The introduction of endoscopic sinus surgery techniques with intraoperative surgical navigation has revolutionized the management of sinonasal pathology. Neoplastic masses of the lateral nasal wall and maxillary sinus were approached through a lateral rhinotomy incision and or Caldwell-Luc approach until the advent of endoscopic sinus surgery. Endoscopic medial maxillectomy offers an alternative to open procedures with similar cure rates for the appropriate indications with preservation of the nasolacrimal duct. Additionally, the endoscopic medial maxillectomy can be used for patients in which mucociliary clearance in the maxillary sinus is dysfunctional, necessitating lavage with gravity drainage. The endoscopic approach offers significant reduction of the morbidity encountered with open surgical approaches.

Total intravenous anesthesia should be used to minimize blood loss. The patient should be placed in the supine position and once intubated should be turned 180 degrees and draped in the normal sterile fashion. The head of the bed is raised 15 to 30 degrees to minimize blood loss. For right-handed surgeons, the tube should be secured in the left oral commissure (and right commissure for left-handed surgeons), independent of the side of surgery.

The nose is decongested with neurosurgical pledgets that have been soaked in 1:1,000 epinephrine and rung out prior to being inserted into the nose. These pledgets should remain in the nose for a minimum of 10 minutes. A transoral pterygopalatine injection through the greater palatine foramen with 1% lidocaine with 1:100,000 epinephrine assists with hemostasis. The foramen can be found approximately 1 cm medial to the second maxillary molar, and injection should be made with a 25-gauge needle bent 90 degrees at 20 mm from the tip to prevent injecting too deeply. It is critical to aspirate during this step to prevent injecting directly into the greater palatine artery.

Initial inspection into the nasal cavity is made with a zero-degree telescope in order to view the surgical field. A submucosal injection with 1% lidocaine with 1:100,000 epinephrine into the axilla of the middle turbinate is performed with evidence of further vasoconstriction evident with blanching of the lateral nasal wall as well as the middle turbinate. The middle turbinate is then medialized to expose the middle meatus and widen the operative field. It is critical during this stage, as well as throughout the procedure, to perform a thorough examination during resection of an inverted papilloma to isolate the stalk of the mass.

The maxillary ostium is a critical landmark used to initiate the medial maxillectomy dissection. In order to expose the ostium, the uncinate process is reflected medially using various techniques either reflection with a ball-tipped probe or incising its insertion with a sickle knife. The maxillary antrostomy is then accomplished with a back-biting instrument with inferior-anterior tension applied. Caution during this step should be taken to ensure that there is no violation of the lacrimal bone. It is important to be certain that the entire uncinate process is removed as retention of the superior portion can impact frontal sinus drainage.

Using a through-cutting forceps, the posterior aspect of the antrostomy is carried back until it is flush with the pterygoid plates. Once dissection is started, hemostasis is obtained using neurosurgical pledgets that were soaked in 1:1,000 epinephrine with 1,000 units of thrombin/mL and well wrung out.