The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
How I Do It
Endoscopic Endonasal Anterior Maxillotomy Smita Upadhyay, MD; Ricardo L. L. Dolci, MD; Lamia Buohliqah, MD; Daniel M. Prevedello, MD; Bradley A. Otto, MD; Ricardo L. Carrau, MD
Key Words: Endonasal, maxillotomy, sublabial anterior maxillotomy, endoscopic. Laryngoscope, 125:2668–2671, 2015
INTRODUCTION The last few decades have witnessed radical changes in the management of pathologic processes of the sinonasal cavity. Endoscopy precipitated a paradigm shift in the diagnostic and surgical approach to lesions in the paranasal sinuses and skull base. A better understanding of the surgical anatomy, aided by the superior visualization of the endoscope catapulted the design and adoption of minimally invasive techniques. This is exemplified by the transition from medial maxillectomy via transfacial incisions (i.e., lateral rhinotomy) to a completely endoscopic approach. Another notable example is that of the Caldwell-Luc procedure, which was widely performed in the last century, yet has fallen out of favor owing to its relatively high incidence of complications and the successful treatment of sinonasal diseases, either by current medical management or by safer and less invasive endoscopic sinus surgery. However, access to the anterior half of the maxillary sinus is challenging, even with the use of a 45 and 70 rod-lens endoscope and angled instruments.1 The anterior half of the maxillary sinus has been traditionally accessed sublabially by way of a canine fossa puncture or an anterior maxillotomy. There is abundant literature discussing the advantages, disadvantages, and potential complications associated with these procedures, and therefore the need for various technical modifications.2,3
From the Department of Otolaryngology–Head & Neck Surgery (S.U., R.L.L.D., L.B., D.M.P., B.A.O., R.L.C.) and the Department of Neurosurgery (D.M.P., B.A.O., R.L.C.), Wexner Medical Center at The Ohio State University, Columbus, Ohio, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 20, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ricardo L. Carrau, MD, Professor, Director of the Comprehensive Skull Base Surgery Program, Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Starling-Loving Hall, B221, Columbus, OH 43210-1282. E-mail: [email protected] DOI: 10.1002/lary.25205
Laryngoscope 125: December 2015
2668
This study describes an alternative technique for performing an endonasal anterior maxillotomy, thus obviating the need for a separate sublabial incision. Endoscopic endonasal anterior maxillotomy is a versatile technique, and the size and site of the maxillotomy can be modified according to the course of the anterosuperior alveolar nerve to minimize the possibility of damage.
MATERIALS AND METHODS Ten fresh cadaveric heads, previously prepared with intravascular injections of colored latex, were dissected bilaterally at the Anatomical Laboratory Towards Visuospatial Innovations in Otolaryngology and Neurosurgery at the Wexner Medical Center at The Ohio State University. Every specimen underwent a high-resolution computed tomography (CT) scan to obtain stereotactic measurements of the anatomical field during the surgical simulation with the assistance of a surgical navigation device (Stryker, Kalamazoo, MI). A 0 rod-lens endoscope coupled to a high-definition camera and monitor (Karl Storz Endoscopy, Tuttlingen, Germany) was utilized for dissections and to record and save images. After palpating the edge of the piriform aperture, just anterior to the head of the inferior turbinate, the mucosa was incised vertically and the incision was carried through the periosteum. A subperiosteal dissection of the pyriform aperture and anterior maxilla exposed the infraorbital foramen and neurovascular bundle. The course of the anterosuperior alveolar nerve was identified, and a window was created in the anterior wall of the maxilla using a high-speed drill, staying inferior to the infraorbital foramen and preserving the anterosuperior alveolar nerve trunk and any major branches. The size of the window was between 0.5 and 1.0 cm. The lateral and the anteroinferior limits of dissection through the window were documented using a stereotactic probe placed through the window (Fig. 1).
RESULTS The anterosuperior alveolar nerve could be identified through the endonasal route bilaterally in all specimens (n 5 10). The anteroinferior corner of the maxillary sinus was reached on all 20 sides. The junction of the anterior and lateral wall of the maxillary sinus could also be accessed in all specimens. Upadhyay et al.: Endoscopic Endonasal Anterior Maxillotomy
Fig. 1. Surgical technique. (A) Palpation of the pyriform aperture anterior to the inferior turbinate guides the placement for a vertical mucosal incision. (B) Subperiosteal elevation to expose the anterior face of the maxilla. (C) Identification of the infraorbital and anterosuperior alveolar nerve (ASAN). (D) Maxillotomy. AWMS, anterior wall of the maxillary sinus; IOF, infraorbital foramen; ION, infraorbital nerve; IT, inferior turbinate; MT, middle turbinate.
DISCUSSION Following initial strong and visceral criticisms, the advantages of endoscopic surgery (superior visualization and less morbidity) were universally accepted. Many traditional approaches have been abandoned in lieu of endonasal endoscopic approaches. Following the seminal description of medial maxillectomy by Sessions and Larson in 1977, Kamel described an endoscopic technique for the treatment of inverted papillomas in 1995.4,5 Similarly, we have witnessed the transition of the anteromedial maxillectomy as originally described by Alfred Denker in 1906, to the endonasal technique described by Sturmann and Canfield, to evolve into the current endoscopic technique.6–8 Endoscopic surgery, however, has limitations. The anterior recesses of the maxillary sinus are often inaccessible with an endoscopic medial maxillectomy alone; thus, reaching these areas requires an alternative or adjunctive approach.1 Multiple factors affect the selection of this adjunctive approach, including the geometry and degree of pneumatization of the maxillary sinus, ability or willingness of the surgeon to use angle-lens endoscopes and instruments or to perform an endoscopic dacryocystorhinostomy (DCR), and tumor extent into the anterior recesses of the antrum. An endoscopic Denker’s approach will provide ample visualization and ease of instrumentation; however, the loss of the piriform ridge may lead to alar Laryngoscope 125: December 2015
collapse.9 An anteriorly extended medial maxillectomy, as described by Dean et al., provided adequate outcomes for the control of inverting papilloma invading the anterior wall of the antrum.10 However, this technique required using 70 endoscopes with curved instruments, and in two-thirds of the patients it also required an endoscopic DCR. Less experienced surgeons may have difficulty with these techniques. Additional access can also be achieved by a “crosscourt” approach using a transseptal or septal dislocation technique. Harvey et al. suggested the use of the transseptal technique but warned about the potential for an anterior septal perforation and the difficulty of the dissection in the face of prior septal surgery or trauma.11 Ramakrishnan et al. described a septal dislocation technique that provides good access to the anterolateral wall in most patients.12 However, the authors acknowledge that protrusion of the contralateral piriform ridge and the concave shape of the anterior maxillary wall might pose some difficulty and require angled-lens endoscopes and curved instruments. A sublabial route via a 5-mm canine fossa puncture or a more elaborate anterior maxillotomy are also feasible to obtain additional access. Each of these individual procedures offer specific advantages, as well as caveats and limitations. Neurological complications are most commonly related to the damage to the anterior superior alveolar nerve.13 The anterior superior alveolar nerve Upadhyay et al.: Endoscopic Endonasal Anterior Maxillotomy
2669
Fig. 2. Variations in the anterosuperior alveolar nerve (ASAN). (A) Single trunk of the ASAN. (B) Double trunk of the ASAN. (C) Double trunk of the ASAN with branches. (D) Multiple trunks of the ASAN.
branches from the infraorbital nerve within its bony canal at a variable distance from the infraorbital foramen. It then courses anteroinferomedially toward the piriform aperture within the bone of the maxilla to form a plexus, which courses through the alveolar process of the maxilla (Fig. 2). Based on cadaveric dissections, Robinson and Wormald suggested that the most suitable area for performing a canine fossa puncture is the intersection of the mid–pupillary line, with a horizontal line drawn at the level of the floor of the nasal vestibule.1 If the procedure is performed following the anatomical landmarks under endoscopic guidance, the incidence of complications is further reduced.14 The intent of this article was not to demonstrate superiority of the endonasal endoscopic maxillotomy over other approaches but to describe it as a reasonable alternative. Nonetheless, an endonasal endoscopic maxillotomy provides direct entry into the maxillary sinus and unhindered visualization of the lateral and anterior walls and their pertinent recesses; thus, it may be the preferred approach in select cases with the previously mentioned characteristics regarding tumor extent, anatomy of the nasal and antral cavities, or surgeon’s skills. In addition, an endoscopic endonasal anterior maxillotomy may also complement an endoscopic medial maxillectomy to provide exposure of the infratemporal fossa.15 It provides Laryngoscope 125: December 2015
2670
transantral access to the most anterior aspect of the infratemporal fossa, which may be inadequate with some of the other previously described techniques (except an endoscopic Denker’s and the sublabial approach). Sublabial maxillotomy has been associated with a high incidence of complications.2 Major modifications were suggested to overcome some of the complications16: replacing the horizontal gingivobuccal incision with a vertical incision, opening a relatively smaller window in the poorly innervated posterior part of the anterior wall, and restricting the lower limit of the window to prevent damage to the alveolar plexus. Consequently, these modifications resulted in a significant reduction in neurological complications.3 The endoscopic anterior maxillotomy provides a similar port of entry to that of a sublabial approach; however, the absence of a sublabial incision and the higher placement of the maxillotomy are in agreement with the recommended modifications for the CaldwellLuc procedure. Avoidance of a sublabial incision better preserves the anterosuperior alveolar nerve and avoids the contamination with oral flora and the possibility of an oroantral fistula. Furthermore, the size and site of the window in an endoscopic endonasal anterior maxillotomy can be modified according to the indication of the surgery, and the course of the anterosuperior alveolar Upadhyay et al.: Endoscopic Endonasal Anterior Maxillotomy
nerve and the infraorbital nerve can be better visualized. Therefore, the entry point can be chosen with greater precision. All contemporary indications for a Caldwell-Luc or sublabial anterior maxillotomy approaches can be carried over to the endoscopic endonasal anterior maxillotomy. These include extended approaches to the infratemporal fossa, removal of foreign body and neoplasms of the maxillary sinus, closure of oroantral fistula, orbital decompression of the inferior orbital wall, management of odontogenic disease, and treatment of endoscopic sinus surgery failures with irreversible mucosal disease.17 Some of the complications of a sublabial maxillotomy, such as cheek swelling and pain, can occur with the endoscopic endonasal anterior maxillotomy. However, the dissection and retraction of the cheek required for the endonasal technique is much less than that required for a sublabial approach, and the absence of a sublabial incision and higher placement of the maxillotomy better preserves the anterior superior alveolar nerve and the dental plexus. Regardless, the sublabial anterior maxillotomy remains a viable approach and may be advantageous for some lesions that extend to the most anterior aspect of the infratemporal fossa.
CONCLUSION The endoscopic endonasal anterior maxillotomy is an effective technique that complements existing techniques in providing additional access to the maxillary sinus. It exposes lesions, such as inverted papilloma, that involve the anterolateral wall of the maxillary sinus. It can also be used as a second port while accessing lesions of the infratemporal fossa. Placement of an antrostomy can be tailored according to the course of the infraorbital and the anterosuperior alveolar nerve, thus minimizing the potential for their injury. Furthermore, this technique
Laryngoscope 125: December 2015
provides an additional port of entry to the maxillary sinus that can be fully exploited while dealing with benign sinonasal and infratemporal fossa pathologies.
BIBLIOGRAPHY 1. Robinson S, Wormald PJ. Patterns of innervation of the anterior maxilla: a cadaver study with relevance to canine fossa puncture of the maxillary sinus. Laryngoscope 2005;115:1785–1788. 2. DeFreitas J, Lucente FE. The Caldwell-Luc procedure: institutional review of 670 cases: 1975–1985. Laryngoscope 1988;98:1297–1300. 3. Ferekidis E, Tzounakos P, Kandiloros D, Kaberos A, Adamopoulos G. Modifications of the Caldwell-Luc procedure for the prevention of postoperative sensitivity disorders. J Laryngol Otol 1996;110:228–231. 4. Sessions RB, Larson DL. En bloc ethmoidectomy and medial maxillectomy. Arch Otolaryngol 1977;103:195–202. 5. Kamel RH. Transnasal endoscopic medial maxillectomy in inverted papilloma. Laryngoscope 1995;105:847–853. 6. Denker A. Ein neuer Wegfur die Operation der Malignen Nasentumoren. Munchener Medizinische Wochenschrift 1906;20:953–956. 7. Sturmann D. Die Intranasale Eroffnung der Kieferhohle. Berliner klinische Wochenschrift 1908;45:1273–1274. 8. Canfield RB. The submucous resection of the lateral nasal wall in chronic empyema of the antrum, ethmoid and sphenoid. JAMA 1908;14:1136– 1141. 9. Prosser JD, Figueroa R, Carrau RI, Ong YK, Solares CA. Quantitative analysis of endoscopic endonasal approaches to the infratemporal fossa. Laryngoscope 2011;121:1601–1605. 10. Dean NR, Illing EA, Woodworth BA. Endoscopic resection of anterolateral maxillary sinus inverted papillomas [published online ahead of print November 21, 2014]. Laryngoscope. doi: 10.1002/lary.25033. 11. Harvey RJ, Sheehan PO, Debnath NI, Schlosser RJ. Transseptal approach for extended endoscopic resections of the maxilla and infratemporal fossa. Am J Rhinol Allergy 2009;23:426–432. 12. Ramakrishnan VR, Suh JD, Chiu AG, Palmer JN. Septal dislocation for endoscopic access of the anterolateral maxillary sinus and infratemporal fossa. Am J Rhinol Allergy 2011;25:128–130. 13. Robinson SR, Baird R, Le T, Wormald PJ. The incidence of complications after canine fossa puncture performed during endoscopic sinus surgery. Am J Rhinol 2005;19:203–206. 14. Singhal D, Douglas R, Robinson S, Wormald PJ. The incidence of complications using new landmarks and a modified technique of canine fossa puncture. Am J Rhinol 2007;21:316–319. 15. Theodosopoulos PV, Guthikonda B, Brescia A, Keller JT, Zimmer LA. Endoscopic approach to the infratemporal fossa: anatomic study. Neurosurgery 2010;66:196–202; discussion 202–203. 16. Brusis T. How to prevent the various neuralgic complaints after operation of maxillary sinus? [in German]. Laryngol Rhinol Otol (Stuttg) 1979;58: 54–65. 17. Matheny KE, Duncavage JA. Contemporary indications for the CaldwellLuc procedure. Curr Opin Otolaryngol Head Neck Surg 2003;11:23–26.
Upadhyay et al.: Endoscopic Endonasal Anterior Maxillotomy
2671
Rhinological and Otological Society, Inc.
How I Do It
Endoscopic Endonasal Anterior Maxillotomy Smita Upadhyay, MD; Ricardo L. L. Dolci, MD; Lamia Buohliqah, MD; Daniel M. Prevedello, MD; Bradley A. Otto, MD; Ricardo L. Carrau, MD
Key Words: Endonasal, maxillotomy, sublabial anterior maxillotomy, endoscopic. Laryngoscope, 125:2668–2671, 2015
INTRODUCTION The last few decades have witnessed radical changes in the management of pathologic processes of the sinonasal cavity. Endoscopy precipitated a paradigm shift in the diagnostic and surgical approach to lesions in the paranasal sinuses and skull base. A better understanding of the surgical anatomy, aided by the superior visualization of the endoscope catapulted the design and adoption of minimally invasive techniques. This is exemplified by the transition from medial maxillectomy via transfacial incisions (i.e., lateral rhinotomy) to a completely endoscopic approach. Another notable example is that of the Caldwell-Luc procedure, which was widely performed in the last century, yet has fallen out of favor owing to its relatively high incidence of complications and the successful treatment of sinonasal diseases, either by current medical management or by safer and less invasive endoscopic sinus surgery. However, access to the anterior half of the maxillary sinus is challenging, even with the use of a 45 and 70 rod-lens endoscope and angled instruments.1 The anterior half of the maxillary sinus has been traditionally accessed sublabially by way of a canine fossa puncture or an anterior maxillotomy. There is abundant literature discussing the advantages, disadvantages, and potential complications associated with these procedures, and therefore the need for various technical modifications.2,3
From the Department of Otolaryngology–Head & Neck Surgery (S.U., R.L.L.D., L.B., D.M.P., B.A.O., R.L.C.) and the Department of Neurosurgery (D.M.P., B.A.O., R.L.C.), Wexner Medical Center at The Ohio State University, Columbus, Ohio, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 20, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ricardo L. Carrau, MD, Professor, Director of the Comprehensive Skull Base Surgery Program, Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Starling-Loving Hall, B221, Columbus, OH 43210-1282. E-mail: [email protected] DOI: 10.1002/lary.25205
Laryngoscope 125: December 2015
2668
This study describes an alternative technique for performing an endonasal anterior maxillotomy, thus obviating the need for a separate sublabial incision. Endoscopic endonasal anterior maxillotomy is a versatile technique, and the size and site of the maxillotomy can be modified according to the course of the anterosuperior alveolar nerve to minimize the possibility of damage.
MATERIALS AND METHODS Ten fresh cadaveric heads, previously prepared with intravascular injections of colored latex, were dissected bilaterally at the Anatomical Laboratory Towards Visuospatial Innovations in Otolaryngology and Neurosurgery at the Wexner Medical Center at The Ohio State University. Every specimen underwent a high-resolution computed tomography (CT) scan to obtain stereotactic measurements of the anatomical field during the surgical simulation with the assistance of a surgical navigation device (Stryker, Kalamazoo, MI). A 0 rod-lens endoscope coupled to a high-definition camera and monitor (Karl Storz Endoscopy, Tuttlingen, Germany) was utilized for dissections and to record and save images. After palpating the edge of the piriform aperture, just anterior to the head of the inferior turbinate, the mucosa was incised vertically and the incision was carried through the periosteum. A subperiosteal dissection of the pyriform aperture and anterior maxilla exposed the infraorbital foramen and neurovascular bundle. The course of the anterosuperior alveolar nerve was identified, and a window was created in the anterior wall of the maxilla using a high-speed drill, staying inferior to the infraorbital foramen and preserving the anterosuperior alveolar nerve trunk and any major branches. The size of the window was between 0.5 and 1.0 cm. The lateral and the anteroinferior limits of dissection through the window were documented using a stereotactic probe placed through the window (Fig. 1).
RESULTS The anterosuperior alveolar nerve could be identified through the endonasal route bilaterally in all specimens (n 5 10). The anteroinferior corner of the maxillary sinus was reached on all 20 sides. The junction of the anterior and lateral wall of the maxillary sinus could also be accessed in all specimens. Upadhyay et al.: Endoscopic Endonasal Anterior Maxillotomy
Fig. 1. Surgical technique. (A) Palpation of the pyriform aperture anterior to the inferior turbinate guides the placement for a vertical mucosal incision. (B) Subperiosteal elevation to expose the anterior face of the maxilla. (C) Identification of the infraorbital and anterosuperior alveolar nerve (ASAN). (D) Maxillotomy. AWMS, anterior wall of the maxillary sinus; IOF, infraorbital foramen; ION, infraorbital nerve; IT, inferior turbinate; MT, middle turbinate.
DISCUSSION Following initial strong and visceral criticisms, the advantages of endoscopic surgery (superior visualization and less morbidity) were universally accepted. Many traditional approaches have been abandoned in lieu of endonasal endoscopic approaches. Following the seminal description of medial maxillectomy by Sessions and Larson in 1977, Kamel described an endoscopic technique for the treatment of inverted papillomas in 1995.4,5 Similarly, we have witnessed the transition of the anteromedial maxillectomy as originally described by Alfred Denker in 1906, to the endonasal technique described by Sturmann and Canfield, to evolve into the current endoscopic technique.6–8 Endoscopic surgery, however, has limitations. The anterior recesses of the maxillary sinus are often inaccessible with an endoscopic medial maxillectomy alone; thus, reaching these areas requires an alternative or adjunctive approach.1 Multiple factors affect the selection of this adjunctive approach, including the geometry and degree of pneumatization of the maxillary sinus, ability or willingness of the surgeon to use angle-lens endoscopes and instruments or to perform an endoscopic dacryocystorhinostomy (DCR), and tumor extent into the anterior recesses of the antrum. An endoscopic Denker’s approach will provide ample visualization and ease of instrumentation; however, the loss of the piriform ridge may lead to alar Laryngoscope 125: December 2015
collapse.9 An anteriorly extended medial maxillectomy, as described by Dean et al., provided adequate outcomes for the control of inverting papilloma invading the anterior wall of the antrum.10 However, this technique required using 70 endoscopes with curved instruments, and in two-thirds of the patients it also required an endoscopic DCR. Less experienced surgeons may have difficulty with these techniques. Additional access can also be achieved by a “crosscourt” approach using a transseptal or septal dislocation technique. Harvey et al. suggested the use of the transseptal technique but warned about the potential for an anterior septal perforation and the difficulty of the dissection in the face of prior septal surgery or trauma.11 Ramakrishnan et al. described a septal dislocation technique that provides good access to the anterolateral wall in most patients.12 However, the authors acknowledge that protrusion of the contralateral piriform ridge and the concave shape of the anterior maxillary wall might pose some difficulty and require angled-lens endoscopes and curved instruments. A sublabial route via a 5-mm canine fossa puncture or a more elaborate anterior maxillotomy are also feasible to obtain additional access. Each of these individual procedures offer specific advantages, as well as caveats and limitations. Neurological complications are most commonly related to the damage to the anterior superior alveolar nerve.13 The anterior superior alveolar nerve Upadhyay et al.: Endoscopic Endonasal Anterior Maxillotomy
2669
Fig. 2. Variations in the anterosuperior alveolar nerve (ASAN). (A) Single trunk of the ASAN. (B) Double trunk of the ASAN. (C) Double trunk of the ASAN with branches. (D) Multiple trunks of the ASAN.
branches from the infraorbital nerve within its bony canal at a variable distance from the infraorbital foramen. It then courses anteroinferomedially toward the piriform aperture within the bone of the maxilla to form a plexus, which courses through the alveolar process of the maxilla (Fig. 2). Based on cadaveric dissections, Robinson and Wormald suggested that the most suitable area for performing a canine fossa puncture is the intersection of the mid–pupillary line, with a horizontal line drawn at the level of the floor of the nasal vestibule.1 If the procedure is performed following the anatomical landmarks under endoscopic guidance, the incidence of complications is further reduced.14 The intent of this article was not to demonstrate superiority of the endonasal endoscopic maxillotomy over other approaches but to describe it as a reasonable alternative. Nonetheless, an endonasal endoscopic maxillotomy provides direct entry into the maxillary sinus and unhindered visualization of the lateral and anterior walls and their pertinent recesses; thus, it may be the preferred approach in select cases with the previously mentioned characteristics regarding tumor extent, anatomy of the nasal and antral cavities, or surgeon’s skills. In addition, an endoscopic endonasal anterior maxillotomy may also complement an endoscopic medial maxillectomy to provide exposure of the infratemporal fossa.15 It provides Laryngoscope 125: December 2015
2670
transantral access to the most anterior aspect of the infratemporal fossa, which may be inadequate with some of the other previously described techniques (except an endoscopic Denker’s and the sublabial approach). Sublabial maxillotomy has been associated with a high incidence of complications.2 Major modifications were suggested to overcome some of the complications16: replacing the horizontal gingivobuccal incision with a vertical incision, opening a relatively smaller window in the poorly innervated posterior part of the anterior wall, and restricting the lower limit of the window to prevent damage to the alveolar plexus. Consequently, these modifications resulted in a significant reduction in neurological complications.3 The endoscopic anterior maxillotomy provides a similar port of entry to that of a sublabial approach; however, the absence of a sublabial incision and the higher placement of the maxillotomy are in agreement with the recommended modifications for the CaldwellLuc procedure. Avoidance of a sublabial incision better preserves the anterosuperior alveolar nerve and avoids the contamination with oral flora and the possibility of an oroantral fistula. Furthermore, the size and site of the window in an endoscopic endonasal anterior maxillotomy can be modified according to the indication of the surgery, and the course of the anterosuperior alveolar Upadhyay et al.: Endoscopic Endonasal Anterior Maxillotomy
nerve and the infraorbital nerve can be better visualized. Therefore, the entry point can be chosen with greater precision. All contemporary indications for a Caldwell-Luc or sublabial anterior maxillotomy approaches can be carried over to the endoscopic endonasal anterior maxillotomy. These include extended approaches to the infratemporal fossa, removal of foreign body and neoplasms of the maxillary sinus, closure of oroantral fistula, orbital decompression of the inferior orbital wall, management of odontogenic disease, and treatment of endoscopic sinus surgery failures with irreversible mucosal disease.17 Some of the complications of a sublabial maxillotomy, such as cheek swelling and pain, can occur with the endoscopic endonasal anterior maxillotomy. However, the dissection and retraction of the cheek required for the endonasal technique is much less than that required for a sublabial approach, and the absence of a sublabial incision and higher placement of the maxillotomy better preserves the anterior superior alveolar nerve and the dental plexus. Regardless, the sublabial anterior maxillotomy remains a viable approach and may be advantageous for some lesions that extend to the most anterior aspect of the infratemporal fossa.
CONCLUSION The endoscopic endonasal anterior maxillotomy is an effective technique that complements existing techniques in providing additional access to the maxillary sinus. It exposes lesions, such as inverted papilloma, that involve the anterolateral wall of the maxillary sinus. It can also be used as a second port while accessing lesions of the infratemporal fossa. Placement of an antrostomy can be tailored according to the course of the infraorbital and the anterosuperior alveolar nerve, thus minimizing the potential for their injury. Furthermore, this technique
Laryngoscope 125: December 2015
provides an additional port of entry to the maxillary sinus that can be fully exploited while dealing with benign sinonasal and infratemporal fossa pathologies.
BIBLIOGRAPHY 1. Robinson S, Wormald PJ. Patterns of innervation of the anterior maxilla: a cadaver study with relevance to canine fossa puncture of the maxillary sinus. Laryngoscope 2005;115:1785–1788. 2. DeFreitas J, Lucente FE. The Caldwell-Luc procedure: institutional review of 670 cases: 1975–1985. Laryngoscope 1988;98:1297–1300. 3. Ferekidis E, Tzounakos P, Kandiloros D, Kaberos A, Adamopoulos G. Modifications of the Caldwell-Luc procedure for the prevention of postoperative sensitivity disorders. J Laryngol Otol 1996;110:228–231. 4. Sessions RB, Larson DL. En bloc ethmoidectomy and medial maxillectomy. Arch Otolaryngol 1977;103:195–202. 5. Kamel RH. Transnasal endoscopic medial maxillectomy in inverted papilloma. Laryngoscope 1995;105:847–853. 6. Denker A. Ein neuer Wegfur die Operation der Malignen Nasentumoren. Munchener Medizinische Wochenschrift 1906;20:953–956. 7. Sturmann D. Die Intranasale Eroffnung der Kieferhohle. Berliner klinische Wochenschrift 1908;45:1273–1274. 8. Canfield RB. The submucous resection of the lateral nasal wall in chronic empyema of the antrum, ethmoid and sphenoid. JAMA 1908;14:1136– 1141. 9. Prosser JD, Figueroa R, Carrau RI, Ong YK, Solares CA. Quantitative analysis of endoscopic endonasal approaches to the infratemporal fossa. Laryngoscope 2011;121:1601–1605. 10. Dean NR, Illing EA, Woodworth BA. Endoscopic resection of anterolateral maxillary sinus inverted papillomas [published online ahead of print November 21, 2014]. Laryngoscope. doi: 10.1002/lary.25033. 11. Harvey RJ, Sheehan PO, Debnath NI, Schlosser RJ. Transseptal approach for extended endoscopic resections of the maxilla and infratemporal fossa. Am J Rhinol Allergy 2009;23:426–432. 12. Ramakrishnan VR, Suh JD, Chiu AG, Palmer JN. Septal dislocation for endoscopic access of the anterolateral maxillary sinus and infratemporal fossa. Am J Rhinol Allergy 2011;25:128–130. 13. Robinson SR, Baird R, Le T, Wormald PJ. The incidence of complications after canine fossa puncture performed during endoscopic sinus surgery. Am J Rhinol 2005;19:203–206. 14. Singhal D, Douglas R, Robinson S, Wormald PJ. The incidence of complications using new landmarks and a modified technique of canine fossa puncture. Am J Rhinol 2007;21:316–319. 15. Theodosopoulos PV, Guthikonda B, Brescia A, Keller JT, Zimmer LA. Endoscopic approach to the infratemporal fossa: anatomic study. Neurosurgery 2010;66:196–202; discussion 202–203. 16. Brusis T. How to prevent the various neuralgic complaints after operation of maxillary sinus? [in German]. Laryngol Rhinol Otol (Stuttg) 1979;58: 54–65. 17. Matheny KE, Duncavage JA. Contemporary indications for the CaldwellLuc procedure. Curr Opin Otolaryngol Head Neck Surg 2003;11:23–26.
Upadhyay et al.: Endoscopic Endonasal Anterior Maxillotomy
2671
