Canine Fossa Puncture for Severe Maxillary Disease in Unilateral Chronic Sinusitis With Nasal Polyp

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1 The Laryngoscope VC 2013 The American Laryngological, Rhinological and Otological Society, Inc. Canine Fossa Puncture for Severe Maxillary Disease in Unilateral Chronic Sinusitis With Nasal Polyp Jang Yul Byun, MD; Jae Yong Lee, MD, PhD Objectives/Hypothesis: To evaluate the efficacy of canine fossa puncture (CFP) by comparing patients with unilateral chronic rhinosinusitis (CRS) accompanying nasal polyposis (NP) who underwent CFP with those who underwent maxillary sinus clearance through a middle meatal antrostomy (MMA). Study Design: Prospective randomized study. Methods: Twenty-nine patients were randomly assigned to the CFP and MMA groups. Preoperative computed tomography (CT) established that all patients had severely diseased maxillary sinuses. Subjective outcomes were evaluated preoperatively and at 3, 6, and 12 months postoperatively using the Sino-Nasal Outcome Test 20 (SNOT-20) and a visual analogue scale (VAS). Additionally, mucosal thickening was measured as a percentage of total maxillary sinus volume on CT images taken 12 months postoperatively. Results: Twenty-five patients who completed the follow-up, questionnaires, and postoperative CT evaluation were included in the analysis. SNOT-20 and VAS scores improved significantly at 3, 6, and 12 months postprocedure in both groups. However, significant improvement of SNOT-20 at 12 months and VAS scores for purulent discharge, foul odor, and postnasal drip at 6 and 12 months were observed in the CFP group compared with the MMA group. In addition, the volume of mucosal thickening was significantly greater in the MMA group than in the CFP group on postoperative CT images. Conclusions: CFP is a useful method for the removal of severe maxillary mucosal disease that cannot be reached through MMA, and is superior to conventional MMA for improving subjective and objective outcomes in patients with unilateral CRS accompanying NP. Key Words: Unilateral chronic rhinosinusitis, nasal polyposis, maxillary sinus, canine fossa puncture, middle meatal antrostomy, Sino-Nasal Outcome Test 20, visual analogue scale, computed tomography. Level of Evidence: 1b. Laryngoscope, 123:E79 E84, 2013 INTRODUCTION Chronic rhinosinusitis (CRS) with nasal polyposis (NP) is a common chronic disease that seriously affects the quality of life. 1 Endoscopic sinus surgery (ESS) has become a standard surgical procedure for CRS with NP that does not respond to conservative therapy. CRS with NP affects the anterior ethmoid and maxillary sinuses in the majority of patients requiring ESS. 2 An adequate middle meatal antrostomy (MMA) is sufficient in most of patients for the maxillary sinus lesions. However, a small group of patients have extensive mucosal disease within the maxillary sinus that is difficult to manage using the middle meatal approach. It is acknowledged that MMA offers only a limited exposure to the anterior, inferior, and lateral regions of the antrum. 3,4 In these cases, a traditional Caldwell Luc From the Department of Otorhinolaryngology Head and Neck Surgery, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, South Korea. Editor s Note: This Manuscript was accepted for publication May 30, The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Jae Yong Lee, MD, PhD, 1174 Jung-Dong, Wonmi-Gu, Bucheon-Si, Gyeonggi-Do, , South Korea. jyent@schmc.ac.kr DOI: /lary operation can be considered to visualize the blind area. However, this approach is often associated with significant morbidities such as facial numbness or paresthesia, oroantral fistulas, and gingivolabial wound dehiscences. 5 Therefore, canine fossa puncture (CFP) has been proposed as an alternative method of obtaining access to the maxillary antrum, and has replaced the previous conventional approach in a significant number of surgeries. We demonstrated previously that more favorable objective surgical outcomes could be achieved in patients with unilateral CRS and NP than in those with bilateral CRS and NP, perhaps due to the different developmental mechanisms of the two disease entities. 6 In another report, we compared the efficacy of CFP and MMA in patients with bilateral CRS accompanying NP. 7 No significant difference between methods was detected in subjective or objective outcome, probably due to the presence of diffuse bilateral NP in all patients included in the study. However, the effectiveness of CFP may differ in patients with unilateral disease. To our knowledge, no study has compared surgical outcomes of CFP and MMA in unilateral cases. Therefore, we compared the results of the two surgical methods and evaluated the efficacy of CFP in patients with unilateral CRS accompanying NP and severely diseased maxillary sinuses. E79

2 Fig. 1. Endoscopic views of the (A) left and (B) right maxillary sinuses showing diffuse nasal polyposis and extensive mucosal disease. MATERIALS AND METHODS This prospective clinical study was conducted between June 2008 and July 2011 in patients diagnosed with unilateral CRS accompanying NP who underwent ESS with nasal polypectomy on the lesion side. Informed consent was provided from the participants, and the institutional review board of Soonchunhyang University approved the study. All patients showed extensive unilateral maxillary sinusitis on preoperative computed tomography (CT). The patients were randomly allocated to undergo CFP as the surgical procedure addressing the antrum (CFP group) or maxillary sinus clearance through MMA (MMA group). Randomization was performed according to a randomized list constructed using a statistical random number table. Exclusion criteria were: 1) age 15 years; 2) acute or fungal sinusitis, retention cyst, antrochoanal polyp, mucocele, or benign or malignant tumor; 3) maxillary sinus filled with mucopus with a normal-appearing mucosal lining; 4) cystic fibrosis, ciliary dysfunction, immune deficiency, or immunodepressed status; 5) previous sinus surgery; 6) sinus surgery for sinusitis complications; 7) absence of NP diagnosis on a postoperative pathological report; and 8) refusal to participate or study dropout before the 12-month follow-up endpoint. The extent of polyps was graded on nasal endoscopic examination as: 1) polyps present within the middle meatus; 2) polyps extending beyond the middle meatus; and 3) large polyps extending to or below the lower border of the inferior turbinate or polyps present medial to the middle turbinate. Preoperative CT images of the sinuses were staged using the Lund Mackay scoring system. The highest score was 12, because we examined patients with unilateral disease. Lund Mackay scores were calculated for all sinuses and for the maxillary sinus separately. The same surgeon (J.Y.L.) performed all surgical procedures. Septoplasty was performed in three patients in the CFP group and four patients in the MMA group, because the approach to the operation side was difficult due to a deviated septum in these cases. Additionally, inferior turbinoplasty was performed in six patients in each group with chronic nasal obstruction and hypertrophied turbinates that did not respond to proper medical treatment. In the CFP group, adequate widening of the natural ostium was performed for the observation of the antrum status. A 4-mm-diameter round opening was created at the point of the intersection of the mid pupillary line and a horizontal line running along the lower border of the nasal ala using the maxillary sinus trocar (Karl Storz, Tuttlingen, Germany). 8 A curved 4-mm microdebrider blade (Stryker Instruments, Kalamazoo, MI) was inserted through the CFP, and the pathological mucosa of the maxillary sinus was removed under visualization with a rigid, straight, 4-mmdiameter 70 endoscope (Karl Storz). In the MMA group, a large E80 MMA was performed and the maxillary sinus was cleared using curved microdebrider blades, various curved forceps, and curved or malleable suction tips. Great care was taken to avoid injury of the nasolacrimal duct when widening the ostium anteriorly. After surgery, a single 20-mg dose of prednisolone was prescribed daily for 10 days, and proper medications were also administered postoperatively. Each patient visited our office once per week for the first 4 to 6 weeks, once per month for 2 months thereafter, and at 6 and 12 months postoperatively. To evaluate the patients subjective symptoms, the Sino- Nasal Outcome Test 20 (SNOT-20) 9 and a visual analogue scale (VAS) were used. On the SNOT-20 and VAS, a score of 0 represented the absence of a symptom. Scores of 5 and 10 indicated the greatest symptom severity and the most bothersome state on the SNOT-20 and VAS, respectively. The questionnaire included queries regarding the patient s experience of nasal obstruction, purulent discharge, foul odors, headache, facial pain or discomfort, and postnasal drip. The SNOT-20 and VAS were administered preoperatively and at 3, 6, and 12 months postoperatively. CT images were acquired in both groups 12 months postoperatively. The author and another physician (J.Y.B.) blinded to the surgical technique (CFP or MMA) calculated Lund Mackay scores for all sinuses and for the maxillary sinus separately, and average scores of two physicians were used in the analysis. Mucosal thickening was also calculated as a percentage of total maxillary sinus volume using the Aquarius intution program (version ; TeraRecon, San Mateo, CA), which performs three-dimensional CT reconstruction. Study results were analyzed using the Mann Whitney and Wilcoxon signed-rank tests. Statistical analyses were carried out using SPSS software (version 16.0; SPSS, Chicago, IL), with statistical significance defined as P <.05. RESULTS Twenty-nine patients (CFP group, n 5 14; MMA group, n 5 15) fulfilled the inclusion criteria of the study. Of these, 12 patients in the CFP group and 13 patients in the MMA group completed the follow-up, questionnaires, and postoperative CT evaluation and were included in the analysis. Two patients in each group dropped out of the study during the follow-up period or refused to take postoperative CT. All study participants had unilateral CRS with NP and extensive maxillary sinus disease (Fig. 1). The characteristics of patients in both groups are summarized in Table I. The extent of preoperative NP was in the CFP group and in the MMA group

3 TABLE I. Information on Patients in the CFP and MMA Groups. CFP MMA Total Patients, No Male:female 8:4 10:3 18:7 Mean age, yr (range) 47.7 (26 69) 52.0 (18 77) 49.9 CFP 5 canine fossa puncture; MMA 5 middle meatal antrostomy. (P ). The respective preoperative Lund Mackay scores for all sinuses and for the maxillary sinus were and in the CFP group, and and in the MMA group. These parameters did not differ significantly between groups (P and P 5.912). Mean SNOT-20 and VAS scores for each symptom improved significantly at 3, 6, and 12 months postoperatively in both groups compared with preoperative scores. The degree of improvement did not differ significantly between groups at 3 months postoperatively, but SNOT- 20 at 12 months and VAS scores for purulent discharge, foul odor, and postnasal drip at 6 and 12 months were significantly better in the CFP group than in the MMA group. VAS scores for nasal obstruction, headache, and facial pain or discomfort drip did not differ significantly between groups at 6 or 12 months postoperatively (Tables II and III). The respective postoperative Lund Mackay scores for all sinuses and for the maxillary sinus significantly improved compared to preoperative values. Postoperative Lund Mackay scores for all sinuses did not differ significantly between groups, whereas scores for the maxillary sinus were significantly better in the CFP group than in the MMA group. The percentage of mucosal thickening on postoperative CT images was significantly greater in the MMA group than in the CFP group (Table IV, Figs. 2 and 3). DISCUSSION In the present study, we compared the efficacy and outcomes of CFP and MMA using symptom scores and postoperative CT findings. All patients included in this TABLE II. Comparison of Sino-Nasal Outcome Test 20 Scores. CFP MMA P Preoperative (NS) At 3 months * *.742 (NS) At 6 months * *.229 (NS) At 12 months * *.017 Data are given as mean 6 standard deviation. *Statistically different from preoperative values (all P values are.002). Statistical difference between CFP and MMA groups, better in the CFP group. CFP 5 canine fossa puncture; MMA 5 middle meatal antrostomy; NS 5 statistically not significant. TABLE III. Comparison of Visual Analogue Scale Scores. CFP MMA P Nasal obstruction Preoperative (NS) At 3 months * *.186 (NS) At 6 months * *.441 (NS) At 12 months * *.429 (NS) Purulent discharge Preoperative (NS) At 3 months * *.273 (NS) At 6 months * *.039 At 12 months * *.034 Foul odors Preoperative (NS) At 3 months * *.741 (NS) At 6 months * *.001 At 12 months * *.001 Headache Preoperative (NS) At 3 months * *.773 (NS) At 6 months * *.677 (NS) At 12 months * *.729 (NS) Facial pain/discomfort Preoperative (NS) At 3 months * *.535 (NS) At 6 months * *.711 (NS) At 12 months * *.571 (NS) Postnasal drip Preoperative (NS) At 3 months * *.907 (NS) At 6 months * *.025 At 12 months * *.013 Data are given as mean 6 standard deviation. *Statistically different from preoperative values (all P values are.009). Statistical difference between CFP and MMA groups, better in the CFP group. CFP 5 canine fossa puncture; MMA 5 middle meatal antrostomy; NS 5 statistically not significant. study had unilateral CRS with NP and extensive maxillary sinus disease. Previous reports revealed that CFP was superior to MMA in symptom control and postoperative radiologic findings. 4,8 However, these studies were retrospective and included diverse disease entities, such as CRS, nonallergic eosinophilic fungal sinusitis, and allergic fungal sinusitis. In contrast to those studies, we reported that evidence for the superiority of CFP over MMA was lacking in a study that compared the effectiveness of CFP and MMA approaches in patients with bilateral CRS accompanying NP. 7 Although SNOT-20 and VAS scores improved significantly at 3, 6, and 12 months postoperatively in both groups, no significant difference between methods was detected in subjective or objective outcome. NP has a high propensity for recurrence, and mucosal E81

4 TABLE IV. L-M Scores and Percentage of Mucosal Thickening of the Maxillary Sinus. CFP MMA P L-M scores All sinuses Preoperative (NS) Postoperative * *.295 (NS) Maxillary sinus Preoperative (NS) Postoperative * *.022 Average volume of MS, ml Average volume of MT, ml (NS) Percentage of MT Data are given as mean 6 standard deviation. *Statistically different from preoperative values (all P values are.002). Statistical difference between CFP and MMA groups, better in the CFP group. Statistical difference between CFP and MMA groups, greater in the MMA group. CFP 5 canine fossa puncture; L-M 5 Lund Mackay; MMA 5 middle meatal antrostomy; MS 5 maxillary sinus; MT 5 mucosal thickening; NS 5 statistically not significant. edema, polypoid changes, and inflammation are frequently observed after operation, which necessitate further surgical revision. 10,11 In our opinion, the presence of bilateral diffuse NP in all patients included in the study was the main reason that findings differed from those of the previous report. In another report, we revealed that more favorable objective surgical outcomes could be achieved in patients with unilateral CRS and NP than in those with bilateral CRS with NP, perhaps due to the different developmental mechanisms and predisposing factors of the two disease entities. 6 In our opinion, unresolved acute sinus infection is the most common cause of unilateral CRS with NP. Acute sinusitis generally occurs unilaterally and is most frequently followed by upper respiratory infection, which occasionally produces mucosal edema and obstruction of the natural ostia or ostiomeatal unit. With the improvement of upper respiratory infection, mucosal edema, ostial obstruction, and acute sinus inflammation resolve spontaneously in most cases. However, ostial blockage may persist in some patients, resulting in CRS and, ultimately, polyp formation. In contrast, bilateral CRS is thought to be more intimately related to host factors, including an innate genetic tendency to develop NP, systemic conditions, and/or inheritance. In summary, we hypothesized that unilateral Fig. 2. (A) Preoperative and (B) 12-month postoperative computed tomographic images of two patients who underwent canine fossa puncture. Postoperative mucosal thickening is minimal. E82

5 Fig. 3. (A) Preoperative and (B) 12-month postoperative computed tomographic images of two patients who underwent middle meatal antrostomy. Postoperative mucosal thickening is much more pronounced in these patients than in those who underwent canine fossa puncture. disease has more definite predisposing factors than does bilateral disease, and thus that resolution of the causative condition may result in a more favorable surgical outcome. The results of our previous studies indicated that CFP was not superior to MMA in patients with bilateral CRS and NP, and that more favorable objective surgical outcomes could be achieved in unilateral than in bilateral CRS cases accompanied by NP. Therefore, we expected that the CFP approach would yield more successful results than conventional MMA in patients with unilateral CRS and NP. As predicted, SNOT-20 at 12 months and VAS scores for three symptoms at 6 and 12 months indicated significantly more improvement in the CFP group than in the MMA group, and the MMA group showed a significantly greater percentage of mucosal thickening on postoperative CT images. No symptomatic difference was observed between groups at 3 months, perhaps due to postoperative medication use and the lack of significant mucosal thickening at that time. However, in our opinion, remnant mucosal disease in the MMA group was worsened, and thickening was more pronounced with time. These conditions produced mucosal inflammation progressively, resulting in worse symptom scores in the MMA group than in the CFP group at 6 and 12 months postoperatively. In addition, although Lund Mackay scores for all sinuses did not differ significantly at 12 months postoperatively, postoperative scores for the maxillary sinus were significantly higher in the MMA group, suggesting that maxillary sinus disease was responsible for worse symptoms. These results indicate that CFP is a more effective and promising method for the management of severely diseased maxillary sinuses in patients with unilateral CRS accompanying NP. Although several complications related to the CFP procedure occurred in several patients (e.g., facial swelling, numbness, bruising, and tingling sensation), these symptoms resolved spontaneously within 1 month in most cases, with no symptom persisting at 3 months after the procedure. CONCLUSION We reported previously that CFP was not effective in patients with bilateral CRS and diffuse NP. However, in this study, we found that CFP provided better management and subjective and objective surgical outcomes than MMA for severely diseased maxillary sinuses in patients with unilateral CRS accompanying NP. We suggest that the differences in results between unilateral and bilateral cases may be associated with different developmental mechanisms and predisposing factors of E83

6 the two disease entities. Based on the results of the present study, we recommend CFP as a useful and effective method for the management of severe maxillary mucosal disease in patients with unilateral CRS and NP. BIBLIOGRAPHY 1. Fokkens W, Lund V, Bachert C, et al. EAACI position paper on rhinosinusitis and nasal polyps executive summary. Allergy 2005;60: Yonkers AJ. Sinusitis: inspecting the causes and treatment. Ear Nose Throat J 1992;71: 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: Seiberling K, Ooi E, MiinYip J, Wormald PJ. Canine fossa trephine for the severely diseased maxillary sinus. Am J Rhinol Allergy 2009;23: DeFreitas J, Lucente FE. The Caldwell-Luc procedure: institutional review of 670 cases: Laryngoscope 1988;98: Lee JY, Byun JY, Shim SS, Lee SW. Outcomes after endoscopic sinus surgery for unilateral versus bilateral chronic rhinosinusitis with nasal polyposis. Am J Rhinol Allergy 2010;24: Lee JY, Lee SH, Hong HS, Lee JD, Cho SH. Is the canine fossa puncture approach really necessary for the severely diseased maxillary sinus during endoscopic sinus surgery? Laryngoscope 2008;118: Sathananthar S, Nagaonkar S, Paleri V, Le T, Robinson S, Wormald PJ. Canine fossa puncture and clearance of the maxillary sinus for the severely diseased maxillary sinus. Laryngoscope 2005;115: Piccirillo JF, Merritt MG Jr, Richards ML. Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg 2002;126: Wynn R, Har-EI G. Recurrence rates after endoscopic sinus surgery for massive sinus polyposis. Laryngoscope 2004;114: Deal RT, Kountakis SE. Significance of nasal polyps in chronic rhinosinusitis: symptoms and surgical outcomes. Laryngoscope 2004;114: E84