Extended middle meatal antrostomy via antidromic extended medial wall for the treatment of fungal maxillary sinusitis

Abstract

Objective The objective of this study was to compare the long-term results of extended middle meatal antrostomy (MMA) and MMA combined with inferior meatal antrostomy (IMA, combined approach) for the treatment of fungal maxillary sinusitis (FMS). Methods and materials A retrospective analysis including 90 patients with non-invasive FMS was treated with endoscopic extended MMA via antidromic extended medial wall (extended MMA group), or with both MMA and IMA (combined approach group). The recurrence rate, operation time, and complications were evaluated at postoperative 12 and 36 months. Results Of the 90 patients, 52 patients were in the extended MMA group and 38 patients in the combined approach group. CT revealed the thin medial wall or bone defect in 63.33% (57/90) patients. The mean operation time in the extended MMA group was significantly shorter than that of combined approach group (42.5 ± 6.5 vs 57.4 ± 4.9, P < 0.01). At postoperative 12 months postoperatively, the recurrence rate was 3.85% (2/52) in the extended MMA group and 0.0% (0/38) in the combined approach group, the difference wasn’t significant (X2 = 0.618, P > 0.05). The recurrence rate wasn’t increased during the follow-up period over time in both groups.13.5% (7/52) patients complained of cheek numbness in the extended MMA group, 60.5% (23/38) patients complained of cheek numbness and epiphora in 5.3% (2/38) patients in the combined approach group, the difference was significant (X2 test, P < 0.01). However, no major complications were observed in both groups. In addition, IMA closure was observed in 4 (10.5%) in the combined approach group at 12 months postoperatively and in 9 (23.6%) at 36 months postoperatively. Conclusions Extended MMA via antidromic extended medial wall may effectively prevent the recurrence and reduce the complications of FMS, IMA wasn’t necessary for the treatment of FMS in most cases.

The impact of maxillary dimensions on determining surgical approach of fungal ball in the maxillary sinus

“…MS fungal balls, which correspond to the location of most fungal balls 2 , 3 , 7 , 8 , are primarily removed with ESS and MMA. However, several studies have suggested that endoscopic MMA alone has limitations in observing the entire MS 9 – 11 . This visual limitation of MMA seems to be due to the anatomical features of the MS. General MMA is performed at the posteromedial portion of the MS by removing the membranous portion between the anterior and posterior fontanelle after uncinectomy 12 .…”

The impact of maxillary dimensions on determining surgical approach of fungal ball in the maxillary sinus

“…5,15 Extended endoscopic approaches to widen the MMA to obtain improved visualization, such as extended MMA, endoscopic maxillary mega-antrostomy, modi ed endoscopic Denker's approach, and endoscopic medial maxillectomy, have also been proposed. 7,9,16,17 However, these are very harsh approaches for the treatment of non-invasive fungal balls, and are di cult to advocate for as the rst-choice alternative approach due to the excessive damage to surrounding normal tissues and the lengthening of the operation time. A gauze-assisted technique was proposed to overcome the short visualization; however, it has a fundamental limitation in that remaining fungal debris cannot be completely identi ed.…”

“…MS fungal balls, which correspond to the location of most fungal balls, 2,3,7,8 are primarily removed with ESS and MMA. However, several studies have suggested that endoscopic MMA alone has limitations in observing the entire MS. [9][10][11] This visual limitation of MMA seems to be due to the anatomical features of the MS. General MMA is performed at the posteromedial portion of the MS by removing the membranous portion between the anterior and posterior fontanelle after uncinectomy. 12 In addition, the angle of access to the anterior inferior wall, the anterior medial wall, and the prelacrimal recess of the MS through MMA requires a visual direction change of more than 120 degrees based on the direction of the initial access path.…”

“…The recurrence rate of MS fungal ball removed with MMA alone is between 3 to 14%, indicating that such inadequate visualization may leave fungal debris and increase the risk of MS fungal ball recurrence with incomplete surgery. 7,9,14 Various additional approaches have been utilized to overcome the limitations of the visualization of endoscopic MMA. External approaches (Caldwell-Luc surgery and canine fossa approaches) may be inadequate for the non-invasive treatment of fungal balls as they can lead to various complications, such as trigeminal nerve palsy, facial pain, and stula.…”

“…Although IMA is controversial due to its impaired MS mucociliary clearance, risk of lacrimal duct injury, and high spontaneous occlusion rate, it nonetheless seems the most preferred option for further visualization after MMA. 9 Moreover, IMA does not harm the nasolacrimal duct, despite concerns, and MMA with IMA allows for the largest surgical and visual extent. 5 According to a recently published meta-analysis of the treatment of paranasal sinus fungal balls, IMA is the most frequently used alternative approach after MMA.…”