Abstract
Purpose
To describe a technique of endoscopic medial maxillectomy with mucosal flap for postoperative maxillary sinus mucoceles and to present a case series of subjects who underwent this procedure.
Materials and methods
This case series includes four subjects with postoperative maxillary sinus mucoceles who underwent resection via endoscopic partial medial maxillectomy with a mucosal flap. We will discuss the clinical presentation, imaging characteristics, operative details, and outcomes.
Results
Four subjects are included in this study. The average age at the time of medial maxillectomy was 52 years (range 35–65 years). Three subjects (75%) were female. One subject (25%) had bilateral postoperative maxillary sinus mucoceles. Two subjects (50%) had unilateral right sided mucoceles, and the remaining subject had a unilateral left sided mucocele.
All subjects had a history of multiple sinus procedures for chronic sinusitis including Caldwell–Luc procedures ipsilateral to the postoperative mucocele. All subjects underwent endoscopic medial maxillectomy without complication and were symptom free at the last follow up appointment, average 24 months (range 3–71 months) after medial maxillectomy.
Conclusions
For postoperative maxillary sinus mucoceles in locations that are difficult to access via the middle meatus antrostomy, we recommend endoscopic medial maxillectomy with mucosal flap. Our preliminary experience with four subjects demonstrates complete resolution of symptoms after this procedure.
1
Introduction
Mucoceles are benign, locally expansive, cyst-like paranasal sinus masses Mucoceles are most commonly found in the frontal sinus . Maxillary sinus mucoceles are relatively rare and account for 10% of all paranasal sinus mucoceles in the United States and Europe .
Mucoceles are believed to form following obstruction of the sinus ostia, with accumulation of fluid within a mucoperiosteal lined cavity . As mucus is produced within the mucocele, it enlarges gradually, resulting in erosion and remodeling of the surrounding bone leading to nasal obstruction, facial asymmetry, vision changes, and/or dental problems . The most common causes of mucoceles are trauma, previous surgery, allergic sinonasal disease, chronic sinusitis, and, in some cases, the cause remains unknown .
Postoperative maxillary sinus mucoceles are mucoceles which develop in the maxillary sinus as a result of previous surgery, most commonly Caldwell–Luc surgery. These mucoceles are thought to arise from mucosa trapped along the edge of the antrostomy which develops into a mucocele years later . The reported incidence of postoperative maxillary sinus mucoceles is greater in Japan than in other countries, such as the UK, Germany, and the USA . The reasons for this variation are unknown.
Historically, the recommended treatment for maxillary sinus mucoceles was complete excision through an open approach with removal of the mucocele lining . The endoscopic approach has gained popularity over the past ten years for treatment of maxillary sinus mucoceles . Despite the popularity of endoscopic resection, prior studies suggest that some maxillary sinus mucoceles cannot be adequately accessed via maxillary antrostomy, especially large mucoceles with extra-sinus extension .
This study describes a novel technique for treating postoperative maxillary sinus mucoceles via endoscopic partial medial maxillectomy followed by placement of a mucosal flap along the inferior border of the maxillectomy to prevent re-stenosis. We also present a series of four consecutive subjects who underwent this procedure.
2
Methods
This is a retrospective study which includes consecutive subjects with postoperative maxillary sinus mucoceles who underwent endoscopic partial medial maxillectomy with mucosal flap from January 1, 2005 to October 1, 2011. This study was approved by the University of California, San Francisco Committee on Human Research.
All subjects had remote history of sinus surgery including a Caldwell–Luc procedure and were referred to our institution for postoperative maxillary sinus mucoceles. All subjects underwent preoperative sinus CT imaging. The diagnosis of postoperative maxillary sinus mucocele was made based on physical examination, including nasal endoscopy, as well the CT scan findings. Medical records were reviewed for subject demographics, presenting symptoms, nature of original sinus surgery, extent of disease, operative details, perioperative complications, postoperative endoscopy findings, and postoperative symptoms.
All subjects underwent endoscopic partial medial maxillectomy with mucosal flap performed by the senior author (ANG). After topical administration of Neosynephrine and 1:1000 epinephrine, a maxillary antrostomy was performed if there was no prior antrostomy created during prior sinus procedures. Image guidance was used to confirm the location of the mucocele. Then, needle monocautery or beaver blades (Alcon Surgical Inc, Fort Worth, Texas) were used to create an inferiorly-based mucosal flap on the lateral nasal wall in the region of the mucocele ( Fig. 1 ). Partial resection of the anterior inferior turbinate was required to obtain adequate access to the lateral nasal wall in three subjects. Then, a Cottle elevator and suction Freer were used to elevate the inferiorly-based mucosal flap off of the lateral nasal wall onto the nasal floor ( Fig. 2 ). With the lateral nasal wall exposed, an endoscopic partial medial maxillectomy was performed using a cutting burr to take down the lateral nasal wall to the floor of the nose at the site of the mucocele. Care was taken to prevent drilling in the region of the nasolacrimal duct. Once the mucocele was identified, its contents were evacuated using suction. When the partial medial maxillectomy was of adequate size and the mucocele was evacuated, the previously creased inferiorly-based mucosal flap was draped along the floor of the nose covering the inferior bony border of the partial medial maxillectomy to prevent re-stenosis ( Figs. 3 and 4 ). For the subject with bilateral postoperative maxillary sinus mucoceles, this procedure was repeated on the contralateral side.
All subjects were discharged home following the procedure and were seen in clinic for the first post-operative visit two weeks following the procedure. No postoperative imaging was performed for any of the subjects in this study. The surgical outcome was based on patency of the partial medial maxillectomy, appearance of maxillary sinus mucosa, and resolution of symptoms.
2
Methods
This is a retrospective study which includes consecutive subjects with postoperative maxillary sinus mucoceles who underwent endoscopic partial medial maxillectomy with mucosal flap from January 1, 2005 to October 1, 2011. This study was approved by the University of California, San Francisco Committee on Human Research.
All subjects had remote history of sinus surgery including a Caldwell–Luc procedure and were referred to our institution for postoperative maxillary sinus mucoceles. All subjects underwent preoperative sinus CT imaging. The diagnosis of postoperative maxillary sinus mucocele was made based on physical examination, including nasal endoscopy, as well the CT scan findings. Medical records were reviewed for subject demographics, presenting symptoms, nature of original sinus surgery, extent of disease, operative details, perioperative complications, postoperative endoscopy findings, and postoperative symptoms.
All subjects underwent endoscopic partial medial maxillectomy with mucosal flap performed by the senior author (ANG). After topical administration of Neosynephrine and 1:1000 epinephrine, a maxillary antrostomy was performed if there was no prior antrostomy created during prior sinus procedures. Image guidance was used to confirm the location of the mucocele. Then, needle monocautery or beaver blades (Alcon Surgical Inc, Fort Worth, Texas) were used to create an inferiorly-based mucosal flap on the lateral nasal wall in the region of the mucocele ( Fig. 1 ). Partial resection of the anterior inferior turbinate was required to obtain adequate access to the lateral nasal wall in three subjects. Then, a Cottle elevator and suction Freer were used to elevate the inferiorly-based mucosal flap off of the lateral nasal wall onto the nasal floor ( Fig. 2 ). With the lateral nasal wall exposed, an endoscopic partial medial maxillectomy was performed using a cutting burr to take down the lateral nasal wall to the floor of the nose at the site of the mucocele. Care was taken to prevent drilling in the region of the nasolacrimal duct. Once the mucocele was identified, its contents were evacuated using suction. When the partial medial maxillectomy was of adequate size and the mucocele was evacuated, the previously creased inferiorly-based mucosal flap was draped along the floor of the nose covering the inferior bony border of the partial medial maxillectomy to prevent re-stenosis ( Figs. 3 and 4 ). For the subject with bilateral postoperative maxillary sinus mucoceles, this procedure was repeated on the contralateral side.
