Validation of modular endoscopic medial maxillectomies for inverted papilloma of the maxillary sinus.

BACKGROUND: Treatment of inverted papilloma of the maxillary sinus (IPMS) has a lower success rate compared to other IPs. As such, its correct management generally needs trans-nasal endoscopic medial maxillectomy (EMMs) for adequate resection. The aim of this manuscript is to describe outcomes and major prognostic factors of a cohort of patients with IPMS who were treated with EMM. METHODOLOGY: In this multicentric study, patients affected with IPMS and treated with EMMs were included. The site of origin of the IPMS were studied as well as the type of EMM performed. The histological features (IP vs dysplasia), type of mucosal resection (total vs. pedicle oriented), and post-operative complications were analyzed. RESULTS: 310 patients were included (212 primary and 98 recurrent cases). After a mean follow-up of 45.4 months, 15 patients experienced recurrence (4.8%) due to the application of EMMs tailored to the surgical insertion point. Dysplasia was significantly associated with a higher risk of recurrence. The rates of early and late complications were 11.6% and 11.9%, respectively. CONCLUSIONS: IPMS resection via tailored EMM is associated with excellent disease control, thus excluding the systematic use of extended EMMs, which can however be justified in case of dysplastic IPMS given its significant impact on recurrence.

Extended Endoscopic Pre-Lacrimal Medial Maxillectomy To the Anterior Maxillary Sinus Wall.

Endoscopic pre-lacrimal medial maxillectomy involving the resection of the antero-medial maxillary sinus wall is a novel expanded procedure that allows the management of far lateral or antero-medial benign pathologies of the maxillary sinus, without increasing peri-operative morbidity. Laryngoscope, 133:2874-2877, 2023.

Primary maxillary sinus carcinosarcoma with multidisciplinary management: a case report with 4 years follow-up and literature review.

BACKGROUND: Primary maxillary sinus carcinosarcoma (CS) is an extremely rare malignant tumor characterized by biphasic histologic components, lack of standardized treatment, high recurrence rate, and poor prognosis. This paper presents a case of primary maxillary sinus CS and its treatment. CASE PRESENTATION: A 39-year-old female patient complained of right facial pain and maxillary teeth numbness on March 21, 2018. Computed tomography examination revealed a malignant mass with osteolytic destruction. Preoperative biopsy suggested sarcomatoid carcinoma or CS. A total right maxillectomy under general anesthesia was performed on April 12, 2018. The final staging was T3N0M0 (ACJJ 2019). Postoperative radiotherapy and chemotherapy were performed. On May 26, 2018, the patient received the first cycle of doxorubicin plus ifosfamide. Two days before radiotherapy, the patient received an intra-oral prosthesis. From June 20, 2018, to August 22, 2018, the patient received concurrent chemoradiotherapy: radiotherapy (60 Gy in 30 fractions) and the second cycle of doxorubicin. Then, the patient received four cycles of doxorubicin plus ifosfamide. The patient was followed for 39 months with no evidence of disease. CONCLUSION: Using multidisciplinary therapy, clinical-stage T3N0M0 (ACJJ 2019) maxillary sinus CS may achieve a good prognosis.

The choice of endoscopic surgical approach and four steps of operation of inverted papilloma of the maxillary sinus.

OBJECTIVE: The aim of this study was to determine the long-term efficacy of four steps of operation on the treatment of maxillary sinus (MS) inverted papilloma (IP). METHODS: 83 patients who were diagnosed with IP that originated from the MS, underwent four step procedure of attachment sites, including mucosal stripping, periosteum ablation, bone drilling and bone ablation and had postoperative follow-up of 3 years were enrolled. RESULTS: Of the 83 patients, 59 (71.1%) patients were primary surgery and revision surgery in 24 (28.9%), single attachment was in 31(37.3%) patients and multifocal attachments in 52 (62.7%).When the numbers were not mutually exclusive, the most common origin sites of IPs were the medial wall in 54 (37.2%), lateral wall in 29 (20.0%), anterior wall in 18 (12.4%), inferior wall in 22 (15.2%), posterior in 15 (10.3%), and superior wall in 7 (4.8%). Large MMA alone was performed in 5 (6.0%), MMA combined with medial maxillectomy 76 (91.6%), and MMA combined with Caldwell-Luc approach in 2 (2.4%). No major intra- or postoperative complications were observed. The average follow-up was 41 months (range, 37-61 months). CT and endoscope showed that tumor and symptom recurrence occurred in 2 patients (2.41%). In addition, although the opening of antrostomy was closed and CT revealed the uniform soft tissue shadow and hyperostosis of MS in 11(13.3%) patients, they didn't report any symptoms and showed well epithelization of middle meatus mucosa. CONCLUSION: The four steps of operations of attachment sites of MS IP, including mucosal stripping, periosteum ablation, bone drilling and bone ablation, may effectively prevent the recurrence of MS IP.

Palatal mucoperiosteal flap for oro-nasal fistula following maxillectomy for maxillary sinus cancer.

OBJECTIVES: This study aimed to describe the technique and clinical outcomes of using a palatal mucoperiosteal flap for oro-nasal fistula closure following resection of maxillary sinus cancer. METHODS: The study was conducted with the permission of the internal review board of the Japanese Red Cross Wakayama Medical Center. Five consecutive cases from 2016 to 2020 of surgically treated maxillary sinus cancer in which the oro-nasal fistulas were closed using a palatal mucoperiosteal flap were retrospectively reviewed. RESULTS: Following tumor resection, the oro-nasal fistula was closed using a palatal mucoperiosteal flap. Complete separation of the oral and nasal cavities was achieved in four patients. Oral intake was resumed within two weeks in four patients. All the patients were able to eat foods similar to those in the preoperative period. Their postoperative speech function was excellent, with no difficulty in communicating with others. CONCLUSION: In the selected cases of maxillary sinus cancer, preservation of the palatal mucosa and closure of an oro-nasal fistula using a palatal mucoperiosteal flap was possible with reasonable outcomes for swallowing and speech functions. The use of this local flap is recommended as a minimally invasive procedure that can be performed especially in patients with limited physiological reserves which preclude free flap reconstruction.

Endoscopic Management of Maxillary Sinus Schwannoma.

ABSTRACT: Schwannomas are benign tumors originate from nerve sheath. In this article, the authors aimed to share our experience and review the literature on endonasal endoscopic intervention for a maxillary sinus schwannoma. A 30-year-old Caucasian female patient applying to ophthalmology clinic due to exophthalmos and proptosis in her left eye for the last 6 months. A well-defined mass was detected in left maxillary sinus that was filling and expanding the sinus. Endoscopic biopsy from the patient was reported as ancient schwannoma. The encapsulated mass was completely removed by performing a combined endoscopic medial maxillectomy and Caldwell-Luc procedure under general anesthesia. The authors have been following the patient for 2 years and there was no evidence of recurrence, however, a decrease in the volume of the maxillary sinus occurred, suggesting chronic maxillary atelectasis. In conclusion, schwannoma should be considered in the differential diagnosis of sinonasal masses.

Modified Endoscopic Denker's Approach for Management of Anterior Maxillary Sinus Tumors: Multicenter Series of 58 Cases.

OBJECTIVES: Tumors involving the anterior portion of the maxillary sinus remain technically challenging to access via an endoscopic approach. The modified endoscopic Denker's (MED) procedure was recently introduced to address such lesions. We present a multicenter series of 58 patients with tumors involving the anterior maxillary sinus successfully resected using a MED procedure and present the clinical outcomes and complications. METHODS: A multi-institution retrospective chart review was performed on patients who underwent the MED approach for the management of tumors involving the anterior maxillary sinus from 2009 to 2020. Demographic data, pathology, surgical outcomes, and complications were reviewed. RESULTS: Fifty-eight patients were identified, including 34 (58.6%) male and 24 (41.4%) female patients. The most common pathologies included: inverted papilloma (n = 27; 46.6%), adenoid cystic carcinoma (n = 9; 15.5%), and squamous cell carcinoma (n = 8; 13.8%). Thirty-eight patients (65.5%) underwent MED alone, while 20 (34.5%) had combined expanded endonasal approaches for lesions extending beyond the maxillary sinus. All maxillary sinus lesions were successfully accessed with the MED procedure without the need for an additional approach. After a mean follow-up of 30 months (range, 1-127), 8 of 58 (13.8%) patients developed complications related to the MED, including epiphora requiring an additional procedure (n = 4; 6.9%), prolonged facial/palatal numbness (n = 3; 5.2%), severe epistaxis (n = 1; 1.7%), and vestibular stenosis (n = 1; 1.7%), the latter of which occurred following postoperative radiation. CONCLUSION: The MED procedure is a safe and highly effective approach for benign and malignant tumors involving the anterior maxillary sinus. However, patients should be counseled preoperatively on potential complications including the risk of facial numbness and epiphora.

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.

Endoscopic Modified Medial Maxillectomy for Inverted Papilloma of the Maxillary Sinus.

BACKGROUND: Sinonasal inverted papilloma (SNIP) is a benign tumor that can be surgically managed by an endoscopic approach. However, SNIP has a high recurrence rate, mainly due to incomplete resection. AIM: This study aimed to analyze the outcomes of endoscopic modified medial maxillectomy in treating SINP originating from the maxillary sinus. METHODS: The authors retrospectively analyzed 24 patients treated for SNIP via endoscopic modified medial maxillectomy at our institution between August 2014 and June 2019. During surgery, the mucosa involved in the tumor was stripped, and the bone underlying the tumor base was completely excised. Demographic data, surgical technique, location of SNIP attachment, complications, follow-up duration, and recurrence were recorded. RESULTS: Twenty four patients with SNIP were identified (16 males). All patients had Krouse stage-III disease. Eleven patients presented with single attachment and 13 with multiple attachments. None of the patients had any complications during surgery. Four patients had postsurgical facial numbness around the cheek and upper lip. After a mean follow-up of 35.12 ±â€Š14.98 months, no recurrence of SNIP was observed. CONCLUSIONS AND SIGNIFICANCE: Endoscopic modified medial maxillectomy is a safe and effective technique for treating SNIP. Recurrence can be reduced by complete excision of the attachment sites.

Locally advanced undifferentiated sarcomatoid carcinoma of the right maxillary sinus with PDCD6-TERT fusion: A rare case report.

Sarcomatoid carcinoma of maxillary sinus tumor is extremely rare in head and neck tumors and has poor prognosis and frequently occurs to relapse locally after surgery. We first reported a case of locally advanced undifferentiated sarcomatoid carcinoma of right maxillary sinus with PDCD6-TERT fusion gene. The patient with a previous history of moderate alcohol drinking and smoking. The patient underwent surgical treatment. The tumor tissue using NGS analysis, no other driver gene mutations, and the PD-L1 IHC was negative. He received TPF regimen induction chemotherapy combined with anti-PD1 inhibitor and radiotherapy. The effect of treatment was good.

Modified endoscopic medial maxillectomy for a mixed maxillary inverted papilloma and mycetoma with absent prelacrimal recess.

Endoscopic prelacrimal recess approach is a promising technique for treating various maxillary sinus diseases because it allows for adequate visualization and wide access to the entire maxillary sinus. However, the incidence of absent prelacrimal recess (PLR) has ranged from 7% to 17.5%, implying that there is a limitation for the application of EPLA in this population. Here, a male patient with concomitant Krouse T2 maxillary inverted papilloma and mycetoma presenting with unilateral nasal obstruction and blood-tinged secretion is described. The presurgical computed tomography showed no recess. By dislocating the nasolacrimal duct from the bony canal and removing the medial maxillary wall sufficiently to extend the surgical corridor; and by preserving the inferior turbinate, nasal mucosa, and nasolacrimal duct, the patient did not experience any postoperative complications. In conclusion, our modified technique may be an effective and safe strategy for treating maxillary sinus disease without prelacrimal recess.

Ameloblastoma of the maxillary sinus: conservative surgical management considering high recurrence risk potential.

Ameloblastoma (AM) in the maxillary sinus is rare. This benign entity shows locally invasive, destructive and aggressive behaviour and a high rate of recurrence. Therefore, the course of treatment is radical resection. We report the case of a 38-year-old man presenting with signs of recurrent sinusitis in the Ear, Nose and Throat Department. Transnasal flexible endoscopy revealed a cystic mass in the right inferior and middle nasal passage. CT scan showed an obliterated right maxillary sinus with a ballooning effect and pressure atrophy of the lateral sinus wall, without possible differentiation of the middle and low nasal turbinate. The patient was treated with transnasal functional sinus surgery; pathology stated AM. AM in the maxillary sinus is rare, locally destructive and therefore as a gold standard is resected radically to prevent recurrence. We demonstrate a conservative approach; explicitly, we combined a transvestibular and functional endoscopic sinus surgery resection of the AM to maintain function and reduce the possibility of postoperative impairments. Whether the strategy of treatment for AM is conservative, it nonetheless can result in a recurrence-free status. Nevertheless, inclusion into an oncological follow-up-programme with regularly performed MRI and CT is recommended.

Localized Maxillary Sinus Papilloma: Management of Incidental Lesion.

Most maxillary sinus papillomas are confirmed when they have extended beyond the nasal cavity and are rarely found while localized in the maxillary sinus. We experienced two cases of localized papilloma in the maxillary sinus. Case 1 was a 69-year-old man with a localized left maxillary sinus lesion detected during a routine imaging examination. As the lesion was likely to be papilloma, we recommended that the patient undergo diagnostic surgery, which he refused. He experienced bloody rhinorrhea 1 year and 9 months after the first visit, and computed tomography (CT) showed increased lesions and bone destruction. Histological examinations revealed squamous cell carcinoma ex inverted papilloma. He died 5 years after the first visit. Case 2 was a 46-year-old woman in whom positron emission tomography/CT showed a localized right maxillary sinus lesion. Tissue biopsy results indicated oncocytic papilloma. Endoscopic resection was performed later. On an imaging examination, sinonasal papilloma was determined accidentally to be a localized lesion of the maxillary sinus. A detailed interpretation of the CT scan was useful in estimating sinonasal papilloma. Tissue biopsy or diagnostic surgery should be performed when sinonasal papilloma is suspected during appropriate image evaluation.

Radical Exenteration of the Skull Base for End-Stage, Locally Advanced Sinonasal Malignancies: Challenging the Dictum of Unresectability.

BACKGROUND: The role of surgery is not well defined in locally advanced sinonasal cancers with intracranial involvement after all medical options have been exhausted. We hypothesize that patients whose tumors are deemed unresectable and referred to palliative care may benefit from radical salvage surgery. METHODS: We performed a single-center retrospective review of patients with malignant, locally advanced (stage T4b) sinonasal cancers with intracranial involvement from 2000 to 2020, inclusive. Data were collected on the patient demographics, details of chemotherapy, radiation, histology, perioperative complications, surgical approaches, and survival. We compared the survival outcomes of patients with different duration of disease before presentation. RESULTS: We identified 17 patients who had undergone salvage surgical resection of treatment-recalcitrant, locally advanced sinonasal tumors. Almost all patients had undergone prior surgery, radiotherapy, and chemotherapy. Perioperative complications occurred in 6 of 17 patients with 1 death. Patients with clinically less aggressive disease had significantly longer progression-free and overall survival compared with the more aggressive group. CONCLUSIONS: Salvage surgery for locally advanced sinonasal cancers with intracranial invasion that is recalcitrant to all other therapies should be considered for patients who otherwise have no other treatment options.

Combined Simultaneous Multiportal Approach via Minimally Invasive Transciliary and Endoscopic Endonasal Approaches for Tumors Invading Both the Skull Base and the Sinonasal Area.

BACKGROUND: A combined transcranial and transfacial approach has long been the gold standard for surgical management of large tumors with sinonasal and skull base involvement. The extended endoscopic endonasal approach for such pathologies has its advantages, but it has flaws as well, such as anatomic limitations and more ponderous skull base reconstruction and thus higher risk of postoperative complications. Our primary technique for surgical treatment of these pathologies has been a combination of transfacial and minimally invasive transciliary supraorbital keyhole approaches. With the aim to further minimize invasiveness, potential complications, and unsatisfactory aesthetic outcomes during surgical treatment of large tumors invading both the sinonasal area and the skull base, we abandoned the transfacial approach and simultaneously combined the transciliary supraorbital keyhole approach with the endoscopic endonasal approach. METHODS: The well-known microscope-assisted minimally invasive approach via a transciliary supraorbital keyhole craniotomy was combined with the endoscopic endonasal approach. RESULTS: Six patients with different histologic types of tumors affecting the sinonasal area and the skull base were operated on. The mean operative time was 3 hours, there were no unexpected intraoperative or postoperative complications, and total tumor removal was achieved in each patient. None of the patients experienced complications associated with the surgery during follow-up. CONCLUSIONS: Our combined simultaneous multiportal approach enables total tumor eradication with reduced operative time and is associated with minimal intraoperative and postoperative complications, low mortality rate, and excellent cosmetic results.

Endoscopic maxillectomy: anatomo-radiological description of the "double" maxillary sinus window.

OBJECTIVES/HYPOTHESIS: To present a modified endoscopic medial maxillectomy (MEMM) approach to control maxillary sinus pathologies. METHODS: MEMM was completed in 13 fresh-frozen specimens. An MEMM includes cutting the nasolacrimal duct, inferior meatus flap, and repositioning the inferior turbinate (IT). The following measurements were obtained: length of IT, height from the nasal floor to valve of Hasner, height of the IT at the level of valve of Hasner, height of the IT at the insertion of the middle turbinate, and distance from the piriform aperture to the posterior wall of maxillary sinus and to the posterior border of palatine bone. Similar measurements were also performed on craniofacial computed tomography (CT) scans (n = 50). The surgical technique was performed in a case series (n = 8). RESULTS: The mean of the specimens was 82 (range 70-95) years old. The average area of the harvested inferior meatus flap area was 9.6 ± 1.0 cm2. In the radiologic study, the mean maximum antrostomy area was 8.8 ± 1.7 cm2 and the IT area overlapping the antral window was 5.8 ± 1.1 cm2, the area allowing a double window control was 3.1 ± 1.9 cm2, the posterior IT insertion length was 0.7 ± 0.4 cm, and the inferior meatus flap covering the inferior meatotomy had an area measuring 6.7 ± 1.7 cm2. Eight patients underwent MEMM for various benign conditions showing no recurrence after 26 month follow-up. CONCLUSION: The proposed modifications of MEMM provide a "double" window maxillary sinus control with access to all maxillary walls and preservation of the IT.

Management of a Unique Sinonasal Undifferentiated Carcinoma Subtype in the Era of SARS-CoV-2.

The novel coronavirus (SARS-CoV-2) pandemic has influenced the timeliness of care for patients with both common and rare conditions, particularly those affecting high-risk operative sites such as the upper aerodigestive tract. Sinonasal undifferentiated carcinoma (SNUC) represents a rare malignancy of the sinonasal tract, a unique subset of which has never been previously reported in the otolaryngology literature and is characterized by inactivation of the SMARCB (INI-1) tumor suppressor gene. This subtype exhibits a particularly poor prognosis and is characterized pathologically by its rhabdoid appearance. Here we present the case of an individual who was diagnosed with a sinonasal mass during the SARS-CoV-2 pandemic, which was ultimately found to be SMARCB (INI-1)-deficient sinonasal carcinoma. Advanced imaging was deferred in the interest of limiting the patient's exposure to the virus, and expedited operative management was performed which facilitated prompt referral for adjuvant chemoradiation. The SARS-CoV-2 pandemic presents unique challenges, but the work-up of high-risk lesions must be prioritized; this continues to be paramount as SARS-CoV-2 resurges in many cities across the USA.

Delayed Infection of Porous Polyethylene Implants After Oncologic Maxillectomy and Reconstruction: 2 Case Reports and Review of Literature.

Medpor porous polyethylene implants are commonly used for facial skeletal reconstruction due to reported biocompatibility, fibrovascularization, and durability. While uncommon, late implant infections are an important consideration. We report delayed infections in 2 patients after unilateral total oncologic maxillectomy and reconstruction using Medpor implants for an ossifying fibroma and squamous cell carcinoma, respectively. In the first patient, annual interval computed tomography (CT) scans showed no recurrence of tumor or inflammatory changes. The second was lost to follow-up after adjuvant chemoradiation 1 year after resection. Patients both presented with swelling, drainage, and erythema around the implant at a mean of 4.5 years following maxillectomy. Both failed several attempts at conservative treatment. Cultures of implants removed at a mean of 2.5 months after infection grew α-hemolytic Streptococcus in the first and multiple organisms in the second, showing that the potential for delayed infection should be considered years after reconstruction.

Maxillary Sinus Ameloblastoma: Transnasal Endoscopic Management.

Ameloblastoma (AM) is a slow growing and aggressive benign tumor with an odontogenic epithelial origin arising from the mandible or maxilla. The odontogenic neoplasm invades local tissues asymptomatically and accounts for 1% of oral tumors and over 10% of odontogenic tumors. A 64-year-old man with a history of allergic fungal rhinosinusitis (AFRS) undergoing a revision image-guided endoscopic sinus surgery was found to have a fibrous mass suspicious of malignancy projecting inferolaterally and attached to the floor of the left maxillary sinus. Diagnostic biopsies were taken, and additional surgery was required to successfully resect the tumor via a transnasal endoscopic dissection. Multiple permanent pathology samples concluded the diagnosis of an AM. Endoscopic investigations led to the incidental discovery and ultimate complete endoscopic resection of the AM. The utilization of an endoscopic resection compared to the traditional maxillectomy with reconstruction results in significant less short and long-term morbidity for the patient.