Comparison of endoscopic multiport approaches to the petrous apex: contralateral transmaxillary versus contralateral medial transorbital corridor.

OBJECTIVE: Accessing the petrous apex (PA) via an endoscopic endonasal approach (EEA) is challenging due to its posterior and lateral anatomical relationship with the paraclival carotid artery. Typically, the EEA requires the mobilization or compression of the vessel and the use of angled-lens endoscopes and instruments. A sublabial contralateral transmaxillary (CTM) corridor has been used to overcome these challenges. Still, it requires extensive osteo-meatal disruption and drilling of the medial pterygoid process, which risks the vidian nerve and increases nasal morbidity. Furthermore, the CTM corridor positions the endoscope in the same horizontal plane as the instruments passing through the nostrils, leading to fencing. The authors propose a novel minimally invasive route to the PA, the precaruncular contralateral medial transorbital (cMTO) corridor, to address these issues. This anatomical study compares the EEA+CTM and EEA+cMTO corridors in accessing the PA. METHODS: The authors dissected 14 fresh, preinjected cadaveric specimens (28 sides) using neuronavigation to complete EEA, cMTO, and CTM on each side. In addition to qualitative analysis, they measured and compared the working distance between the entry point (nose, orbit, maxilla) and the petrosal process of the sphenoid bone (PPSB), superomedial PA, and foramen lacerum (FL); angle of attack (AoA); area of surgical freedom; endoscope-instrument fencing angle; and visual angle for each approach. RESULTS: The cMTO corridor provided the shortest working distance to the petroclival region (PA = 67.4 ± 4.47 mm, PPSB = 67.57 ± 4.33 mm, and FL = 66.30 ± 4.77 mm) compared to the CTM (PA = 75.85 ± 3.63 mm, PPSB = 76 ± 3.96 mm, and FL = 74.52 ± 4.26 mm) and to the EEA (PA = 85.16 ± 3.16 mm, PPSB = 84.55 ± 3.02 mm, and FL = 83.42 ± 3.21 mm, p < 0.001). Both CTM and cMTO corridors had a similar visual angle to the PA (20.72° ± 2.16° and 21.63° ± 1.84°, respectively), offering a similar but significantly better visualization than EEA alone (44.71° ± 3.24°, p < 0.001). The cMTO corridor provided better instrument maneuverability than the CTM, as evidenced by a significantly greater fencing angle (30.9° ± 4.9°) than with the CTM (21.7° ± 4.02°, p < 0.001). The vertical AoAs for the EEA, cMTO, and CTM corridors were 9.79° ± 1.75°, 10.65° ± 0.82°, and 9.82° ± 1.43°, respectively (p = 0.009), whereas in the horizontal plane, these were 9.29° ± 1.51°, 9.10° ± 0.73°, and 10.49° ± 1.43° (p < 0.001), respectively. Both the CTM and cMTO corridors offered similar areas of surgical freedom (678.06 ± 99.5 mm2 and 673.59 ± 104.8 mm2, p = 0.986), but they were more significant than that provided by the EEA 487.29 ± 112.9 mm2 (p < 0.001). CONCLUSIONS: The EEA+cMTO multiport technique may be a better alternative than the EEA+CTM multiport approach for targeting the petroclival region. However, clinical validation is required to confirm these laboratory findings.

Dentigerous Cyst in a Pediatric Patient: A Case Report.

One of the most prevalent types of odontogenic cysts is a dentigerous cyst, which is usually connected to the crown of an immature tooth. We report the case of an 11-year-old boy, who had a swelling over his left cheek, which was determined to be a dentigerous cyst by radiological imaging and clinical examination. Over the course of two months, the peanut-sized mass grew to 3x2 cm. A massive, well-defined cystic lesion connected to an unerupted premolar tooth was found on a CT scan of the left maxillary alveolar arch and sinus floor. Under general anesthesia, the patient had a Caldwell-Luc surgery to remove the cyst. In order to avoid difficulties related to cyst formation, which can invade surrounding tissues and even result in cancer if left untreated, early detection using radiological imaging is essential. Complete excision of the cyst is the treatment, particularly for big lesions, in order to limit morbidity and lower the likelihood of aggressive behavior. This case emphasizes the necessity of thorough examination and surgical intervention when necessary, underscoring the significance of early identification and adequate therapy to minimize potential problems related to dentigerous cysts. In cases of dentigerous cysts, early intervention, and appropriate surgical procedures are critical to reducing morbidity and improving patient outcomes.

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.

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.

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.

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.

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.

Comparison Between Endoscopic Prelacrimal Medial Maxillectomy and Caldwell-Luc Approach for Benign Maxillary Sinus Tumors.

OBJECTIVES: Endoscopic prelacrimal medial maxillectomy (EPMM) was previously reported to treat maxillary inverted papilloma. This study aimed to compare prelacrimal recess approach with the conventional Caldwell-Luc approach (CLA) to remove benign maxillary sinus tumors and to evaluate the usefulness of this approach based on our experience. METHODS: Ten patients who underwent EPMM at our hospital from January 2013 to December 2017 were reviewed. We also reviewed 30 patients who underwent benign maxillary sinus tumor resection via CLA during the same period. From medical records, postoperative pathological results complications due to surgery, and recurrence rate were evaluated. RESULTS: There were eight inverted papilloma, one ameloblastoma, and one ossifying fibroma in the EPMM group. In the CLA group, all 30 cases were inverted papilloma. There were no cases of failure at gross total removal during surgery, and no recurrences were observed during follow-up in either groups. Mean follow-up period was 13.0 months in CLA group and 10.8 months in EPMM group. Regarding postoperative complications, 11 patients of the CLA group (37%) and three patients of the EPMM group (30%) had numbness around the cheek and upper lip area after surgery (P=0.715). In the CLA group, there were eight patients who had numbness lasting more than 3 months after surgery, and two patients had numbness for more than 1 year. However, facial numbness disappeared within 3 months in all patients in the EPMM group, in which epiphora was not observed. CONCLUSION: EPMM is the effective surgical approach for resecting benign maxillary sinus tumor compared with CLA. Although facial numbness was reported in EPMM, the duration of numbness was shorter than CLA.

Comparison Between Endoscopic Prelacrimal Medial Maxillectomy and Caldwell-Luc Approach for Benign Maxillary Sinus Tumors

OBJECTIVES: Endoscopic prelacrimal medial maxillectomy (EPMM) was previously reported to treat maxillary inverted papilloma. This study aimed to compare prelacrimal recess approach with the conventional Caldwell-Luc approach (CLA) to remove benign maxillary sinus tumors and to evaluate the usefulness of this approach based on our experience. METHODS: Ten patients who underwent EPMM at our hospital from January 2013 to December 2017 were reviewed. We also reviewed 30 patients who underwent benign maxillary sinus tumor resection via CLA during the same period. From medical records, postoperative pathological results, complications due to surgery, and recurrence rate were evaluated. RESULTS: There were eight inverted papilloma, one ameloblastoma, and one ossifying fibroma in the EPMM group. In the CLA group, all 30 cases were inverted papilloma. There were no cases of failure at gross total removal during surgery, and no recurrences were observed during follow-up in either groups. Mean follow-up period was 13.0 months in CLA group and 10.8 months in EPMM group. Regarding postoperative complications, 11 patients of the CLA group (37%) and three patients of the EPMM group (30%) had numbness around the cheek and upper lip area after surgery (P=0.715). In the CLA group, there were eight patients who had numbness lasting more than 3 months after surgery, and two patients had numbness for more than 1 year. However, facial numbness disappeared within 3 months in all patients in the EPMM group, in which epiphora was not observed. CONCLUSION: EPMM is the effective surgical approach for resecting benign maxillary sinus tumor compared with CLA. Although facial numbness was reported in EPMM, the duration of numbness was shorter than CLA.

A large-scale study of treatment methods for foreign bodies in the maxillary sinus.

Recently, reports regarding a foreign body in the maxillary sinus have considerably increased, with the majority being iatrogenic cases resulting from dental treatment. This study involves an extensive review of the Japanese literature, including 112 papers from 1978 to 2017. These papers documented total 407 cases of a foreign body in the maxillary sinus. Among the 392 cases for which treatment details were available, the Caldwell-Luc approach was used for 216, the alveolar approach for 116, extraction using nasal endoscopy for 15, and extraction using oral endoscopy for eight. Spontaneous passage occurred in 19 cases, follow-up with medication was used in 17, and "other" was noted in one. This study determined that surgical removal remains the most common method for treating both tooth roots and other foreign bodies and that the Caldwell-Luc approach is used in majority of the surgeries. No marked differences were noted among the removal methods used in relation to the foreign body type.

Removal of Infected Maxillary Third Molar from the Infra-temporal Fossa by Caldwell Luc Procedure - Rare Case Report with Literature Review.

Dentigerous or follicular cysts of odontogenic origin are innocuous benign cysts that are often linked with the crowns of permanent teeth. A dentigerous cyst circumventing permanent teeth fails to erupt and is often displaced into ectopic positions in the upper and lower jaw in the maxillofacial region. In the maxilla or upper jaw region, the impacted teeth are often displaced and/or shift into the maxillary sinus and apart from the nasal septum, mandibular condyle, coronoid process and the palate, to harbour such ectopic eruptions of teeth. We report a rare case of an impacted left third molar of maxilla, associated with dentigerous cyst. The impacted tooth was embedded in the anterosuperior part of the infratemporal space. The cyst along with the tooth was removed using a modified Caldwell Luc incision.

Early Practice: External Sinus Surgery and Procedures and Complications.

External approaches to the paranasal sinuses are rarely used in the endoscopic era. However, their indications for use have not changed, and in every surgeon's career those indications may present themselves. For residents training in the endoscopic era, these procedures are also very rarely seen. In this article, the external approaches to the maxillary, ethmoid, and frontal sinuses are described: their original descriptions, modern use, and potential complications. It is hoped that this article will serve to instruct residents and practitioners alike in these techniques.

A Case of Ameloblastoma in the Maxilla

Ameloblastoma is a benign tumor originating from residues of the dental lamina. Ameloblastoma constitute approximately 1% of all tumors of the jaw, and the occurrence in the mandible is four times higher than that in the maxilla, suggesting that maxillary ameloblastoma is a rare histopathological entity. Although these tumors grow slowly and demonstrate a histologically benign appearance, ameloblastomas are notorious for local invasiveness and a high incidence of local recurrence. We experienced a case of ameloblastoma arising from the left maxilla in a 70-year-old male who complained of left nasal obstruction. The ameloblastoma was completely removed via the endoscopic endonasal approach combined with the Caldwell-Luc approach. At a 29-month follow-up, there was no evidence of recurrence.

Fibrous dysplasia of the maxillary sinus: case report

Introduction and objective: Fibrous dysplasia is a non-neoplastic lesion of unknown origin with one-fourth involving head and neck. The aim of this paper is to report a case of fibrous dysplasia of the maxillary sinus, describing its clinical presentation, radiological features, histopathological appearance and surgical management. Case report: 38-year-old female patient who presented with a history of fullness of the right cheek and intraoral swelling was diagnosed to have fibrous dysplasia of the maxilla with involvement of the maxillary sinus based on the radiological features. The case was managed surgically via a conventional Caldwell-Luc approach. The histopathology of the excised tissue confirmed the diagnosis of fibrous dysplasia. Conclusion: Fibrous dysplasia is a benign non-neoplastic lesion of unknown origin that rarely involves the maxillary sinus. This case report highlights the clinical, radiological and pathological features of fibrous dysplasia and its surgical management. Conventional Caldwell-Luc approach allows more exposure and ensures complete removal of the lesion.

Two Cases of Pneumocele of Maxillary Sinus / 대한이비인후과학회지

Pneumocele is a rare disease involving one or more paranasal sinuses. It is defined as abnormal dilatation of paranasal sinus, which is air-filled with either focal or generalized thinning of bony sinus walls. The aim of pneumocele treatment is two-fold: to re-establish permanent pressure equilibrium in the involved sinus and to correct the possible facial deformities. The first goal can be achieved by middle meatal antrostomy. When alterations of the maxillary or orbital contour are present, corrections can be obtained by osteotomies through Caldwell-Luc or an infraorbital approach. We report two cases of pneumocele of maxillary sinus. The first case was treated with osteotomy via Caldwell-Luc approach and the second case was treated simultaneously with osteotomy and rhinoplasty. No recurrence was observed after surgical treatment in both cases.

Treatment of Blow-out Fracture Located in the Posterior Portion of the Orbital Floor

Until now, there has been many papers about orbital blow-out fracture, but reports regarding the treatment and the prognosis of fractures located in the posterior portion of the orbital floor have been limited. The most common fracture site of the orbital floor is the medial portion of the infraorbital groove and repairing of the floor fracture located in the anterior portion of the floor is relative easy and has minimal complications. But when the fracture is located in the posterior portion of the floor, the possibility of the optic nerve injury is anticipated by surgical manipulation itself and the implanted silastic sheet Authors reconstructed posterior portion of the orbital floor fracture through conjunctival approach combined with Caldwell-Luc procedure in 5 patients, confirmed posterior orbital floor fracture on CT scan from July 1993 to November 1994. The results were satisfactory with no residual diplopia. Complications including prolonged maxillary sinusitis and lateral canthal deformity were encountered in each patient, but cured with ENT treatment and lateral canthoplasty. In reconstruction of orbital floor fracture, Caldwell-Luc approach was seldom used because of several reasons including the poor predictability, bleeding problrm, and the high incidence of sinus infection. But recently, Caldwell-Luc approach is reanimated by some endoscopic surgeons because of good visualization and less traumatic. In case of posterior floor fracture, our surgical method can reduce the possibility of injury to optic nerve and vital tissues around the orbital apex in spite of enlarging surgical field.