterior wall of MS could be partially resected if necessary. At the end of the operation, reposition of NLD-IT flap with 3 absorbable sutures led to a complete reconstruction of the lateral wall of nasal cavity (Figure 7). So the anatomical structure and physiological function of NLD and IT were well preserved. In terms of postoperative observation and drainage, IMA was usually done after suture in this group. Most of patients had a wide opened middle meatal window, so the postoperative endoscopic observation or management of MS could be easily done via both middle and inferior meatal window.

Figure 8. Schematic diagram shows the cavity of MS can be easily observed under 0 degree rigid endoscope via the prelacrimal recess approach. Arrow: prelacrimal recess.

In our group, there were no operative complications. The follow-up results showed no postoperative complications, such as epiphora, dry nose or facial numbness. Only one IP patients had a local recurrence just at the edge of inferior meatal window 6 months after the operation.

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Therefore, we considered if it is necessary to adopt IMA routinely, that will require a long term follow-up for further observation. The postoperative CT scan demonstrated that the volume of MS became smaller and had a morphological shrink due to scarring in a few patients of this group, particularly in IP patients. That may have a relation to the nature of diseases or the overall removing of the mucosa (Figure 7D). In conclusion, our preliminary clinical study demonstrated that PLRA is an ideal minimally invasive technique to deal with the problems of MS and showed some advantages with preservation of IT and NLD. The anterior bony insertion of IT is a key anatomical landmark for locating and dissecting NLD. All the area could be observed and managed under 0° rigid endoscope. As the lateral wall of the nasal cavity was kept intact, the nasal physiological function, such as humidity, warm and cleaning, may well be preserved. Our follow-up data showed no intraoperative or postoperative complications, such as epiphora, dry nose, or numbness. The diffuse or severe diseases of MS, especially a tumor originating from MS, may be the potential indications for PLRA. Whether or not it could be used for dealing with malignancy of MS needs further study. Acknowledgements: We want to express our thanks to Diana Shenqian Dai (M.D.& M.Sc. BMC, Chinese Academy of Medical Sciences) for her excellent drawings. With her help, we can correctly and precisely show our academic idea of our technique.

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(Received July 1, 2012) Edited by GUO Li-shao