Powered endoscopic inferior meatal antrostomy under canine fossa telescopic guidance.

A 34-year-old woman came to us with a mucous cyst (mucocele) in her left maxillary sinus that was associated with septal deviation. An initial attempt to remove the mass via the middle meatus failed because of anatomic restrictions. The lesion was subsequently removed with powered instrumentation via an inferior meatal approach, with observation through a telescope passed via the canine fossa (figure).

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Biopsy or excision of lesions in the maxillary sinus can be achieved via (1) a middle meatal approach, (1,2) (2) an inferior meatal approach, (1,2) (3) a canine fossa maxillary sinoscopy approach, (2,3) and (4) a mini-Caldwell-Luc approach. (4)

Most benign lesions of the maxillary sinus can be removed via an endoscopic middle meatal approach. However, when a lesion is situated inferomedially, inferoanteriorly, or inferolaterally or when the medial wall of the antrum is bulging laterally, access with a biopsy forceps via the middle meatus might not be possible. In such an event, the surgeon should attempt the inferior meatal approach. After local anesthesia is applied to the lateral nasal wall in the inferior meatus, exposure is maximized by medializing the inferior turbinate. A trocar with sheath is passed through the middle portion of the medial wall of the maxillary sinus. After the trocar is removed, a 4-mm, 0[degrees]s telescope is inserted and the antrum is carefully examined. A 2.7-mm optical biopsy forceps is inserted, and the biopsy is taken. If better access is required, the inferior meatal window can be widened and the biopsy can be taken through this wider window.

A more practical and effective alternative to the preceding type of inferior meatal approach is to make a powered endoscopic excision through the inferior meatal window while visualizing the antral mass lesion with a telescope passed through the canine fossa (figure, A). The inferior meatal window is created with a chisel and enlarged with a curved antral Kerrison's forceps anteriorly and Gruenwald's bone-cutting forceps posteriorly. Care should be taken to avoid injury to the nasolacrimal duct and Hasner's valve. The trocar with sheath is passed through the ipsilateral canine fossa. Then a 4-mm, 0[degrees] telescope is passed through the sheath to visualize the mass. A curved or straight: microdebrider is passed through the inferior meatal window, and the lesion is removed in a precise and controlled manner (figure, B, C, and D). For anteroinferior lesions, a curved microdebrider might become necessary. An angulated cup forceps can also be helpful for biopsy.

Powered endoscopic excision via an inferior meatal antrostomy under canine fossa telescopic guidance is a useful and effective procedure for removing inferior antral lesions. If this approach fails, the mini-Caldwell-Luc approach can be considered.

References

(1.) Yanagisawa E. Atlas of Rhinoscopy: Endoscopic Sinonasal Anatomy and Pathology. San Diego: Singular Publishing, 2000.

(2.) Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: B.C. Decker, 1991.

(3.) Yanagisawa E, Klenoff JR. Trans-canine4ossa maxillary sinoscopy for biopsy via the Stammberger technique. Ear Nose Throat J 2001;80:432-3.

(4.) Yanagisawa E, Yanagisawa K, Fortgang P. Endoscopic excision of large benign antral lesion via a modified ("mini") CaldwellLuc procedure. Ear Nose Throat J 1995;74:620-1.

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, Conn.; the Section of Otolaryngology, Yale University School of Medicine, New Haven; and the Section of Otolaryngology, Hospital of St. Raphael, New Haven.