The evolution of maxillary sinus surgery: open approaches in the era of nasal endoscopy

Introduction

In the field of otolaryngology, the management of conditions affecting the maxillary sinus has undergone significant evolution. With the advent of nasal endo­scopy, minimally invasive techniques have become the cor­ner­stone of sinus surgery. Despite the advancements in minimally invasive techniques, such as endoscopic sinus surgery, certain clinical scenarios continue to necessitate traditional open approaches. These situations underscore the ongoing relevance of these techniques, particularly in resource-limited settings or in cases involving complex anatomical challenges.

The evolution of technologies in sinus surgery has dramatically changed surgical practice in otolaryngology. The introduction of endoscopic techniques has enabled surgeons to address sinus pathologies with unprecedented precision and minimal invasiveness. Functional endoscopic sinus surgery (FESS) has become the standard approach, allowing efficient access to the sinus cavities through natural pathways and significantly reducing the morbidity associated with open surgical approaches. However, despite the success of these modern techniques, there remain clear indications for the use of open surgical approaches, such as the Caldwell-Luc procedure, in certain complex clinical scenarios.

Although endoscopic surgery offers numerous advantages, including superior visualization and reduced patient recovery time, it also presents certain limitations. For instance, the ability to fully visualize and access certain regions of the maxillary sinus, particularly the lateral wall, can be challenging with an endoscopic approach. Additionally, endoscopic surgery may not be readily available in resource-limited settings, making traditional open approaches not only relevant but necessary. These challenges highlight the ongoing need for a thorough understanding of both endoscopic and open surgical techniques in the management of sinus pathologies.

This article explores the indications and utility of open approaches to the maxillary sinus in the context of the modern era of nasal endoscopy. In the current era of advanced endoscopic techniques, the role of open approaches may seem diminished, yet their relevance persists in specific contexts. Conditions such as extensive tumors, complex trauma, and certain infections may require the comprehensive access provided by open surgery. Furthermore, in situations where endoscopic equipment is unavailable or the pathology is inaccessible through endoscopic means, procedures like the Caldwell-Luc remain invaluable. This underscores the importance of maintaining proficiency in these traditional techniques, ensuring that surgeons are equipped to provide the best possible care in all scenarios.

Anatomy of the maxillary sinus

The maxillary sinus (MS), also known as the antrum of Highmore, is a paired paranasal sinus located within the body of the maxillary bone⁽¹⁾. The MS is pyramidal in shape and it is the largest and first to develop of the paranasal sinuses⁽²⁾.

The anterior wall of the MS is formed by the anterior wall of the maxilla, and it has three major landmarks: the thin canine fossa, the infraorbital foramen, and the infraorbital groove⁽³⁾. The posterior wall is formed by the infratemporal plate of the maxilla. Pterygopalatine and infratemporal fossae lie posterior to it⁽⁴⁾. The roof of the MS is the floor of the orbit with the infraorbital groove running through it. The floor of the MS is formed by the alveolar and palatine processes of the maxilla. It typically lies about 1.5 cm below the floor of the nasal cavity, aligned with the lower border of the ala of the nose. It normally extends from the medial surface of the first premolar tooth to the distal surface of the third molar tooth, with its lowest point situated adjacent to the first and second molar teeth⁽⁴⁾.

The medial wall of the maxillary sinus (also considered the base of the pyramid) is adjacent to the lateral wall of the nasal cavity⁽⁵⁾. It is rectangular in shape and presents a slight deficiency at the maxillary hiatus. This aperture is partly obstructed in an articulated skull by segments of the inferior turbinate, the uncinate process of the ethmoid bone, the perpendicular plate of the palatine bone, the lacrimal bone, and the overlying mucosa, forming the ostium along with anterior and posterior fontanelles⁽²⁾. The ostium opens into the inferior part of the ethmoid infundibulum, traversing through the semilunar hiatus before reaching the middle nasal meatus.

Surgical approaches to the maxillary sinus

Various surgical approaches to the maxillary sinus can be considered in addressing inflammatory or neoplastic rhinological pathology. Externally, the MS can be accessed most commonly through the anterior wall using the Caldwell-Luc (CL) operation. Other external approaches to the maxillary sinus include transconjunctival, transpalatal and preauricular hemicoronal approaches, where access into the sinus is gained through its superior, inferior, posterior and lateral walls, respectively⁽⁶⁾. However, due to the relative invasiveness of these procedures, their significant morbidity and the fact that they do not respect the natural physiology of the sinuses, endoscopic sinus surgery (ESS) has become the standard of care nowadays⁽⁷⁾. Functional endoscopic sinus surgery (FESS) was first applied by Prof. Heinz Stammberger, who popularized Walter Messerklinger’s technique using the Hopkins rod⁽⁸⁾. Since its introduction, the techniques applied in ESS have been in a constant race with technical advances in imaging, instrumentation, and navigation. Navigation-guided ESS uses imaging obtained before surgery to guide the surgeon intraoperatively⁽⁹⁾.

Objectives

At present, endoscopic sinus surgery is the mainstay approach to sinus pathology, with its indications surpassing the field of rhinosinusitis. Even lesions located in the pterygopalatine and infratemporal fossae can be accessed by endoscopy through the posterior wall of the maxillary sinus. However, this technique is not widely available in health resource-limited settings, hence it is the external approach that enables patients to receive treatment.

This study aims to review the relevance of, and the indications for an external approach to the maxillary sinus, to describe the types of external surgical approaches and to compare the results between external and endoscopic surgery.

Materials and method

Types of external approaches to the maxillary sinus

1. The anterior wall and CL (anterior transmaxil­lary) approach

The Caldwell-Luc operation was first described by Caldwell (1893) and Luc (1897). This technique proves its efficiency to this day in a number of pathologies involving the anterior wall of the maxillary sinus – odontogenic lesions, tumors (inverted papilloma), trauma, and also for accessing the pterygopalatine and infratemporal fossae. Despite the replacement of the external approach to the maxillary sinus with functional endoscopic sinus surgery, Caldwell-Luc procedure is still relevant, especially in health resource-limited settings. This operation seems to be highly effective in the management of refractory chronic sinusitis after failed endoscopic middle meatus antrostomy⁽¹⁰⁾.

It also serves as a supplement to endoscopic cranial base approaches, enabling contralateral or ipsilateral approaches (to infratemporal fossa). Additionally, the CL approach can address pathology in the masticator space or the lateral recess of the sphenoid sinus⁽⁶⁾.

The Caldwell-Luc procedure is performed under general anesthesia, with the patient in a supine position. A mucosal incision is made over the canine fossa, and the anterior wall of the maxillary sinus is drilled for approximately 3 cm. The pathological mucosa is then visualized, followed by excision. In the standard Caldwell-Luc operation, an inferior meatal antrostomy is performed to promote sinus drainage, though some studies show that the inferior meatal antrostomy is not necessary when treating odontogenic sinusitis. A 0-30-degree endoscope can be used to facilitate further dissection⁽¹¹⁾.

2. The osteoplastic procedure

This procedure is an alternative to the CL operation, and the only difference between the two is the fact that a bone flap is created in the anterior wall of the maxillary sinus. At the end of the surgical intervention, this flap will be placed back into its anatomical position⁽¹²⁾.

Due to its proximity to the orbit – superiorly, the pterygopalatine fossa – posteriorly, and the infraorbital fossa – posterolaterally, the maxillary sinus can serve as an entry point to these areas. Nowadays, the approach can be a combination of open and endoscopic techniques for a comprehensive visualization of the sinus. The following approaches are detailed below.

3. Transconjunctival approach

It is mostly used in maxillofacial trauma, to access the infraorbital nerve or the inferior orbital fissure, in tumors of the maxillary sinus extending to the orbit⁽⁶⁾.

A conjunctival incision (with lateral canthotomy if necessary) is performed. The infraorbital nerve and artery are identified and exposed. The superior wall of the maxillary sinus is then drilled, medial to the infraorbital nerve, and then lateral to it for a clearer view of the cavity.

4. The inferior wall and transpalatal approach

This approach is indicated in oral cavity neoplasms extended to the maxillary sinus and the alveola, in MS osteomas with extension through the inferior wall of the MS or palate into the oral cavity. The procedure is contraindicated in patients with severe trismus and tumors beyond the midline of the hard palate⁽⁶⁾.

A U-shaped incision is made at the level of the hemipalate, corresponding to the maxillary sinus intended to be approached. The mucoperiosteum is raised to expose the hard palate. The inferior wall of the maxillary sinus is then drilled and the cavity is exposed.

5. The preauricular hemicoronal approach

The coronal and hemicoronal approaches are frequently utilized in neurosurgery and craniofacial procedures. Originally described in 1907 by Hartley and Kenyon, these techniques were used particularly in Le Fort II and III fractures. These approaches are commonly used to access the frontal, temporal and zygomatic regions. Furthermore, they offer a vision of the posterior and lateral walls of the maxillary sinus. Additionally, this approach can be used to facilitate transmaxillary access to the central skull base for cranial base reconstruction⁽⁶⁾.

An incision is made posterior to the hairline from the tragus to the middle of the forehead, lifting the skin anteriorly. The zygomatic arch is exposed, from which the middle third is excised. The temporal muscle is incised above its insertion to visualize the posterolateral walls of the maxillary sinus. The deep temporal artery and internal maxillary artery are identified, lateral to the wall of the maxillary sinus, then the lateral wall is drilled to expose the maxillary sinus.

Complications of the endoscopic approach versus the external Caldwell-Luc procedure

The endoscopic approach has now replaced external approaches as the standard of care, because of the reduced morbidity, improved visualization and lower recurrence rates of benign tumors. Despite that, there are still some complications that arise with endoscopic surgery, including bleeding, cerebrospinal fluid (CSF) leaks, and orbital and lacrimal pathway involvement⁽¹³⁾.

The most common complications for the Caldwell-Luc procedure are facial swelling, pain and/or numbness of the face and upper lip and pain and/or hypoesthesia of the teeth and gums. Rare complications are postoperative epistaxis, oroantral fistulae, epiphora and dental discoloration⁽¹⁴⁾. The inferior meatal antrostomy (used to promote sinus drainage) has its risks of injury to the nasolacrimal duct and prolonged healing time, and it can be omitted during surgery⁽¹⁵⁾. Additionally, a study by Stefánsson et al.⁽¹⁶⁾ described neuralgia of the infraorbital nerve as another possible complication.

Anesthesia

Typically, for both endoscopy and CL method, the standard procedure is general anesthesia. The use of TIVA has also allowed the performance of endoscopic intervention on patients with significant decrease of both cardiac and respiratory functions, with the benefit of a fast-awakening time. Both procedures can be performed under local anesthesia if the patient is allergic to medications used during general anesthesia, though not preferable for neither surgeon, nor patient.

Results

To support the usefulness of the external approaches to the maxillary sinus in the era of endoscopic sinus surgery, we present two cases of two different pathologies with indications for open surgery.

Inverted papilloma

Inverted papilloma is a rare sinonasal benign epithelial tumor. It has three characteristics that make it different from other sinonasal tumors: it is locally destructive, has a high rate of recurrence after surgery, and it is a risk for carcinomatous evolution⁽¹⁷⁾. The key when approaching this tumor is the proper management of its site of origin, allowing for complete removal. There are a few relative limits for endoscopy in patients with inverted papilloma: the anterior and lateral wall of the maxillary sinus, massive frontal sinus extension, extension into the orbit, and intracranial extension.

We present the case of a 50-year-old woman, who presented to the ENT department with complete nasal obstruction for over a year. The ENT clinical examination revealed a tumor of the left nostril (Figure 1), with brain-like appearance, visualized in the nasopharynx from the right fossa. The MRI showed a thickening of the inferior and middle nasal turbinates, filling the left nasal fossa and extending to both the nasopharynx and the semilunar hiatus into the left maxillary sinus, occupying it almost completely (Figure 2). The imaging also described thickening of mucosa in the left ethmoid cells and sphenoid sinus. The suspicion of inverted papilloma was raised. The histopathological results confirmed the initial diagnosis: Schneidirian papilloma, the inverted type. 
 

Prior to the surgical intervention, the patient underwent bilateral angiography with embolization of the left internal maxillary artery for hemostatic purposes in the Interventional Radiology Department. Resection of the nasosinusal tumor with combined approach: transantral and nasal endoscopy, ethmoidectomy and Caldwell-Luc procedure (Figure 3) were performed, under general anesthesia. Inferior antrostomy was made to drain the sinus. 
 

The patient remained under supervision for the recurrence of the inverted papilloma.

Mucormycosis

Mucormycosis is a rare but life-threatening fungal infection that mainly occurs in patients with underlying comorbidities or immunosuppression. Early diagnosis and rapid initiation of aggressive surgical debridement and antifungal therapy are key to improve survival⁽¹⁸⁾. 

A 68-year-old female patient presented to the hospital with fever and inflammatory syndrome on the blood tests. The patient was transferred to our ENT department for emergency surgical intervention. At presentation, the patient had a moderate general state, being conscious and drowsy. The ENT clinical examination revealed discrete bilateral exophthalmos and left facial palsy corresponding to the middle and inferior branches of the VII cranial nerve. Nasal endoscopy revealed crusty, black molds of the nasal fossae, black turbinates and nasal floor, with no signs of normal mucosa (Figure 4). The nasal septum was largely perforated. In the oral cavity, the corresponding mucosa to the alveolar recess looked devitalised. Patient’s medical history noted carotid body tumor, diagnosed 10 years prior. 
 

Preoperatively, the patient was prescribed the following antimycotics by infectious diseases physicians: Meronem®, vancomicine, caspofungin. Under general anesthesia, the Caldwell-Luc procedure was performed. Extended nasal necrectomy was performed under endoscopic visualization. During the CL procedure, the thin bone did not require drilling. The contents of the sinus showed both fungal and bacterial infection.

After the surgery, the patient presented remission of the exophthalmos. 

Discussion

Despite the unquestionable success of endoscopic sinus surgery in the present day, there are still well-documented indications for the Caldwell-Luc operation, which provides good access to the sinus and pterygomaxillary fossa. One of the main limitations of the endoscopic approach is the difficulty to visualize the lateral wall of the maxillary sinus, which could require multiple entry points. 

Current indications for an open surgery include intrasinus foreign bodies, cysts or tumors, oroantral fistulae, epistaxis control, mycotic fungal balls, and facial trauma^(19,20).

Effectiveness of open versus endoscopic ap­­­proaches

The classic Caldwell-Luc operation was described more than 100 years ago. Initially, an inferior meatal antrostomy was implemented together with the canine fossa trepanation because it was thought to aid in sinus drainage⁽²¹⁾. Subsequent studies have revealed, however, that primary mucociliary flow pattern is maintained towards the natural ostium of the maxillary sinus, despite the existence of the surgically created inferior meatal antrostomy⁽²²⁾.

Technical limitations

Despite its advantages, ESS is not without limitations. Accessing the lateral wall of the maxillary sinus, for instance, can be challenging, which might necessitate the use of multiple entry points or combined approaches. On the other hand, open procedures such as the Caldwell-Luc operation allow direct access to the entire sinus cavity, which is essential for the complete removal of pathological tissues, especially in cases of inverted papilloma or malignancies⁽¹⁰⁾. Furthermore, the availability of endoscopic equipment and expertise can be a significant barrier in resource-limited settings, making open surgery the only viable option in such contexts.

Patients’ outcomes and quality of life

From the perspective of patient outcomes, both FESS and open surgery have their respective advantages. FESS is generally associated with lower postoperative morbidity, including less facial swelling and faster recovery times⁽²³⁾. However, when it comes to managing more complex cases, such as extensive tumors or severe maxillofacial trauma, open surgery might offer better long-term outcomes due to the thorough access it provides. The impact on the patient’s quality of life, particularly concerning symptom relief and recurrence rates, must be carefully considered when choosing the surgical approach⁽²⁴⁾.

Future directions in maxillary sinus surgery

Looking ahead, the integration of advanced imaging technologies, such as intraoperative CT scanning and surgical navigation systems, is expected to further refine both endoscopic and open surgical techniques. These innovations will likely reduce the complications associated with both approaches and improve overall surgical outcomes. Additionally, the development of new, less invasive techniques may eventually diminish the need for traditional open surgeries. However, the ongoing relevance of the Caldwell-Luc procedure in certain clinical scenarios underscores the importance of maintaining a diverse surgical repertoire⁽²⁵⁾.

Comparison of presented cases with literature

The cases of inverted papilloma and mucormycosis presented in this article underscore the relevance of open surgical approaches in specific, complex clinical scenarios. The use of the Caldwell-Luc procedure in these cases highlights its effectiveness in ensuring comprehensive access to the maxillary sinus, particularly in situations where endoscopic techniques might be insufficient. For example, the successful management of inverted papilloma through a combined approach of transantral and endoscopic techniques is consistent with findings in the literature, which suggest that, while endoscopic resection is often preferred, open approaches remain critical when dealing with tumors that extend to the lateral or anterior walls of the sinus^(13,17).

Similarly, the case of mucormycosis treated with a Caldwell-Luc approach reflects the literature’s emphasis on aggressive surgical debridement in conjunction with antifungal therapy to improve survival rates in such life-threatening infections. Previous studies have documented similar outcomes, where open surgical approaches were necessary to achieve complete removal of necrotic tissue, particularly in cases where the disease had extensively involved the maxillary sinus. This comparison underlines the importance of maintaining proficiency in both endoscopic and open surgical techniques to ensure the best possible outcomes in complex cases⁽¹⁸⁾.

Conclusions

Despite the fact that endoscopic sinus surgery is the standard of care for the maxillary sinus pathology, an external approach using the Caldwell-Luc operation or its modifications is still relevant, particularly in health resource-limited settings, but also in well-selected clinical scenarios. The Caldwell-Luc operation should therefore be part of every otolaryngology surgeon repertoire.

Autori pentru corespondenţă: Mihai Dumitru E-mail: orldumitrumihai@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.