Abstract
Purpose
Transnasal endoscopic marsupialization has replaced the conventional Caldwell-Luc operation for managing postoperative maxillary mucoceles. Inferior meatal antrostomy (IMA) may be an easier and more effective method than middle meatal antrostomy (MMA) because of anatomical and structural changes of the maxillary sinus. We evaluated the long-term efficacy and technical simplicity of both methods.
Methods
This study included 21 and 32 patients who underwent MMA and IMA, respectively. They were diagnosed with a unilateral postoperative maxillary mucocele, and medical records were reviewed for history, clinical presentation, radiographic findings, surgical intervention, complications, and outcomes. During follow-up, the size of the opening and stenosis or obstruction of the antrostomy site were evaluated.
Results
Preoperative symptoms and mean follow-up period were similar in both groups. All patients in the IMA group received the operation as planned, whereas in four MMA patients, the attempt to create an opening failed because of thick bones and anatomical changes from the previous operation; in these patients, IMA was performed. The opening remained large enough for ventilation and drainage between the mucocele and the nasal cavity in both groups. There were no major complications, such as profuse bleeding, wound infection, or orbital or nasolacrimal duct injury.
Conclusions
Although both surgical procedures seem to be effective for managing postoperative maxillary mucoceles, IMA is easier to perform, and no instances of failure to create antrostomy openings occurred. We recommend IMA as the surgical technique of choice, but providing an opening of sufficient size is necessary to ensure long-term efficacy.
1
Introduction
A postoperative maxillary mucocele (previously called a postoperative cheek cyst) is a delayed complication following radical surgery of the maxillary sinus, such as a traditional Caldwell-Luc operation . Patients often complain of facial swelling, pain, tenderness, dental pain, and nasal obstruction . On radiologic study, it usually presents as a round cystic mass lesion and may be accompanied by bony erosion or destruction of the maxilla or orbital walls . Computed tomography (CT) images often show various densities within the cyst according to the protein content, and it is lined with respiratory-type ciliated epithelium histopathologically .
Traditionally, maxillary mucoceles have been removed using a sublabial approach. However, this surgical procedure is associated with significant morbidity, such as facial numbness, dental numbness, soft tissue swelling, hematoma, wound infection, tooth root injury, and oroantral fistula . Recently, transnasal endoscopic marsupialization has replaced the conventional operation and has become accepted as a standard method for managing postoperative maxillary mucoceles effectively . Marsupialization can be performed via a middle meatal antrostomy (MMA) or an inferior meatal antrostomy (IMA). However, bony thickening after a Caldwell-Luc operation, narrowing of the antral access, decreased cavity volume, and mucocele expansion beyond the original maxillary sinus may make MMA more difficult than IMA. Moreover, mucoceles are frequently located near the lateral nasal wall and often present as a bulging mass into the nasal cavity. Under such conditions, IMA may be advantageous over MMA. Because no report has demonstrated and compared long-term efficacy and surgical simplicity between MMA and IMA for the treatment of postoperative maxillary mucoceles, we evaluated the clinical features, radiological characteristics, surgical procedure, long-term results, and complications in patients who underwent MMA and IMA approaches.
2
Patients and methods
This retrospective clinical study evaluated 53 patients diagnosed with a postoperative maxillary mucocele between 2003 and 2012. In all, 21 patients underwent MMA and 32 patients underwent IMA. Previously, they had received unilateral or bilateral radical surgery on the maxillary sinus. Patient medical records were reviewed for history, clinical presentation, radiographic findings, surgical intervention, complications, and outcomes. Diagnosis was made on the basis of a history of a Caldwell-Luc operation, clinical presentation, and radiographic findings. The Soonchunhyang University Institutional Review Board approved this study.
All patients had a unilateral postoperative maxillary mucocele, and the same surgeon (J.Y.L.) performed all surgical procedures under general anesthesia. Mucoceles located laterally that were difficult to reach through MMA or IMA were excluded from the study. IMA was performed in patients with clear sinuses except for the mucocele. Patients with recurrent chronic rhinosinusitis and/or nasal polyposis underwent MMA with endoscopic sinus surgery and/or nasal polypectomy in the same operation. Septoplasty and turbinate surgery were also performed when indicated. In the IMA group, the medial wall of the postoperative maxillary mucocele was opened with an antrostomy knife or a maxillary sinus seeker. The entry point was chosen according to CT findings, at the thinnest bony portion or the medial wall of the mucocele without any bony covering. When the internal cavity of the mucocele was identified, fluid was suctioned out completely. The opening was enlarged with straight-cutting forceps and back-biting forceps anteroposteriorly. To avoid injuring the outlet of the nasolacrimal duct, saline irrigation through the upper and lower canaliculi was performed and the outlet was localized. The opening of the mucocele was created as wide as possible, and the size was 2 × 2 cm or greater in most cases. The opening margin was trimmed with a microdebrider (Stryker Instruments, Kalamazoo, MI, USA). In the MMA group, the remnant uncinate process was removed and pathologic mucosa, nasal polyps, and unopened air cells or obstructed natural ostia were treated delicately. MMA was performed in the usual manner. As in the IMA group, fluid contents were suctioned and the opening was widened sufficiently under the direct vision of angled endoscopes. After surgery, adequate medications were administered and meticulous dressing was performed. Each patient visited our office once per week for the first 4 weeks, once per month for 2 months, and at 3–12-month intervals thereafter. During follow-up, the size of the opening and stenosis or obstruction of the antrostomy site were evaluated.
2
Patients and methods
This retrospective clinical study evaluated 53 patients diagnosed with a postoperative maxillary mucocele between 2003 and 2012. In all, 21 patients underwent MMA and 32 patients underwent IMA. Previously, they had received unilateral or bilateral radical surgery on the maxillary sinus. Patient medical records were reviewed for history, clinical presentation, radiographic findings, surgical intervention, complications, and outcomes. Diagnosis was made on the basis of a history of a Caldwell-Luc operation, clinical presentation, and radiographic findings. The Soonchunhyang University Institutional Review Board approved this study.
All patients had a unilateral postoperative maxillary mucocele, and the same surgeon (J.Y.L.) performed all surgical procedures under general anesthesia. Mucoceles located laterally that were difficult to reach through MMA or IMA were excluded from the study. IMA was performed in patients with clear sinuses except for the mucocele. Patients with recurrent chronic rhinosinusitis and/or nasal polyposis underwent MMA with endoscopic sinus surgery and/or nasal polypectomy in the same operation. Septoplasty and turbinate surgery were also performed when indicated. In the IMA group, the medial wall of the postoperative maxillary mucocele was opened with an antrostomy knife or a maxillary sinus seeker. The entry point was chosen according to CT findings, at the thinnest bony portion or the medial wall of the mucocele without any bony covering. When the internal cavity of the mucocele was identified, fluid was suctioned out completely. The opening was enlarged with straight-cutting forceps and back-biting forceps anteroposteriorly. To avoid injuring the outlet of the nasolacrimal duct, saline irrigation through the upper and lower canaliculi was performed and the outlet was localized. The opening of the mucocele was created as wide as possible, and the size was 2 × 2 cm or greater in most cases. The opening margin was trimmed with a microdebrider (Stryker Instruments, Kalamazoo, MI, USA). In the MMA group, the remnant uncinate process was removed and pathologic mucosa, nasal polyps, and unopened air cells or obstructed natural ostia were treated delicately. MMA was performed in the usual manner. As in the IMA group, fluid contents were suctioned and the opening was widened sufficiently under the direct vision of angled endoscopes. After surgery, adequate medications were administered and meticulous dressing was performed. Each patient visited our office once per week for the first 4 weeks, once per month for 2 months, and at 3–12-month intervals thereafter. During follow-up, the size of the opening and stenosis or obstruction of the antrostomy site were evaluated.
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