Endoscopic Resection of Anterolateral Maxillary Sinus Inverted Papillomas

Transcription

1 The Laryngoscope VC 2014 The American Laryngological, Rhinological and Otological Society, Inc. Endoscopic Resection of Anterolateral Maxillary Sinus Inverted Papillomas Nichole R. Dean, DO; Elisa A. Illing, MD; Bradford A. Woodworth, MD Objectives/Hypothesis: Endoscopic medial maxillectomy (EMM) has become the surgical procedure of choice for resection of maxillary sinus inverted papillomas (IPs). Traditionally, IPs pedicled on the anterior and/or lateral walls of the maxillary sinus have required an adjuvant Caldwell-Luc approach due to decreased visualization with transnasal endoscopy in these locations. The objective of the current study is to evaluate outcomes following endoscopic resection of anterolateral maxillary sinus IPs. Study Design: Prospective case series. Subjects and Methods: Over 6 years, a total of 35 patients underwent EMM for maxillary sinus IPs located on the anterolateral maxillary wall. Demographics, operative technique, pathology, complications, recurrence, and postoperative follow-up were evaluated. Results: The majority of patients were male (71%) with a mean age of 56 years (range 27 83). Most patients (71%) were referred for recurrence after previous attempts at surgical resection. Adequate visualization was obtained following EMM in the majority of patients with use of a 70-degree endoscope and angled instrumentation. The addition of transseptal surgical access was critical to the removal of IPs in 16 patients. No Caldwell-Luc approaches were required. Pathologic dysplasia was identified in nine patients, and three had carcinoma. There were no recurrences with a mean disease-free interval of 29 months (10 72 months). Conclusion: In the present study, EMM provided excellent surgical access to anterolateral maxillary sinus IPs. The transseptal approach allowed enhanced visualization to this challenging location, previously considered accessible only with external procedures. Key Words: Inverted papilloma, inverting papilloma, endoscopic medial maxillectomy, transseptal, modified medial maxillectomy, Caldwell-Luc, endoscopic sinus surgery, endoscopic dacryocystorhinostomy. Level of Evidence: 4. Laryngoscope, 125: , 2015 INTRODUCTION Inverted papillomas (IPs) are benign epithelial tumors that originate in the mucosal membranes of the nasal cavity and paranasal sinuses. These tumors are locally aggressive, often recur, and can become malignant. 1 Squamous cell carcinoma develops in approximately 5% to 21% of patients with IPs and may be present at the time of initial diagnosis or following prior treatment. 1 3 Because of the high recurrence rate (5% 50%), 1 aggressive, primary surgical resection is the treatment of choice. From the Departments of Surgery/Division of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A Editor s Note: This Manuscript was accepted for publication October 21, Presented at the American Academy of Otolaryngology Head and Neck Surgery Annual Meeting, Orlando, FL, 2014, U.S.A., September 23, Bradford A. Woodworth, MD, is a consultant for ArthroCare ENT, Olympus, and Cook Medical. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Bradford A. Woodworth, MD, University of Alabama at Birmingham Otolaryngology Head and Neck Surgery, BDB 563, rd Ave S, Birmingham, AL bwoodwo@hotmail.com DOI: /lary Over the last two decades, surgical techniques have evolved from extensive open radical resection to minimally invasive endoscopic tumor excision. 4 8 Advances in angled instrumentation including suction irrigation drills, improved optics, and computer-aided skull base navigation have allowed for endoscopic and endoscopicassisted IP resection. 9 The surgical management of choice for IPs involving the walls of the maxillary sinus has historically consisted of a medial maxillectomy utilizing a lateral rhinotomy or a midface degloving approach. However, endoscopic medial maxillectomy (EMM) has now become the standard surgical approach to this region. 9,10 The open approach may provide an en bloc resection; however, in certain cases, this can also be accomplished with endoscopic removal. Importantly, the premise of an en bloc resection of the entire tumor has been called into question because resection of the tumor pedicle with frozen section control yields low recurrence rates. 9 Whereas no significant difference in local recurrence has been noted following endoscopic when compared to open resection, outcomes could be skewed due to selection bias because endoscopic resection is often reserved for IPs without extension into the dura/brain, orbit, or frontal sinus Additionally, endoscopic management of lesions involving the anterior or lateral walls of the maxillary sinus has remained a significant 807

2 Fig. 1. Transnasal endoscopic view of a wide endoscopic medial maxillectomy on the right side. The arrow indicates the remaining portion of inferior maxillary wall (A). Note that the inverted papilloma (IP) appears suspended from the anterior aspect of the maxillary sinus and wraps around the lacrimal bone (B). The tumor and involved bone are removed from the nasolacrimal duct (NLD) (C). Using 70-degree endoscopy, the tumor has been debulked to the anterior maxillary wall where the pedicle is identified (arrow). challenge to the sole use of endoscopic techniques. An adjuvant Caldwell-Luc approach is often required due to decreased visualization with transnasal endoscopy in these locations. 9 The objective of the present study is to evaluate outcomes of endoscopic resection of anterolateral maxillary sinus IPs utilizing angled instrumentation and transseptal access. MATERIALS AND METHODS Prospective evaluation of patients who presented with inverted papilloma was performed ( ) at the University of Alabama at Birmingham following institutional review board approval. A total of 35 patients underwent endoscopic medial maxillectomy for primary or recurrent anterolateral maxillary sinus IPs. Pedicles were on the anterior and/or lateral walls of the maxillary sinus with or without involvement of the osteomeatal complex and or nasal cavity, sphenoid, ethmoid, or frontal sinuses. Demographic characteristics including patient age, gender, and previous treatment for inverted papilloma were recorded. Postoperative complications, pathology, and the need for adjuvant radiation were evaluated. Tumors were staged using the IP staging system developed by Krouse. 20 Subjects were generally followed quarterly for the first 2 years, semiannually for the next 2 years, and annually thereafter. Surgical Technique Preoperative nasal endoscopy with or without biopsy was performed in all patients. Standard protocol at our institution is to obtain an image-guided surgical navigation computed tomography to evaluate the location of the tumor pedicle as determined by osteitis at the site of attachment 21 and to aide in surgical planning. Magnetic resonance imaging was performed 808 on a case-by-case basis. All patients underwent EMM with or without the addition of transseptal surgical access, as determined by appropriate visualization with 70 transnasal endoscopy and instrument access. If necessary, ethmoidectomy and/or sphenoid or frontal sinusotomy were performed for exposure prior to endoscopic medial maxillectomy. 9 A middle-meatal antrostomy was performed first, if possible, with complete removal of the uncinated process. Using a turbinate scissors, an incision is made posterior to the anterior third of the inferior turbinate at the level of the anterior aspect of the maxillary antrostomy such that Hasner s valve is not disturbed. The posterior two-thirds of the inferior turbinate can be removed at this point for more exposure or left intact. The maxillary wall is punctured in the inferior meatus, and the hole is connected with the maxillary antrostomy superiorly with thru-cut forceps. The inferior maxillary wall is incised posteriorly with a thrucut forceps or osteotome. The medial maxillary wall is then removed following completion of a posterior vertical cut approximately at the level of the posterior maxillary wall (Fig. 1). 9,22,23 Additional exposure, with removal of the nasolacrimal duct and thinning of the medial maxillary buttress, was performed as necessary, depending on exposure or involvement with tumor. Small tumors on the lateral wall were often removed en bloc with the underlying bone, whereas large tumors were debulked with a microdebrider or radiofrequency coblation (Coblator; ArthroCare ENT, Austin, Tx) when additional exposure was required. All contents were collected with a suction trap and sent to pathology following completion of the case. The mucosa surrounding the area of the tumor was excised and sent for intraoperative frozen section to confirm negative margins. Bone at the site of IP attachment was cauterized and then drilled down with a diamond burr to ensure that no tumor remained. The decision to perform an adjuvant transseptal approach was made intraoperatively when visualization was suboptimal or the pedicle could not be addressed with angled instrumentation. Techniques are similar to those described by Harvey et al. 24

3 Fig. 2. Transseptal access is then performed via elevation of a septal mucoperichondrial (SM) flap on the left side and incision of a mucosa/cartilage window on the right side (A). Opposing incisions (arrows) in the contralateral flap are within the confines of the left-sided flap such that no incisions are juxtaposed (B). A 0-degree endoscopic view of entry through the septal window (C). Lidocaine 1% with epinephrine is infiltrated into the contralateral nasal septum, and a hemitransfixion incision is performed. A posteriorly based nasoseptal flap is then elevated off the septal cartilage, and a septal window is made with two angled cuts to create a triangular opening on the ipsilateral side. This is created at the level of the contralateral head of the inferior turbinate and is large enough to accommodate two instruments at the same time (Fig. 2). With this angle of approach, a 0-degree endoscope and 15-degree diamond burr were typically all that were required for access to the anterior wall (Fig. 3). The resulting cartilage/mucosal flap is within the border of the contralateral nasoseptal flap such that no incisions are in opposition. At the end of the procedure, the nasoseptal flap is stitched anteriorly and flaps are quilted with chromic suture. RESULTS From 2008 to 2013, a total of 35 patients (average age 55.7) underwent endoscopic medial maxillectomy for primary (n 5 10) or recurrent (n 5 25) anterolateral maxillary sinus IPs. Patient demographics and tumor characteristics are presented in Table I. Presenting symptoms included facial pain/pressure (91%) and nasal obstruction (31%) and/or epiphora (6%). The majority of patients presented with Krouse stage T3 tumors (n 5 29) (Table II). Patients with recurrent disease (n 5 25) underwent a total of 39 prior operations before presenting to the University of Alabama at Birmingham for secondary treatment. EMM was performed in all patients, with an additional transseptal approach required for the removal of IPs in 16 patients. The transseptal approach allowed for excellent visualization of far anterolateral IPs when complete resection was not feasible with angled instrumentation. Endoscopic dacryocystorhinostomy was performed in 22 patients and was significantly more likely to be performed when a transseptal approach was necessary (EMM 5 6; EMM 1 transseptal 5 16; P < 0.001) Fig. 4. Six patients had tumor involvement of the nasolacrimal duct. No Caldwell-Luc approaches were required. No septal perforations were noted postoperatively. All dacryocystorhinostomies were patent, with no symptomatic epiphora. The only significant complication was infraorbital paresthesia in three patients (9%) secondary to tumor removal off the nerve. Pathologic dysplasia was identified in 12 patients (low, n 5 4; TABLE I. Patient Characteristics. Characteristic N (%) Fig. 3. The external view of the transseptal access created with this approach shows placement of a 0-degree scope through the window for visualization of the anterior or lateral walls of the maxillary sinus. Age, years Mean (range) 55.7 (27 83) Gender Male 25 (71) Female 9 (29) Side Right 21 (60) Left 14 (40) T classification T3 29 (83) T4 6 (17) Primary 10 (29) Recurrent 25 (71) 809

4 TABLE II. Operative Data. Patient Prior Surgery Attempts Site of Attachment Krouse Stage Transseptal Endo DCR Dysplasia/Carcinoma 1 1 AMW, LMW 3 Yes Yes None 2 0 LMW 3 No No Intermediate 3 0 LMW 3 No No Intermediate 4 1 AMW 3 No No Low 5 4 AMW 3 Yes Yes None 6 1 LMW 3 No No None 7 1 AMW 3 Yes Yes None 8 0 LMW 3 No No None 9 2 AMW 4 Yes Yes None 10 1 AMW, LMW 3 Yes Yes None 11 4 AMW LMW 4 Yes Yes Intermediate 12 1 AMW 3 Yes Yes Low 13 4 AMW 3 No Yes None 14 1 AMW, LMW 3 Yes Yes None 15 3 LMW 4 No No Carcinoma 16 0 AMW 4 Yes Yes Carcinoma 17 1 AMW,LMW 3 Yes Yes Low 18 2 AMW 4 Yes Yes None 19 1 LMW 4 No Yes CIS 20 0 LMW 3 No No None 21 1 LMW 3 No No None 22 2 AMW 3 No No None 23 0 AMW 3 No Yes None 24 2 LMW 3 No No None 25 4 AMW,LMW 3 No Yes None 26 0 LMW 3 No No None 27 2 AMW, LMW 3 Yes Yes None 28 0 AMW 3 Yes Yes None 29 0 LMW 3 No No None 30 1 AMW 3 Yes Yes None 31 1 AMW 3 No Yes None 32 1 AMW, LMW 3 Yes Yes None 33 2 LMW 3 No No Low 34 1 AMW, LMW 3 Yes Yes Intermediate 35 0 AMW 3 No Yes High AMW 5anterior maxillary wall; DCR 5 dacryocystorhinostomy; LMW 5 lateral maxillary wall. intermediate, n 5 4; high grade dysplasia, n 5 1; carcinoma in situ, n 51; and carcinoma, n 5 2). No patients underwent postoperative radiation treatment. One individual refused adjuvant radiation therapy despite tumor board recommendations. There were no recurrences, with a mean disease-free interval of 29 months (10 72 months). DISCUSSION Over the last 20 years, the surgical management of IPs has evolved from traditional open approaches, including lateral rhinotomy with medial maxillectomy, to endoscopic or endoscopic-assisted tumor excision. EMM has now become the gold standard surgical treatment for the majority of IPs that involve the maxillary sinus. Although tumors attached to the lateral nasal/medial maxillary wall can easily be accessed with an endoscope and resected under direct visualization, tumors that are attached to the anterior and/or lateral wall of the maxillary sinus are much more difficult to visualize and surgically remove. An adjuvant Caldwell-Luc approach provides direct access to the maxillary sinus for IPs pedicled on the anterolateral wall without removing the nasomaxillary buttress. If tumor extends into the lacrimal bone, then removal of the buttress can be achieved using a midface degloving and Denker s procedure. Because direct access to the sinus through a Caldwell-Luc or Denker s procedure requires a gingivobuccal sulcus incision, consequences may include significant facial swelling, pain and/or numbness, and oroantral fistula formation. 810

5 Fig. 4. A dacryocystorhinostomy (DCR) has been performed, exposing the pedicle on the anterior wall through the transseptal view (A). The pedicle is drilled down to fresh bone through the septal window (B) with a clean surface at the site of tumor attachment (C). In the present study, adequate visualization was obtained following EMM in the majority of patients with use of a 70-degree endoscope and angled instrumentation, whereas the transseptal approach was required for resection in 16 patients. The transseptal approach allows for excellent endoscopic visualization through careful dissection and creation of a composite cartilage/mucosal flap via a standard septoplasty hemitransfixion incision; it also alleviates the need for an open Caldwell-Luc approach for access to anterior and/or lateral maxillary IPs. Because no incisions are in opposition, the risk of septal perforation is minimal with this approach. In addition, tumor extending into the sphenoid sinus, frontal recess/sinus, and/or nasolacrimal duct can be adequately visualized and resected under endoscopic guidance. Endoscopic dacryocystorhinostomy was necessary in all patients undergoing a transseptal approach. There were no septal perforations, epiphora, or other complications associated with the surgical approach. Three patients did develop inferior orbital nerve distribution paresthesia due to removal of tumor from the nerve. Despite the benefits of an endoscopic approach to IPs rather than traditional, open procedures, these techniques still remain controversial in terms of risk of tumor recurrence. Several studies have demonstrated equivalent results between endoscopic and open resection. 14,25 29 Perhaps the strongest argument for endoscopic resection of IPs is from a meta-analysis published by Busquets et al., 30 which demonstrated a significantly lower recurrence rate of IPs following endoscopic resection than seen with traditional approaches. In a retrospective review of 114 patients who underwent endoscopic or endoscopicassisted resection for primary and recurrent IPs, recurrence rates were 9% and 20%, respectively, and occurred on average 23 months following resection. 9 In the present study, the majority of patients (71%) presented with recurrent disease after an initial surgical procedure performed elsewhere, but they were 100% disease-free at a mean clinical follow-up of 29 months (10 72 months) after our surgery. No patients have developed tumor recurrence to date; however, the risk of delayed recurrence, as indicated in the previous study (nearly 2 years following resection), emphasizes the importance of longterm follow-up in this patient population. The risk of recurrence and potential malignant transformation necessitates an aggressive surgical resection of IPs. Importantly, all patients in this study presented with at least a Krouse stage 3 tumor, as determined by the attachment at the anterior or lateral maxillary sinus wall. Because the higher stage is associated with a greater risk of recurrence, the basis of this staging system may not be as relevant to tumors in this location when they are accessible with advanced techniques that allow for complete removal. As illustrated in the current study, the precise site of tumor attachment can be visualized endoscopically and the entire tumor removed. 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