Evolution of maxillary sinus surgery in a university hospital

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1 Cir Cir 2012;80: Evolution of maxillary sinus surgery in a university hospital Salomón Waizel-Haiat,* María del Carmen Solano-Mendoza,** and Alejandro Martin Vargas-Aguayo** Abstract Background: Maxillary sinus surgery has been evolving and, due to advances in technology, endoscopic surgery is widely used in the maxillary sinus for multiple pathologies that 15 years ago were treated through open approaches. For this reason, we conducted an observational descriptive study. Methods: We reviewed the clinical records of patients with pathology involving the maxillary sinus and who were surgically treated from January 2008 to December 2009, type of disease, surgical approach used, presence of complications, pre- and postoperative score according to the Lund-Mackay scale, and resolution (or not) of symptoms. We compared these results with a previous study carried out in 1994 in our hospital. We found a total of 177 patients with maxillary sinus-related pathology, of whom 46 patients were excluded. Results: In 131 patients we found a clear predominance of chronic rhinosinusitis without polyps as a presurgical diagnosis. We used four different approaches: endoscopic (88.5%), combined approach (5.5%), sublabial expanded (4.5%) and Caldwell Luc (1.5%); 41% of the patients received 0 points on the postoperative Lund-Mackay scale. Conclusions: Surgery of the maxillary sinus in our hospital has evolved considerably; the endoscopic approach was used as a surgical treatment in >90% of patients with a low percentage of complications. Key words: Maxillary sinus, sinus surgery Introduction Maxillary sinus surgery has evolved over time. The maxillary sinus was previously the center of attention for the study of pathologies and surgical interventions due to its size and accessibility. Changes have been shown over the centuries. Due to current technological advances, endoscopic surgery has been widely developed and is being applied to the maxillary sinus for multiple diseases that 15 years * Clínica para Trastornos del Gusto y Olfato Centro Neurológico ABC, Centro Médico ABC, Mexico, D.F., Mexico ** Servicio de Otorrinolaringología, UMAE Hospital de Especialidades Dr. Bernardo Sepúlveda Gutiérrez, Centro Médico Nacional Siglo XXI, IMSS, Mexico, D.F., Mexico Correspondence: Dr. Salomón Waizel Haiat Av. Carlos Graef Fernández 154 int154 Col. Tlaxcala, Cuajimalpa México, D.F., Mexico Tel: drwaizel@otorrino.com.mx Received for publication: Accepted for publication: ago were treated using open approaches. 1 The objectives of this study were to 1) determine the diseases that involve the maxillary sinus; 2) determine the type of approaches used for surgical treatment; 3) determine complications of each of the approaches; 4) determine whether there was resolution of the pathology through different surgical approaches, and 5) compare results with the analysis of 15 years ago as to the types of surgical techniques to demonstrate the evolution of sinus surgery at a teaching hospital. In order to compare the different approaches, we must know the particular characteristics of each approach as well as the advantages, complications and basic concepts, especially of the Caldwell-Luc (CL) approach and endoscopy. When the inferior meatus antrostomy and the middle meatus antrostomy are compared, not only does the middle meatal antrostomy have a greater long-term patency but also the percentage of patients who have persistence of symptoms after surgery of the inferior meatus is significantly greater than in patients with an antrostomy of the middle meatus. 2 In addition, complications associated with inferior antrostomy and in particular with CL procedures should not be overlooked. As a result, indications for CL procedures today are only for certain accesses (e.g., for the floor in a recurrent antrochoanal polyp, to the lateral wall by a tumor originating in the area, for the roof in trauma of the orbital floor, and to the posterior wall for ligature of the maxillary artery. Volume 80, No. 3, May-June

2 Waizel-Haiat S et al. However, under these circumstances, conventional CL procedure has been replaced by a mini-anterior antrostomy that considerably avoids the main complications of the procedure. Although an inferior meatal antrostomy is indicated in patients with congenital disorder of mucociliary transport, in practice this has not been demonstrated. There is no evidence to support its superiority under these circumstances. 1 Better understanding of the osteomeatal complex in the development of sinus disease led to the knowledge that with the reconstitution of physiological drainage, the previously diseased mucosa may regain its health with physiological function. Moreover, the development of improved anesthetic techniques and improved visualization with microscopes and endoscopes led to a renaissance of endonasal approach to the sinuses. Therefore, in recent years the endonasal approach has become the gold standard in the treatment of inflammatory diseases of the maxillary sinus and other paranasal sinuses. The term functional endoscopic sinus surgery (FESS) has been coined and describes the surgical restoration of physiological drainage and ventilation of the paranasal sinuses through endoscopic repair of the natural drainage. 3 Modern surgery of the maxillary sinus is microanatomic surgery of the nasal space of the middle meatus. Opening of the stenosis allows improvement of the ventilation and drainage of the maxillary sinus, which in turn provides an environment to allow recovery of the mucosa and mucociliary function to be reconstituted. Although there are some absolute indications for surgery in paranasal sinus disease, there is no absolute indication for an endoscopic approach vs. another endonasal or external approach. However, several publications have shown better results and lower morbidity with endoscopic surgery. According to this, endoscopic surgery is typically the choice approach for chronic sinusitis. 4 The treatment of benign lesions such as nasal inverted papilloma requires precise preoperative imaging studies and endoscopic evaluation. One of the surgical objectives should be to create and maintain a large surgical cavity to facilitate long-term endoscopic follow-up. In benign and malignant tumors with extensive involvement of the skull base, endoscopic techniques can help en bloc resection. In patients requiring craniofacial resection, an endoscopic approach may provide excellent intranasal visualization in some lesions and at the same time avoid the need for external facial incisions. Complete resection of malignant tumors by endoscopic techniques has been controversial. In addition to reduced morbidity, endoscopic resection of encephaloceles, meningoceles and closure of cerebral spinal fluid (CSF) leaks provides a significantly higher success rate than open surgery. Endoscopic surgery can be used for orbital and optic nerve decompression or for biopsy of lesions in the medial portion of the orbital apex. Transnasal endoscopic dacriocystorhinostomy offers significant advantages over the open approach, allowing excellent intraoperative visualization and the ability to remove any granulated tissue. 4 The most important change that has allowed the development of surgical approaches is the development of reliable methods for closure of skull base defects. Using free mucosa for lesions >6 mm (free bone grafts), a 95% success rate has been demonstrated. This allows for elective endoscopic approach for tumor resection, which may include small areas of the skull base. If necessary, in case of inadvertent entry into the cranial fossa on resection of the tumor implantation site, the defect can be immediately closed. The second change that has helped in the development of extended endoscopic approaches is the advance in instrumentation. The introduction of burs and thin microdebriders, especially those that perform simultaneous irrigation and suction, has improved the ability to remove bone endoscopically with accuracy without the need for a third or fourth hand to support the instrumentation required. Particularly in the maxillary sinus approach, FESS has practically replaced the CL technique. However, recent evidence calls for rescuing this open surgery, emphasizing its usefulness in specific situations where endoscopic procedures do not yet have satisfactory results. 4 According to Beinbauer et al. 4 in 1897, Caldwell, Spicer and Luc suggested against an opening towards the nose and coined the principle of irreversible damage of the mucosa. Enthusiasm for the CL procedure as the primary treatment option for chronic rhinosinusitis lasted throughout the early 20 th century, although in some centers a more conservative approach prevailed with a wash of the antrum by an inferior meatal antrostomy and the CL procedure reserved for those cases in which it failed. Other authors described modifications to the intranasal window technique in which the entire medial wall of the antrum was removed but with preservation of the middle and inferior turbinates. 4,5 Before the advent of endoscopic surgery in the late 1970s, the classic indication for CL technique was chronic maxillary sinusitis unresponsive to medical treatment. In the 1980s and 1990s it was largely replaced in this role by FESS, and only rarely was chronic sinusitis treated with this classical technique. However, after 20 years of the endoscopic era, a review in 2003 again mentions the role of the CL technique in chronic sinusitis, but in relation to prior failed FESS. 5 CL procedure should remain in the surgeon's surgical repertoire especially in cases where an appropriate endoscopic middle meatal antrostomy has not allowed the resolution of chronic sinusitis due to poor function of the mucociliary transport mechanism caused by irreversible changes in the mucosa Cirugía y Cirujanos

3 Maxillary sinus surgery The principles of endonasal surgery of the sinuses are currently well established and the specific risks of endonasal surgery are well defined. According to May et al., 6 complications of endonasal surgery of the sinuses can be divided into major and minor. Minor complications are associated with low morbidity and the patient does not have any significant sequelae, e.g., emphysema, periorbital hematoma on the eyelids, bronchospasm, epistaxis requiring nasal packing, pain/numbness in the teeth and lips, synechiae requiring treatment, and postoperative atrophic rhinitis. In contrast, the major complications (~0.5% incidence) exhibit significant morbidity, requiring in most situations emergency treatment. These complications may be associated with catastrophic results for the patient, i.e., epiphora (requiring surgery), loss of sense of smell, bleeding (requiring transfusion), CSF leak, postoperative meningitis, orbital hematoma, persistent transient or permanent diplopia, impairment or vision loss, cerebral hemorrhage, brain abscess, or internal carotid artery injury. Several studies have been conducted to measure rates of complication of sinus surgery, such as the incidence of defects in the skull base among large populations of patients. The results of a study 7 analyzing 1000 patients operated on by five surgeons and in whom there were complications revealed CSF fistula in 0.5% of patients. The incidence of a specific complication may vary in different series; therefore, each surgeon should be aware that there is no simple sinus surgery. Fortunately, major complications are rare. With regard to the potential severity of complications, sinus surgery remains one of the most dangerous surgeries in otorhinolaryngology. However, endoscopic middle meatal antrostomy is a procedure with relatively few complications and a high percentage of success. Complications may include bleeding, synechiae, loss of sensation over the cheek or pain secondary to irritation of infraorbital nerve and restenosis. Orbital complications such as retro-orbital hematoma, diplopia or visual defects are rare in maxillary endonasal surgery of the maxillary sinus. 4 Currently, CL surgery is not recommended as first line of treatment for maxillary sinusitis mainly due to a high rate of complications considered to be almost inevitable (10 40%). In a review of 670 procedures there were 19% complications for CL reported, the most frequent being infraorbital nerve injury (9%) followed by dacryocystitis, oroantral fistula, facial asymmetry and dental devitalization. 8 However, recent studies indicate that complications would be largely dependent on experience and surgical skills. According to the surgical technique, reducing the number of complications would include careful entry into the sinuses, protection of the infraorbital nerve during periosteal elevation and careful closure. 5 Some complications of the CL approach are headache, bleeding, paresthesia or anesthesia of the malar region, upper lip, teeth and gums, local infection, gingivolabial wound dehiscence, oroantral fistula, septal perforation, synechia in nostrils, diplopia, injury of the dental roots, devitalization of teeth, injury to the orbital floor, superior maxillary osteomyelitis, facial edema, subcutaneous emphysema, damage to the nasolacrimal duct, ethmoiditis, mucocele of the maxillary antrum, facial asymmetry, fibro-osseous proliferation in the maxillary antrum, and formation of compartments in the maxillary antrum. 9 Patients and Methods We carried out an observational descriptive study. We included patients from the Otolaryngology Service at the UMAE Specialty Hospital, Centro Medico Nacional Siglo XXI, Mexico City, with pathology involving the maxillary sinus treated surgically from January 1, 2008 to December 31, Inclusion criteria were age >18 years, patients operated only in our hospital, and postsurgical data included in the clinical record. Exclusion criteria included patients without postsurgical medical notes or incomplete clinical files. For our comparative sample we included the following information from the 1994 study on the CL procedure whose objectives were 1) to determine the pathology of the maxillary antrum and adjacent structures resolved through a CL approach, 2) single procedure or combined with other surgical procedures, 3) type of surgical extension added to the CL procedure necessary to resolve the pathology of the maxillary antrum and adjacent structures and 4) complications of these procedures. The study period was from January 1992 to December 1993; clinical files of 54 patients with an average age of 38.4 years were reviewed with the following pathologies found: ethmoidmaxillary sinusitis, chronic maxillary sinusitis, nasoantroethmoidal polyposis, retention cysts in the antrum, pansinusitis, maxillary sinusitis of dental origin, nasal tumor and others. There were 54 CL approaches of which 36 were in combination with transnasal ethmoidectomy, transantral ethmoidectomy, nasal polypectomy, right lateral rhinotomy, oroantral fistula closure, antrochoanal polypectomy, and procedure of Denker and Kahler. There were a total of 20 complications as follows: paresthesias of the malar region, symptom persistence, bleeding, gingivolabial wound dehiscence, oroantral fistula, facial edema, dysosmia, and cellulitis of the upper jaw. With this study as background we can see the evolution of sinus surgery at our hospital. Volume 80, No. 3, May-June

4 Waizel-Haiat S et al. Results A total of 177 patients were registered in the surgical log book of our service during the period from January 1, 2008 to December 31, 2009 with pathology related to the maxillary sinus and nasal and paranasal sinus surgery scheduled. Forty six patients were excluded because their medical records were expunged upon the patient s discharge and were not current with the IMSS or because they were lost. Also excluded were patients with a disease unrelated to the maxillary sinus upon analyzing the files. Of a total of 131 patients, 56 were females (42.7%) and 75 males (57.2%). We included patients >18 years of age (range: years) with a predominance in the range years in males and years in females. Pre0 and postoperative diagnoses were recorded. Maxillary mucocele was notable in 12 patients, Samter syndrome in 12 patients, inverted nasal papilloma in nine patients, and antrochoanal polyp in seven patients. Three additional patients were grouped into the category with the following diagnoses: angiomatous polyp with fibrosis, exophytic nasal papilloma with previous surgery and fibroepithelial nasal polyp. In addition, fungus ball was seen in two patients, chronic invasive mycotic rhinosinusitis in two patients, maxillary sinusitis plus oroantral fistula in one patient, retention cysts in one patient, nasoangiofibroma in one patient, and acute complicated rhinosinusitis in one patient. With regard to the postoperative diagnosis of the 131 patients, a larger number of patients had chronic rhinosinusitis without polyps (25 patients), a lower number than according to the preoperative diagnosis because the patients with septal deviation and those with rhinosinusitis were classified in another group. Chronic rhinosinusitis with polyps was the second most common preoperative diagnosis with 17 patients. According to the preoperative diagnosis, patients who were classified with nasal tumors in the study, when the definitive diagnosis was made were added to each pathology, thereby increasing the number of patients with inverted nasal polyp, maxillary mucocele, antrochoanal polyp and others, with the latter group containing six patients with the following diagnoses: rhinolilth causing maxillary sinusitis, inflammatory nasal polyp, fibroepithelial nasal polyp, cavernous hemangioma, angiomatous polyp, and cystic adenoid carcinoma (Table 1). In our hospital we found that there were four different types of approaches used. Patients were grouped according to the type of approach used with the most common being the endoscopic approach used in 116 patients (88.5%) followed by the combined approach in seven patients (5.5%), modified sublabial in six patients (4.5%) and CL approach in two patients (1.5%). Combined approaches included two patients with median endoscopic maxillectomy and modi- Table 1. Postsurgical diagnosis of the total number of patients Postsurgical diagnosis No. of patients Chronic rhinosinusitis without polyps 25 Chronic rhinosinusitis with polyps 17 Maxillary mucocele 13 Inverted nasal papilloma 12 Antrocoanal polyp 11 Samter syndrome 9 Chronic rhinosinusitis with polyps with 7 previous surgery Chronic rhinosinusitis w/o polyps with 6 previous surgery Chronic rhinosinusitis w/o polyps + septal 6 deviation Others 6 Chronic rhinosinusitis w/polyps + septal 5 deviation Samter syndrome with previous surgery 3 Inverted nasal papilloma w/previous 3 surgery Maxillary fungal ball 2 Chronic invasive mycotic rhinosinusitis 2 Maxillary sinusitis + oroantral fistula 1 Retention cysts 1 Meningocele w/ethmoidmaxillary sinusitis 1 Acute complicated rhinosinusitis 1 fied sublabial approach, one patient with endoscopic resection of the disease and modified sublabial approach, and four patients with endoscopic disease resection plus CL (Figure 1). Maxillary sinus disease was reported and patients were divided into three groups with the left maxillary sinus being affected in 24 patients (18.3%), the right maxillary sinus in 31 patients (23.6%) and bilaterally in 76 patients (58.1%). Of the total number of patients, 39.6% (52 patients) did not require placement of nasal packing, in 36.6% (48 patients) bilateral nasal packing with gauze was placed and in 23.6% (31 patients) tamponade of one nostril was done. Regarding type of surgery performed, endoscopic approach has been described as the most often carried out approach with the largest number of patients with FESS with polypectomy in 41 patients, endoscopic resection of pathology in 29 patients and FESS in 27 patients (Table 2). It should be noted that the CL approach was done in only two patients and in an additional four patients associated 206 Cirugía y Cirujanos

5 Maxillary sinus surgery Widened sublabial 4.5% Combined 5.5% Endoscopic 88.5% Caldwell LUC 1.5% Figure 1. Various surgical approaches used during our study. Table 2. Surgery performed in the 131 study patients Surgery performed No. of patients FESS + polypectomy 41 Pathological resection via endoscope 29 FESS (nasal and paranasal sinuses) 27 FESS + septoplasty 6 Endoscopic maxillectomy 6 Endoscopic pathological resection + 4 Cadwell-Luc Maxillectomy via sublabial widening 3 Pathological resection via sublabial 3 widening Maxillary sinuplasty w/balloon 3 Endoscopic biopsy 2 Endoscopic maxillectomy + sublabial 2 widening Caldwell-Luc pathological resection 2 FESS + closure of oroantral fistula 1 FESS + frontal trephination 1 Endoscopic pathological resection + 1 sublabial widening FESS, functional endoscopic sinus surgery. with endoscopic approach. Within the median maxillectomies, endoscopic approach also dominates followed by the extended sublabial approach in three patients and in two patients a combination of the latter was used. FESS was also combined with septoplasty in six patients, one patient had closure of oroantral fistula and another patient had frontal trephening added to the FESS. Follow-up ranged from 6 months to 2 years 4 months. The most predominant follow-up was 2 years with a total of 22 patients. After 2 years, follow-up was 2 months with 17 patients and 1 year with 13 patients, with the least predominant being 2 years 4 months in only six patients. This varied with respect to the date of surgery, but we observed that the majority of patients have a 1-year follow-up, which is considered adequate for most patients. Not all patients had CT follow-up after surgery because this is not required for all pathologies. Persistence of nasosinus symptoms were recorded in the clinical notes because these denote clinical resolution of the pathology. This resulted in 83% of the patients being asymptomatic during follow-up (110 patients) and 16.1% (21 patients) reported symptoms during followup (Figure 2). We should keep in mind that among the pathologies treated surgically, chronic rhinosinusitis with polyps and Samter syndrome were found. Due to their physiopathology, there is a high percentage of recurrence and persistence of symptoms even with the performance of an excellent surgical technique because the majority of the treatment is medical. No 83.9% Yes 16.1% Figure 2. Persistence or absence of symptoms in patients after surgical treatment. Volume 80, No. 3, May-June

6 Waizel-Haiat S et al. Complications were recorded in the medical record with a total of 13 patients later grouped according to type of approach. Endoscopic approach was done in 116 patients, and a total of 12 patients were reported to have complications, the majority of which were synechias, generally turbinoseptal in nine patients. Frontal sinusitis was shown in a patient secondary to inverted nasal polyp resection, and dacryosteosis was shown in a patient subjected to nasal tumor resection and posterior maxillary mucocele after a median maxillectomy, resulting in 2.5% overall with 89.6% (104 patients) free of complications (Figure 3). Modified sublabial approach was done in six patients with only one complication, which was dehiscence of the surgical wound. For the combined approach and CL approach there were no complications. During data collection, recurrence of nasal polyps was recorded in six patients during follow-up. This was not considered to be a complication because of its pathophysiology with three patients being diagnosed with Samter syndrome. There were two patients with recurrence of inverted nasal papilloma: one had endoscopic surgery and the other had a modified sublabial approach. We used the Lund-Mackay 10 scale (0 to a maximum of 24 points) for tomographic evaluation, thereby being able to group the patients according to opacification and paranasal sinuses affected on CT. For graph purposes, there were six groups formed starting with 1. As expected, no patient was disease-free prior to surgery. The group was found to have 5 to 8 points as the predominant score with 37 patients (28.2%), followed by the group with scores of 1 to 4 points with 34 patients (25.9%). There was a lower percentage of the group with 21 to 24 points with 10 patients (7.6%) (Figure 4). Of the total 131 patients, postoperative CT scan was described in the clinical record or available from the hospital s imaging system in only 91 patients. For graph purposes, one additional group was formed with 0 points, which meant that the sinuses were clean and free of recurrence in the control CT scan after surgery. It was noted that the 0 point group had the largest number of patients (40.6% of the total number) followed by the group with a score of 1 4 points (32.9%), and the group with the lowest percentage of points (1%). We observed redistribution of the patients towards groups with less opacification of the paranasal sinuses and above all toward complete disease resolution. This demonstrates that using FESS we have achieved favorable results in controlling the disease in the majority of patients (Figure 5). During the review of the clinical files, we found Mucocele 0.83% Synechiae 7.7% Lacrimal duct obstruction 0.83% Frontal sinusitis 0.83% 17 a 20 points, 9.9% 21 a 24 points, 7.6% 0,0 1 a 4 points, 25.9% 13 a 16 points, 9.1% 9 a 12 points, 19% 5 a 8 points, 28.2% None 89.6% Figure 3. Complications of the endoscopic approach. Figure 4. Patients classified according to Lund-MacKay scale obtained in accordance with opacification of the sinuses before surgery. 208 Cirugía y Cirujanos

7 Maxillary sinus surgery 13 a 16 points, 1% 9 a 12 points, 2.1% 5 a 8 points, 17.5% 17 a 20 points, 2.1% 1 a 4 points, 32.9% 21 a 24 points, 3.2% 0 points, 40.6% Figure 5. Patients classified according to the Lund-MacKay scale during postoperative CT follow-up. that seven patients had MRI, which was used to determine the extent of disease or to make a differential diagnosis, especially in patients with inverted nasal papilloma. Discussion In 1982, Stammberger video recorded the first diagnosis and treatment by endoscopy. Later, Kennedy coined the term "functional surgery of the paranasal sinus" and in 1985 together with Zinreich and Stammberger organized the first course in functional endoscopic sinus surgery (FESS) in Baltimore, gradually spreading throughout the world. In 1994 work was done in our hospital using the CL procedure. Until that time we had not yet performed any endoscopic surgical procedures, only using endoscopy in the office as a diagnostic tool. Currently, FESS is the most-often performed surgery in our department; however, there has been no analysis of the pathologies that are being resolved by this approach, complications, and the current scope in our hospital in this area. We focused on the maxillary sinus because it is the sinus that has attracted attention from the earliest days of anatomic knowledge and surgical care due to its better accessibility and has shown a great evolution in the types of surgical approach. We included 131 patients in our study with pathology involving the maxillary sinus, directly or indirectly by obstruction with the use of tomography. We also verified that a complete medical file was available and that patients were surgically intervened. In 1994, a total of 54 patients were studied during the same time period. Among the most frequently found pathologies were chronic sinusitis without polyps involving one or more paranasal sinuses and chronic rhinosinusitis with polyps as well as Samter syndrome, which coincided with the literature. It is noteworthy that we found 15 cases of inverted nasal papilloma (three patients with prior surgery) and no cases of exophytic papilloma, with the latter being most commonly mentioned in any source consulted. We are unaware of the reason for this. It may be necessary for future studies to determine whether geographic or environmental factors are involved. We also found 11 cases of antrochoanal polyp. The literature reports that these involve 3 6% of all nasal polyps. 11 In our study this figure was 2.68%, which does not differ greatly from what has been reported. It is also noteworthy that we found 13 cases of maxillary mucocele. This represents a large number of patients because the literature reports that only 5 10% of all mucoceles arise in the maxillary and sphenoid sinuses. 12 During our search and data collection, we did not find many other cases of mucocele in paranasal sinuses. We found that four different approaches were used for maxillary sinus surgery, with the endoscopic approach being the most used (88.5% of patients). This approach was also used in additional 5.5% of patients in combination with modified sublabial and CL approach, showing that the endoscopic approach is used in >90% of patient for diseases involving the maxillary sinus, as well as the remainder of the paranasal sinuses. Compared to the 1994 study where all patients (a total of 54) were treated using the CL approach with the option of surgical extension for performing transantral ethmoidectomy, transnasal ethmoidectomy, lateral rhinotomy and nasal polypectomy to resolve pathologies similar to those we found. In our study, CL as the only approach was performed in only two patients and in four additional patients in combination with the endoscopic approach. The latter four patients represented resection of the pathology such as retention cysts (one patient), antrochoanal polyp (one patient) and maxillary mucoceles (two patients), but not for chronic rhinosinusitis as was done previously in our hospital because FESS currently has displaced CL surgery. We must also keep in mind that with the CL approach it is necessary to make an incision in the gingivolabial sulcus, providing Volume 80, No. 3, May-June

8 Waizel-Haiat S et al. access only to the maxillary sinus. Using the endoscopic approach, both maxillary sinuses are able to be maneuvered without cutting. This is significant according to the results of the affected maxillary sinus; in 58.1% of patients both maxillary sinuses were affected in the same patient. Traditionally, median maxillectomy for nasal tumor resection is performed via external resections, whether using a modified sublabial lateral orinotomy or the more recently described median maxillectomy using the endoscopic approach. 13 This was carried out in six patients with the aforementioned diagnosis and in an additional two patients in combination with the modified sublabial approach. Only three patients were intervened with the modified sublabial approach. During follow-up, only one patient treated with endoscopic median maxillectomy presented with recurrence and one patient treated with modified sublabial approach as well, which represents favorable disease control using the endoscopic approach. Regarding complications, the study showed that 89.6% of patients treated with endoscopic approach were free of complications. In only 10.4% of patients were complications reported that did not endanger the patient s life or function, being primarily turbinoseptal synechiae, corresponding to a total of 12/131 patients. Noting that in 1994, using the CL technique in 54 patients, 14 patients (26%) had complications including malar numbness, hemorrhage, gingivolabial wound dehiscence, oroantral fistula, facial edema, dysosmia, and upper maxillary cellulitis. In a study by Penttila, 23% of 115 patients operated on with the CL procedure had constant postoperative pain in the cheek or had hyperesthesia. 14 Although most patients are not at high risk, bleeding may compromise the patient s life. Using the endoscopic approach there were no reports of patients with hemorrhage. We evaluated patients who required nasal tamponade, reporting that 39.6% of patients did not require this, showing not only good control of bleeding but the absence of bleeding. In our study there were no complications with the CL approach, but we must take into account that it was performed in only two patients. Using the modified sublabial approach we found one patient with wound dehiscence as a complication. In 1994, persistence of symptoms was present in six patients, corresponding to 11% of patients. In our study we found symptom persistence to be 16.1%. However, we must consider that 12 patients presented with Samter syndrome, which due to its physiopathology presents a high recurrence of symptoms and nasal polyposis. Various patients presented some type of rhinitis, especially allergic, which causes symptoms of nasal obstruction, mainly rhinorrhea, without recurrence of residual sinus disease. We utilized the Lund-Mackay 10 scale to more uniformly assess disease extension, assigning points according to the occupation of the paranasal sinuses, finding a significant difference when comparing pre- and postoperative CT scans. Taking into consideration that in >90% patients the endoscopic approach was used, we believe this procedure is very useful for pathological resolution of the maxillary sinus and with broad application for approaching all paranasal sinuses as well as for almost all involved pathologies. In conclusion, maxillary sinus surgery in our hospital has evolved considerably because as recent as 15 years ago the endoscopic approach of the nose and sinuses was still not being used. This is in contrast to what we observe today. The endoscopic approach is used as a surgical treatment in >90% of patients with pathology involving the maxillary sinus in addition to being used to perform surgeries that were previously open surgeries and demonstrating a low percentage of complications compared with the CL approach. Significant advantages have been found using the endoscopic approach including 1) adequate control of maxillary sinus disease (as well as in the rest of the paranasal sinuses including the sphenoid and frontal sinus), 2) better control of bleeding, 3) applicable to most diseases that occur in our environment, 4) demonstrating results with significant tomographic improvement and 5) continuous evolution as in the rest of the world, recently applying balloon sinoplasty. References 1. Lund VJ. The evolution of surgery on the maxillary sinus for chronic rhinosinusitis. Laryngoscope 2002;112: Lund VJ. The results of inferior and middle meatal antrostomy under endoscopic control. Acta Otorhinolaryngol Belg 1993;47: Stucker FJ, Souza C, Kenyon GS, Lian TS, Draf W, Schick B. Rhinology and Facial Plastic Surgery. 1st ed. Leipzig, Germany: Springer, 2009 pp Breinbauer HK, Contreras JM, Namoncura CP. Técnica de Caldwell- Luc en los últimos 16 años: revisión de sus indicaciones. Rev Otorrinolaringol Cir Cabeza Cuello 2008;68: Cutler JL, Duncavage JA, Matheny K, Cross JL, Miman MC, Oh CK. Results of Caldwell-Luc after failed endoscopic middle meatus antrostomy in patients with chronic sinusitis. Laryngoscope 2003;113: May M, Levine HL, Schaitkin B. Complications of endoscopic sinus surgery. In: Levine HL, May M, eds. Endoscopic Sinus Surgery. New York: Thieme, 1993 pp Keerl R, Stankiewicz J, Weber R, Hosemann W, Draf W. 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9 Maxillary sinus surgery 11. Hong SK, Min YG, Kim CN, Byun SW. Endoscopic removal of the antral portion of antrochoanal polyp by powered instrumentation. Laryngoscope 2001;111: Zizmor J, Noyek AM. Cysts, benign tumors, and malignant tumors of the paranasal sinuses. Otolaryngol Clin North Am 1973;6: Han JK, Smith TL, Loehrl T, Toohill RJ, Smith MM. An evolution in the management of sinonasal inverting papilloma. Laryngoscope 2001;111: Penttilä MA, Rautiainen ME, Pukander JS, Karma PH. Endoscopic versus Caldwell-Luc approach in chronic maxillary sinusitis: comparison of symptoms at one-year follow-up. Rhinology 1994;32: Volume 80, No. 3, May-June