Endoscopic-Modified Medial Maxillectomy for the Nonfunctioning Maxillary Sinus

Abstract

Background Middle meatal antrostomy (MMA) is the traditional intervention for chronic maxillary sinusitis but often fails to correct a nonfunctioning maxillary sinus that has lost its capability for mucociliary clearance. Endoscopic-modified medial maxillectomy (EMMM) can reshape the maxillary sinus and avoid a “sumping” effect, preventing secondary bacterial colonization, encouraging dependent drainage, and promoting effective nasal irrigation. Objectives We describe a modification of the EMMM surgical technique in patients with recalcitrant maxillary sinusitis and perioperative outcomes. Methods Consecutive adult patients with nonfunctioning maxillary sinuses managed with EMMM were assessed. Primary outcomes were the resolution of the presenting symptom and the absence of mucostasis. Secondary outcomes were early (<90 days) and late (>90 days) morbidity. Results Fifty-seven patients (51.7 ± 17.5 years, 56.1% female) were assessed. Fifty-two patients had complete resolution of their presenting symptom (91.2% [95% CI: 80.7–97.1]) and 52 patients had an absence of mucostasis (91.2% [95% CI: 80.7–97.1]). Those with persistent crusting were also those with symptoms. Early morbidities included temporary dysesthesia (3.2%), bleeding (1.1%), and pain (3.2%), with no late morbidities. Conclusion EMMM is a robust approach for salvaging a nonfunctioning maxillary sinus. The procedure enhances nasal irrigation, supplants mucociliary clearance, and discourages dependent mucus retention.

Histopathology of Recalcitrant Maxillary Sinusitis Necessitating Endoscopic Medial Maxillectomy

“…8 EMM was employed as primary surgery by the present authors if there was a concern for severe underlying mucociliary dysfunction or persistent mucostasis following maxillary antrostomy based on clinical experience and published evidence. 3,4 Indications for primary EMM included fungal ball, AFRS with mucin trapped anteriorly such that a standard antrostomy would not provide sufficient access for clearance, prior radiation, immunodeficiency, severe eosinophilic CRS with asthma and AERD, bacterial biofilm formation, and odontogenic sinusitis from zygomatic dental implants or other maxillary hardware with sinus penetration. 1,3,5 Salvage EMM was performed for patients with persistent symptomatic and endoscopic or imaging evidence of disease after maxillary antrostomy.…”

“…Pathologies that lead to recalcitrant disease include bacterial biofilms, immunodeficiency, severe chronic rhinosinusitis (CRS) with nasal polyposis and aspirin-exacerbated respiratory disease (AERD), primary or secondary ciliary disorders, dental procedures with sinus penetration, 1 allergic fungal rhinosinusitis (AFRS), fungal balls, and prior radiation. [2][3][4][5] Post-operative "sumping" rates may be as high as 20% after standard antrostomy for long-standing fungal balls. 4 Accordingly, endoscopic medial maxillectomy (EMM) is increasingly utilized as primary treatment when risk factors for antrostomy failure and severe mucociliary dysfunction are present, or as salvage surgery for post-antrostomy sinusitis and mucostasis.…”

“…[2][3][4][5] Post-operative "sumping" rates may be as high as 20% after standard antrostomy for long-standing fungal balls. 4 Accordingly, endoscopic medial maxillectomy (EMM) is increasingly utilized as primary treatment when risk factors for antrostomy failure and severe mucociliary dysfunction are present, or as salvage surgery for post-antrostomy sinusitis and mucostasis. The goal of EMM is to create a gravitydependent sinus that affords increased irrigation force and volume as well as easier visualization for in-office culturing, monitoring, and debridements.…”

Infectious disease for the rhinologist

“…The paranasal sinus fungal ball (PSFB) presents as a solitary lesion, most often within the maxillary sinus. Surgical treatment may require extended maxillary sinus procedures such as the endoscopic modified medial maxillectomy [29,30]. A recent consensus statement on the treatment of PSFBs utilized a modified Delphi method to set guidelines regarding the definition, diagnosis and general management of the disease [31 && ].…”

Bringing Together Multiple Perspectives in Rhinology and Allergy

“…Seresirikachorn et al describe a modification of the endoscopic-modified medial maxillectomy (EMMM) procedure performed in adults with nonfunctioning maxillary sinuses managed with EMMM. 7 Most patients had improvement in both symptoms and mucostasis, complicated by rare events of blooding and temporary dysesthesia.…”