Combined Endoscopic Endonasal Transclival and Contralateral Transmaxillary Approach to the Petrous Apex and the Petroclival Synchondrosis: Working "Around the Corner" of the Internal Carotid Artery-Quantitative Anatomical Study and Clinical Applications.

The endoscopic contralateral transmaxillary (CTM) approach has been proposed as a potential route to widen the corridor posterolateral to the internal carotid artery (ICA). In this study, we first refined the surgical technique of a combined multiportal endoscopic endonasal transclival (EETC) and CTM approach to the petrous apex (PA) and petroclival synchondrosis (PCS) in the dissection laboratory, and then validated its applications in a preliminary surgical series. The combined EETC and CTM approach was performed on three cadaver specimens based on four surgical steps: (1) the nasal, (2) the clival, (3) the maxillary and (4) the petrosal phases. The CTM provided a "head-on trajectory" to the PA and PCS and a short distance to the surgical field considerably furthering surgical maneuverability. The best operative set-up was achieved by introducing angled optics via the endonasal route and operative instruments via the transmaxillary corridor exploiting the advantages of a non-coaxial multiportal surgery. Clinical applications of the combined EETC and CTM approach were reported in three cases, a clival chordoma and two giant pituitary adenomas. The present translational study explores the safety and feasibility of a combined multiportal EETC and CTM approach to access the petroclival region though different corridors.

Functional rehabilitation of the maxillary sinus after modified endoscopic sinus surgery for displaced dental implants.

PURPOSE: Dental implants may become displaced into the maxillary sinus due to insufficient primary stability, changes in nasal air pressure, or surrounding bone resorption and should be removed as soon as possible. The aim of this study was to evaluate the efficacy of the modified endoscopic sinus surgery (MESS) approach for removal of displaced dental implants. METHODS: From September 2010 to November 2021, we studied 15 cases with displaced implants in the maxillary sinus. The patient characteristics, medical history, clinical and imaging results, and post-removal outcomes were retrospectively assessed. RESULTS: The symptoms included sinusitis (100%), pain (26.6%), postnasal drip (6.6%), nasal obstruction (26.6%), and oroantral communication (26.6%). Two cases were managed through the crestal approach (13.3%), while two cases were treated with the Caldwell-Luc procedure (13.3%). One case was addressed using functional endoscopic sinus surgery (6.7%), while 10 cases were managed with the MESS approach (66.7%). MESS allows functional rehabilitation of mucociliary clearance by the cilia in the sinus membrane. Implant displacement into the maxillary sinus can be classified as early, late, or delayed displacement. CONCLUSIONS: MESS is a reliable treatment option that can identify migrated dental implants in any part of the sinus with endoscopic assistance for functional rehabilitation of the maxillary sinus without postoperative sequelae.

The feasibility of three port endonasal, transorbital, and sublabial approach to the petroclival region: neurosurgical audit and multiportal anatomic quantitative investigation.

PURPOSE: The petroclival region represents the "Achille's heel" for the neurosurgeons. Many ventral endoscopic routes to this region, mainly performed as isolated, have been described. The aim of the present study is to verify the feasibility of a modular, combined, multiportal approach to the petroclival region to overcome the limits of a single approach, in terms of exposure and working areas, brain retraction and manipulation of neurovascular structures. METHODS: Four cadaver heads (8 sides) underwent endoscopic endonasal transclival, transorbital superior eyelid and contralateral sublabial transmaxillary-Caldwell-Luc approaches, to the petroclival region. CT scans were obtained before and after each approach to rigorously separate the contribution of each osteotomy and subsequentially to build a comprehensive 3D model of the progressively enlarged working area after each step. RESULTS: The addition of the contralateral transmaxillary and transorbital corridors to the extended endoscopic endonasal transclival in a combined multiportal approach provides complementary paramedian trajectories to overcome the natural barrier represented by the parasellar and paraclival segments of the internal carotid artery, resulting in significantly greater area of exposure than a pure endonasal midline route (8,77 cm2 and 11,14 cm2 vs 4,68 cm2 and 5,83cm2, extradural and intradural, respectively). CONCLUSION: The use of different endoscopic "head-on" trajectories can be combined in a wider multiportal extended approach to improve the ventral route to the most inaccessible petroclival regions. Finally, by combining these approaches and reiterating the importance of multiportal strategy, we quantitatively demonstrate the possibility to reach "far away" paramedian petroclival targets while preserving the neurovascular structures.

Outcome of Open Surgery in Disease Progression of Post-COVID Rhinomaxillary Mucormycosis Treated by Functional Endoscopic Sinus Surgery and Proposed Evaluation Scale for Maxillary Sinus Disease and Osteomyelitis.

Introduction: Rhinomaxillary Mucormycosis (RMM) is a condition peculiarly seen as post-COVID-19 opportunistic infections with Maxillary Sinus Disease and Osteomyelitis (MSDO). The open method of debridement and closed method are two types of surgical modalities available. There is no scoring method for this infection in maxilla. This paper aims to study the clinical and CT-based outcome of open versus closed surgery of MSDO in post-COVID-19 RMM and propose a new scoring method to evaluate the disease severity, progression as well as recovery. Material and Methods: Symptomatic cases of RMM (n = 17) with a history of closed surgical treatment were enrolled for this prospective clinical study. These cases were then treated by medicinal and open surgical method. The clinical and CT scan outcomes were compared by proposed new scoring method.The CT-based score for Maxillary Sinus Disease (MSD) and Maxillary Osteomyelitis (MO) from pre-FESS (CT1), Post-FESS (Preoperative, CT2), and Post-operative (CT3) were compared for both right and left sides. One-way ANOVA test and post HOC tests were used for statistical evaluation. Conclusion: The open method of maxillary sinus surgery has given significant improvement in the treatment of RMM already treated by a closed endoscopic approach. Supplementary Information: The online version contains supplementary material available at 10.1007/s12663-022-01803-5.

Maxillary sinus mucocele in a 20-year-old male: a case report of a rare occurrence / Mucocele de seno maxilar en un varón de 20 años: reporte de un caso de rara ocurrencia

Mucocele of Maxillary sinus is a rare entity comprising 2-10% of all mucoceles and develops due to obstruction of drainage ostium. Here, we present a case of maxillary sinus mucocele in a 20-year-old male who presented with diffuse swelling on the left side of his face. Provisional diagnosis of mucocele was made on a computed tomography scan, which was later confirmed on histopathology. The lesion was managed surgically with uneventful healing at 2 weeks and 3 months follow-up.Mucoceles are often misdiagnosed as cysts or tumours of odontogenic origin on the conventional radiograph. Delay in diagnosis can result in complications due to the expansion of mucocele towards adjacent structures such as the nose and orbit. Therefore, it becomes crucial to diagnose it appropriately with the help of higher imaging modalities so that it can be managed well in time. (AU)

El mucocele del seno maxilar es una entidad rara que comprende el 2-10% de todos los mucoceles y se desarrolla debido a la obstrucción del ostium de drenaje. A continuación, presentamos un caso de mucocele del seno maxilar en un hombre de 20 años que presentó una inflamación difusa en el lado izquierdo de la cara. El diagnóstico provisional de mucocele se realizó en una tomografía computarizada, que luego se confirmó en la histopatología. La lesión se manejó quirúrgicamente con curación sin incidentes a las 2 semanas y 3 meses de seguimiento.Los mucoceles a menudo se diagnostican erróneamente como quistes o tumores de origen odontogénico en la radiografía convencional. El retraso en el diagnóstico puede dar lugar a complicaciones debido a la expansión del mucocele hacia estructuras adyacentes como la nariz y la órbita. Por lo tanto, se vuelve crucial diagnosticarlo adecuadamente con la ayuda de modalidades de imágenes superiores para que pueda manejarse bien a tiempo. (AU)

Ectopic Tooth in the Roof of the Left Maxillary Sinus.

The presence of sinonasal ectopic teeth is a rare entity that is usually asymptomatic. In some cases, the presence of foreign bodies in the maxillary sinus, such as ectopic teeth, can lead to chronic maxillary sinusitis. We report a case of chronic sinusitis because of an ectopic tooth in the roof of the left maxillary sinus in a 50-year-old female who presented with complaints of facial pain in the left maxillary region and purulent nasal discharge. The treatment of ectopic teeth usually consists of the removal of the previous, taking into account its location and possible risks. In this case, the close proximity to the orbit could have led to a greater risk of complications involving the infraorbital bundle. CT scan evaluation is frequently required to identify the exact location and is useful for treatment planning. The traditional surgical approaches to maxillary sinus pathology are transoral Caldwell-Luc approaches or transnasal endoscopic surgery. The method used in this case was the Caldwell-Luc approach. Although more invasive, it allows visualization into the maxillary sinus and superior access for instrumentation of the posterolateral region while permitting manipulation and removal of larger objects. Despite maxillary sinus ectopic teeth being uncommon, it is important for clinicians to become aware and to consider this entity to provide early adequate treatment.

Endodontic sealer-induced maxillary sinusitis: intraoral surgical approach and implant placement at a site of failed nasal endoscopic surgeries.

A 28-year-old male patient was referred from an otorhinolaryngologist for managing unilateral chronic maxillary sinusitis (MS). The patient had undergone two functional endoscopic sinus surgeries (FESS), although the MS was not resolved. Based on his dental history, endodontic treatment had been done on the symptomatic area. A leak of endodontic sealer and peri-apical lesion on tooth #14 was found on cone-beam computed tomographic examination. Extraction of tooth #14 and the modified Caldwell-Luc operation were performed to remove the endodontic sealer material and relevant inflammatory tissue. The sinus membrane lining was maintained as much as possible during the surgery. Implant placement was performed on the tooth extraction site. All clinical symptoms disappeared after the surgery. Radiographic and endoscopic examination revealed successful osseointegration of the implant and complete resolution of the MS. FESS alone may not be sufficient to treat MS derived from dental origin. For unilateral MS, dental history should be carefully checked.

Sublabial Approach Versus Modified Denker's Procedure: A Comparative Study of Pre-maxillary Tissue Clearance in Covid-Associated Mucormycosis.

To compare the efficacy of the sublabial and modified Denker's procedure in clearance of fungal disease from the anterior wall of maxilla and the pre-maxillary area i.e. the difficult areas of maxillary sinus. A prospective observational study was conducted over a period of 2 months (April 21-June 21) in the ENT department of Sawai Man Singh hospital, Jaipur. All the patients with clinical involvement of the premaxilla or the cheek abutting the anterior wall of maxilla were included in the study population. Cases matched in both groups were subjected to debridement either by the sublabial or the modified denker's approach. Outcomes were measured by assessing the daily CRP values, post-operative DNE every 3 days after pack removal, and imaging at the end of 1 month. Repeat biopsies were performed in patients that still had persistent symptoms after getting operated on. 16 of the 60 patients (26.6%) operated on by the endoscopic approach showed evidence of residual disease on follow-up whereas only 5 patients (9.6%) in the other category had a similar outcome. Most of the recidivism was seen in the anterior maxilla. Lower rates of complications were found following debridement by the sublabial approach. Since the sublabial approach is the most direct approach for the key areas of fungal involvement of maxillary sinus, it is recommended over the modified Denker's procedure for disease clearance from pre maxilla and the anterior wall of maxillary sinus. This view is also supported by the lower rates of complications encountered following the former.

Three-hundred and sixty degrees of surgical approaches to the maxillary sinus.

Objectives: To demonstrate three-hundred and sixty degrees of maxillary sinus (MS) surgical approaches using cadaveric dissections, highlighting the step-by-step anatomy of each procedure. Methods: Two latex-injected cadaveric specimens were utilized to perform surgical dissections to demonstrate different approaches to the MS. The procedures were documented with macroscopic images and endoscopic pictures. Results: Dissections were performed to approach the MS medially (endoscopic maxillary antrostomy and ethmoidectomy), anteriorly (Caldwell-Luc), superiorly (transconjunctival/transorbital approach), inferiorly (transpalatal approach), and posterolaterally (preauricular hemicoronal approach). Conclusion: A number of approaches have been described to address pathology in the MS. Surgeons should be familiar with indications, limitations, and surgical anatomy from different perspectives to approach the MS. This paper illustrates anatomic approaches to the MS with detailed step-by-step cadaveric dissections and case examples.

Early versus delayed extraction of intraorbital wooden foreign body.

Orbital trauma caused by wooden foreign bodies are relatively uncommon. Both immediate admission and late presentation of wooden trauma may pose a medical challenge to diagnose and manage due to wood can be easily missed on initial imaging. All organic types of intraorbital foreign bodies (IOrbFBs) should be extracted by surgical removal. In this report, we describe two cases of wooden IOrbFBs following penetrating orbital injury at a tertiary eye hospital. The first patient was injured by wood log with early admission, while the second patient presented two months after the injury with penetration by wooden arrow, both involving the sino-orbital. In this case, endoscopic approach is better used to have a more thorough assessment and guided surgery. Eventually, favorable outcomes of both patients can still be achieved. Follow-up is also crucial in patients with intraorbital trauma.

Effectiveness of the Endoscopic Prelacrimal Recess Approach for Maxillary Sinus Inverted Papilloma Removal: A Systematic Review and Meta-Analysis.

BACKGROUND: Conventional minimally invasive surgery has a high recurrence rate, and nasal morbidity can occur if the scope of surgery is expanded to complete removal of maxillary sinus inverted papilloma. OBJECTIVE: To analyze the efficacy of the endoscopic prelacrimal recess approach (EPLRA) for maxillary sinus inverted papilloma removal. METHODS: Eighteen studies were included in this meta-analysis. Articles comparing the prelacrimal recess approach with conventional surgery (endoscopic surgery or the Caldwell-Luc operation) for inverted papilloma removal were included. Outcomes of interest included recurrence and postoperative morbidities. The methodological quality was assessed using the Newcastle-Ottawa scale. RESULTS: The recurrence rates of inverted papilloma, postoperative facial or gingival numbness, and alar collapse were 3.13% (95% confidence interval [CI]: 1.32, 7.27), 9.02% (95% CI: 3.70, 20.39), and 3.39% (95% CI: 1.28, 8.68), respectively. The recurrence rate of inverted papilloma was significantly lower after the EPLRA than after conventional surgery (odds ratio [OR] = 0.2290; 95% CI: 0.0808, 0.6489). However, there were no significant differences between the procedures in the rates of facial or gingival numbness (OR = 0.4567; 95% CI: 0.1497, 1.3933), epistaxis (OR = 0.3150; 95% CI: 0.0471, 2.1044), or periorbital swelling (OR = 1.2405; 95% CI: 0.1205, 12.7731). CONCLUSIONS: The EPLRA can preserve the lacrimal system and is useful for maxillary sinus inverted papilloma removal due to a lower recurrence rate compared with conventional surgeries.

Ectopic Upper Third Molar in Maxillary Sinus: A Case Report and Literature Review.

Ectopic tooth in maxillary sinus is a rare entity. There are many causes of this condition include developmental disturbance, pathological process, iatrogenic, and in some cases there is no identified cause. The ectopic tooth could be asymptomatic or presented with various symptoms depends on its location. A 19-years-old woman presented with left-sided facial pain and slight swelling at the site of the upper 3rd molar tooth for three months. She gave a history of mid-facial trauma with an operation in this area, 11 years ago. Orthopantography and computerized tomography confirm the diagnosis of ectopic tooth within the maxillary sinus. The tooth was removed by Caldwell-Luc procedure. The patient was remained free of the presenting symptoms at three months follow-up. Reporting any case of an ectopic tooth deserves the ability to know the various aspects of this condition. We reported a further case of ectopic 3rd molar tooth in the left maxillary sinus, most probably, due to previous mid-facial trauma or the surgery in this area.

Left-sided facial mass in an adult female.

A left maxillary sinus soft tissue mass was discovered on computed tomography in a 70-year-old woman who had been experiencing blood-tinged mucus for 2 years. The lesion demonstrated mild enhancement, and bony destruction. Magnetic resonance imaging displayed a cerebriform appearance of the mass, which mimicked the appearance of inverted papilloma. However, histology and staining identified the lesion as ameloblastoma. Resection of the tumor was successful with no recurrence 1 month later on follow-up computed tomography. This case represents an unusual imaging presentation of ameloblastoma, and an opportunity to avoid the misdiagnosis of inverted papilloma in similar future cases.

Endoscopic sublabial transmaxillary approach to the inferior orbit: pearls and pitfalls-A comparative anatomical study.

OBJECTIVE: Although orbital surgery has always represented a challenge for neurosurgeons, keyhole and endoscopic techniques are gradually surging in popularity maximizing functional and esthetic outcomes. This quantitative anatomical study first compared the surgical operability achieved through three endoscopic approaches within the inferior orbit: the endoscopic sublabial transmaxillary (ESTMax), the endoscopic endonasal transethmoidal (EETEth), and the endoscope-assisted lateral orbitotomy (ELO). METHODS: Each of these approaches was performed bilaterally on five specimens. We described the ESTMax step-by-step, underlining its advantages and pitfalls in comparison with EETEth and ELO. Then, we assessed surgical measurements and operability in ESTMax, EETEth, and ELO. RESULTS: The ESTMax provided the most favorable operative window (278.9 ± 43.8 mm2; EETEth: 240.8 ± 21.5 mm2, p < 0.001; ELO: 263.1 ± 19.8 mm2, p = 0.006), the broadest surgical field area (415.9 ± 26.4 mm2; EETEth: 386.7 ± 30.1 mm2, p = 0.041; ELO: 305.2 ± 26.3 mm2, p < 0.001), surgical field depths significantly shorter than EETEth (p < 0.001) but similar to ELO, the widest surgical angles of attack (45°-65°; EETEth: 20°-30°, p < 0.001; ELO: 25°-50°, p < 0.001), and the greatest surgical mobility areas (EETEth: p < 0.001; ELO: p < 0.001). Furthermore, the ESTMax allowed multi-angled exposure and handy maneuverability around all the inferior intraorbital targets. Small anterior antrostomy, blunt intraorbital dissections, direct targets' approach, orbital floor reconstruction, and maxillary bone flap replacement may limit the ESTMax morbidity rates. CONCLUSIONS: The ESTMax is a minimally invasive "head-on" orbital approach that exploits endoscopic surgery advantages avoiding the cranio-orbital and trans-nasal approach limitations and possible complications. It represents a promising alternative to EETEth and ELO because of its optimal operability for resecting lesions extending into the entire inferior orbit.

Prelacrimal approach vs conventional surgery for inverted papilloma in the maxillary sinus.

BACKGROUND: The prelacrimal approach, termed endoscopic modified medial maxillectomy (EMMM), has recently been applied for treatment of inverted papilloma (IP) in the maxillary sinus. EMMM provides wider access to the maxillary sinus while preserving the inferior turbinate and nasolacrimal duct. METHODS: We reviewed patients with IP in the maxillary sinus to compare the surgical results obtained by conventional surgery (ie, endoscopic maxillary sinus antrostomy or in combination with the Caldwell-Luc approach) with those obtained by EMMM. RESULTS: All patients had a T3 on the Krouse staging system, and the average follow-up time was 46.0 months. Of the 18 patients in the conventional group, recurrence was seen in 3 patients (16.6%). No recurrence was seen in the 27 patients who showed preservation of the inferior turbinate and nasolacrimal duct, and no complications occurred in the EMMM group. CONCLUSIONS: EMMM is an effective surgical approach that reduces recurrence with fewer complications.

Endoscope-assisted Surgery in the Treatment of Dentigerous Cyst Involving the Maxillary Sinus - Report of Two Cases.

Endoscopic techniques have been applied to oral and maxillofacial surgeries. Previous studies have proved their practicability in the treatment of osteomyelitis of the mandible and displaced residual roots in the maxillary sinus. In this report, two patients with dentigerous cysts in the maxillary sinus underwent endoscope-assisted curettage. Both patients were successfully cured without recurrent lesions or any complications. The follow-up found that the bone cavities had shrunk. An endoscope-assisted Caldwell-Luc operation provided clear visibility of the surgical field and preserved the mucosa of the maxillary sinus.

Combined endoscopic endonasal and sublabial transmaxillary approach for resection of giant infratemporal fossa schwannoma with intracranial extension: operative video and technical nuances.

Tumors of the infratemporal fossa (ITF) are surgically formidable lesions due to their deep location and proximity to critical neurovascular structures. Selecting the optimal surgical corridor for a giant ITF lesion with extensive medial and lateral extension can be challenging due to the limited surgical freedom offered by each individual approach. In this operative video, we demonstrate a case of a 44-year-old female with a giant ITF schwannoma with intracranial extension and erosion of the central skull base. Although we considered several surgical approaches, including a standard binostril endoscopic endonasal approach and an endoscopic Denker's approach, we eventually chose a combined endoscopic endonasal and sublabial (Caldwell-Luc) transmaxillary approach. This combined approach provides significantly greater surgical freedom than a pure endonasal route to the lateral ITF. The sublabial Caldwell-Luc corridor provides a more direct "head-on" trajectory to the target of the lateral ITF than the pure endonasal route. This combined approach provides a multiportal, multicorridor access, allowing for more surgical freedom and preservation of the piriform aperture and nasolacrimal duct. This case illustrates the versatility of the combined endoscopic endonasal and sublabial transmaxillary approach for giant ITF tumors with significant lateral extension. The technical nuances and surgical concepts are demonstrated in this operative video manuscript. The video can be found here: https://youtu.be/gy-pkjLdDgE.

Maxillary Sinus Pneumocele Presenting as Aesthetic Deformity: A Case Report With Literature Review.

We report an interesting case of maxillary sinus pneumocele that presented with aesthetic deformity and completely treated with Caldwell-Luc approach and thoroughly review all of the past literature focusing on clinical symptoms and surgical approach. Based on our comprehensive review of maxillary sinus pneumocele, we found 2 important characteristics. First, maxillary sinus pneumocele may be asymptomatic but cause various symptoms owing to the displacement of neighboring structures, such as facial symptoms, eye symptoms, and nasal obstruction. Second, there is no standard operation technique for maxillary sinus pneumocele, but surgical approach should be individualized depending on patient's symptoms and needs. Therefore, more case studies are needed to confirm this.

Comparison of the efficiency and safety of endonasal and open rhinosurgery in children.

OBJECTIVES/HYPOTHESIS: The objective of this study was to compare the efficiency and safety of endonasal endoscopic maxillary surgery and the Caldwell-Luc approach in children. STUDY DESIGN: Case series. METHODS: A total of 121 children aged 9 to 17 years with chronic rhinosinusitis were included in the study. The patients were operated on using Caldwell-Luc (n = 36) and endoscopic maxillary surgery (n = 85) procedures. Efficiency and safety of the surgeries were assessed using pre- and postoperative endoscopic evaluation of the mucosa of the nasal cavity, 20-item Sino-Nasal Outcome Test (SNOT-20), and subjective (both children's and parents') evaluation of the outcomes. RESULTS: Endoscopic investigation of the mucosa of the nasal cavity demonstrated a significant improvement after both Caldwell-Luc and endoscopic surgery, although the Caldwell-Luc procedure did not result in significant improvement in mucosal color. However, no significant group difference was observed. Both techniques resulted in a significant improvement of mucosal edema and fluid characteristics. Based on the results of the SNOT-20, endoscopic maxillary surgery was characterized by a significant improvement in headache frequency, waking up at night, reduced concentration, ear pain, and emotional suppression as compared to Caldwell-Luc surgery. Although no significant group difference in efficiency between the Caldwell-Luc approach and endoscopic surgery was observed, the latter was characterized by a lower rate of scar formation, and reduced sensitivity, local painfulness, lacrimation, and psychologic discomfort. CONCLUSIONS: The obtained data demonstrate the higher efficiency and safety of endoscopic sinus surgery as compared to the Caldwell-Luc approach in children. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1056-1063, 2020.

Modified Palatal Flap with a Tissue Bridge in the Closure of the Oroantral Fistulae: A Prospective Study.

INTRODUCTION: An oroantral fistula is by definition 'An abnormal communication between the oral cavity and the maxillary sinus.' AIM OF THE STUDY: The aim of this study is to describe the acute and chronic OAFs and to evaluate the efficiency of the modified palatal flaps with tissue bridge in the closure of both acute and chronic OAFs of small to medium size. METHODOLOGY: The study sample was derived from a population of patients from January 2013 to 2018 with the complaint of pain and discharge through the socket. RESULT: The results of this series support the view that the use of modified palatal flap with tissue bridge is a reliable flap for the repair of both acute and chronic oroantral fistulae. CONCLUSION: The ease of mobilization, superior blood supply and minimal donor site morbidity make it an ideal flap and a reliable alternative when other techniques fail.