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punch, curved endoscopic scissors, microdebrider with straight and angled attachments (40- and/or 60-degree attachments), monopolar suction cautery, and endoscopic drill.
N. Ayoub and P. H. Hwang
Surgical Indications
Initial surgical indications for EMMA were focused on resection of tumors, including malignant tumors and benign but locally aggressive neoplasms (e.g., inverted
papilloma) [3]. EMMA improved endoscopic access to the maxillary sinus to resect
these lesions to reduce the need for a Caldwell-Luc or open maxillectomy.
The indications for EMMA have broadened over time to include inammatory
disorders of the maxillary sinus. The main indications for a mega-antrostomy in a
patient with chronic rhinosinusitis include recalcitrant maxillary sinusitis despite
prior surgery, anticipated need to access sinus for topical therapy and surveillance,
and primary or acquired mucociliary dysfunction. EMMA for CRS is most often
performed as a salvage surgical intervention. However, this procedure can, in select
cases, be performed during primary surgery. Primary EMMA is typically reserved
for patients with sinusitis related to primary disorders of mucociliary clearance,
including cystic brosis and primary ciliary dyskinesia. Less common indications
for EMMA include odontogenic cysts, mucoceles, fungus balls, allergic fungal
sinusitis, and mucus recirculation between an inferior meatal window and middle
meatal antrostomy.
Surgical Technique (Video 3.1)
The procedure is performed endoscopically under general anesthesia. General principles of the procedure include sufcient widening of the maxillary antrostomy,
mucosal preservation, avoidance of injury to the nasolacrimal duct, and preservation of the anterior portion of the inferior turbinate. The initial procedure details
vary depending on whether the patient had a prior maxillary antrostomy or is surgically naïve (e.g., patient with CF).
If the patient is surgically naïve, the procedure begins with a traditional endoscopic maxillary antrostomy. Uncinectomy is performed from posterior to anterior
using backbiting and through-cutting instruments. A 30-degree nasal endoscope is
then used to visualize the lateral nasal wall and identify the maxillary os. Once the
true os is identied, it can be dilated gently with a maxillary ball probe or curved
suction. A microdebrider and through-cut instruments can then be used to widen the
antrostomy posteriorly.
When mega-antrostomy is being performed as revision surgery, the prior antrostomy should be inspected with the angled endoscope, with particular attention to the
os. Residual uncinate process and/or scarring that may be obstructing the ostial
outow or causing recirculation are removed. Because the mega-antrostomy is a
3 Mega-antrostomy/Endoscopic Medial Maxillectomy for Recalcitrant Chronic…
31
mucosal sparing procedure, it is expected that the maxillary sinus mucosa will still
direct mucus towards the natural os, even with the extended antrostomy. If not previously done so, the antrostomy is extended posteriorly with through-cut forceps
towards the posterior wall of the maxillary sinus.
Next, the posterior ½ to 2/3 of the inferior turbinate is resected in order to expose
the inferior aspect of the medial wall of the maxillary sinus as it forms the lateral
wall of the inferior meatus. Using curved endoscopic scissors, the inferior turbinate
is rst transected full-thickness with a vertically oriented cut, positioning the scissors at the ventral aspect of the turbinate and aiming the tip of the scissors towards
the maxillary ostium (Fig. 3.1). The planned incision can be marked by crimping the
turbinate with a curved surgical clamp, which may reduce bleeding, although this
step is not routinely used by the senior author. Next, the posterior segment of the
inferior turbinate is detached from the lateral wall of the nasal cavity by using a
straight endoscopic scissor to cut the attachment of the turbinate to the medial wall
of the maxillary sinus (Fig. 3.2). Extension of the scissor cut posteriorly across the
posterior stump of the inferior turbinate fully releases the posterior inferior turbinate, which is removed from the surgical eld. The nal cut across the posterior
stump of the inferior turbinate often exposes the inferior turbinate artery, which
should be cauterized, along with the residual turbinate stump, with monopolar suction cautery to decrease the risk of postoperative epistaxis.
Next, down-biting through-cutting antral punches are used to resect the medial
wall of the maxillary sinus and extend the antrostomy down to the level of the nasal
oor. Some surgeons favor drilling thicker portions of the medial maxillary wall and
rotating local mucosal aps to cover exposed areas of bone, but this is not routinely
performed by the senior author. If additional anterior exposure is required, the
mega-antrostomy can be extended anteriorly along the nasal oor using a backbiting forceps, remaining inferior to Hasner’s valve (Fig. 3.3). This additional anteriorinferior limb of the mega-antrostomy can be brought forward as far anteriorly as the
medial maxillary buttress.
Fig. 3.1 Curved
endoscopic scissors are
used to resect the posterior
½ to 2/3 of the inferior
turbinate. Medialization of
the turbinate prior to
transection can reduce the
risk of injury to the lateral
nasal wall and Hasner’s
valve
32
Fig. 3.2 The posterior
stump of the inferior
turbinate is transected,
which often results in
bleeding from the inferior
turbinate branch of the
sphenopalatine artery
Fig. 3.3 After the medial
wall of the maxillary sinus
is resected to the oor of
the nasal cavity, the
antrostomy can be
extended anteriorly, taking
care to remain inferior to
Hasner’s valve
N. Ayoub and P. H. Hwang
After securing hemostasis with electrocautery and topical vasoconstrictors, the
procedure is concluded without placement of any absorbable or non-absorbable
nasal packing.
Reported Outcomes
There is a growing body of literature showing the benets and overall safety of this
procedure; however, prospective data is limited. There was a2020 systematic review
that included two level 2 evidence studies and four level 4 studies [15].
Cho etal. showed a signicant improvement in symptoms and endoscopy scores
after EMMA, with >80% of patients showing a reduction in the need for antibiotic
and oral steroid use [16]. Long-term follow-up (mean 6.9years) in a subsequent
paper by the same research group showed maintenance of the symptomatic benets
of EMMA, with 72% of patients describing complete or signicant improvement in
3 Mega-antrostomy/Endoscopic Medial Maxillectomy for Recalcitrant Chronic…
33
symptoms and 28% a partial improvement [17]. No patient in that review described
exacerbation of any sinonasal symptoms.
Wang, etal., in a retrospective analysis of 46 patients with recalcitrant maxillary
sinusitis who underwent EMMA, showed a complete resolution of sinonasal symptoms in 80% of patients over a mean 35-month follow-up period [18]. Within a
subgroup of 15 patients who had undergone prior Caldwell-Luc, 73% experienced
symptomatic improvement after EMMA. No patients required revision surgery.
Similarly, Woodworth etal. reviewed 19 patients with chronic maxillary sinusitis,
14 of whom had undergone prior Caldwell-Luc, and showed resolution of hyperplastic mucosa in 95% of patients after a mean 19.5-month follow-up [19].
Thulasidas etal. reported no recurrence of disease in all 24 patients who underwent
EMMA over a mean follow-up of 14.6months [20].
In a review of 551 medial maxillectomies, Wong, etal. showed a 25% incidence
of mucostasis 3months postoperatively, but this incidence decreased to 10.2% at the
last postoperative visit, suggesting an improved rate of sustained mucostasis over
time [21]. Patients in that review had a 5% incidence of revision sinus surgery after
EMMA.Given the widened maxillary antrostomy, the risks of restenosis are arguably lower.
EMMA has also been proposed as an initial or subsequent procedure for patients
with predilection for sinonasal inammatory disease [22]. In a subset of patients
with cystic brosis, Virgin et al. reported signicant improvement in SNOT-22
score and Lund-Kennedy score one year after surgery [23]. The frequency of pulmonary exacerbation-associated hospital admissions also decreased in the year after
surgery. There was a 9.1% reoperation rate in this group of patients with cystic
brosis.
In a cadaveric study, Govindaraju, etal. showed that more extended maxillary
sinus antrostomies, including EMMA, were associated with greater postoperative
irrigation penetration, visualization, and instrument reach [1]. EMMA has also been
shown to improve air entry into the maxillary sinus. Through computational uid
dynamics modeling, Siu etal. showed a positive linear correlation between the maxillary antrostomy size and the rate of airow into the maxillary sinus [24].
Potential Complications
Potential complications specic to EMMA include bleeding from the posterior
stump of the partially resected inferior turbinate, injury to the nasolacrimal duct,
and paradoxical nasal obstruction (i.e., empty nose syndrome) due to partial resection of the inferior turbinate [25]. However, the actual incidence of complications of
EMMA is low. A systematic review by Loftus, etal. reported a total of 4 complications out of 211 (1.9%) included patients. These included nasolacrimal duct obstruction (n=2), epistaxis requiring return to the operating room (n=1), and hypoplastic
maxillary sinus (n=1) [19–21].
34
N. Ayoub and P. H. Hwang
Preservation of a portion of the anterior aspect of the inferior turbinate may
decrease the incidence of certain complications. Using computational uid dynamics modeling, Saibene etal. found greater ow rates and uid velocities at the maxillary sinus after EMMA compared to modied EMMA with preservation of the
inferior turbinate, suggesting a greater disruption in normal nasal airow dynamics
after EMMA [26]. The authors postulated that this difference could contribute to the
more persistent postoperative crusting and reduced nasal air conditioning seen after
EMMA.Gras-Cabrerizo etal. discussed a technique to preserve the inferior turbinate during EMMA [27]. The authors initially make an incision at the head and
body of the inferior turbinate, then perform the medial maxillectomy. At the end of
the procedure, the head and body of the middle turbinate are sutured back to each
other. Using acoustic rhinometry, Gras-Cabrerizo showed maintenance of normal
nasal resistance with this technique.
Tips and Pearls
• Maintain the anterior 1/3 to ½ of the inferior turbinate undisturbed to decrease
the risk of empty nose syndrome.
• When performing the inferior turbinate partial resection, rst medialize the infe-
rior turbinate. This helps decrease the risk of inadvertent injury to the lateral
nasal wall and Hasner valve.
• Cauterize the posterior stump of the inferior turbinate to decrease the risk of
postoperative epistaxis from the inferior turbinate branch of the sphenopala-
tine artery.
• Perform only limited postoperative debridement of the posterior inferior turbi-
nate stump at the rst postoperative visit, as early removal of the crust may lead
to epistaxis.
• If the nasolacrimal duct is injured, a complete inferior transection of the duct
decreases the risk of postoperative nasolacrimal duct stenosis when compared to
incision without complete transection.
• The surgeon can consider upfront EMMA for patients with chronic ciliary dys-
function (e.g., cystic brosis or primary ciliary dyskinesia).
References
1. Govindaraju R, Prepageran N.The role of endoscopic medial maxillectomy in sinus disease.
Curr Opin Otolaryngol Head Neck Surg. 2021;29(1):1–8.
2. Ashman A, Psaltis AJ, Wormald PJ, etal. Extended endoscopic approaches to the maxillary
sinus. J Laryngol Otol. 2020;134:473–80.
3. Kamel RH.Transnasal endoscopic medial maxillectomy in inverted papilloma. Laryngoscope.
1995;105:847–53.
4. Tepedino MS, Miotello Ferrao AC, Morais Higa HC, etal. Reversible endoscopic medial maxillectomy: endonasal approach to diseases of the maxillary sinus. Int Arch Otorhinolaryngol.
2020;24:E247–52.
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5. Coleman JR Jr, Duncavage JA.Extended middle meatal antrostomy: the treatment of circular
ow. Laryngoscope. 1996;106:1214–7.
6. Nakayama T, Asaka D, Okushi T, etal. Endoscopic medial maxillectomy with preservation of
inferior turbinate and nasolacrimal duct. Am J Rhinol Allergy. 2012;26:405–8.
7. Sessions RB, Humphreys DH. Technical modications of the medial maxillectomy. Arch
Otolaryngol. 1983;109:575–7.
8. Ghosh A, Pal S, Srivastava A, etal. Modication of endoscopic medial maxillectomy: a novel
approach for inverted papilloma of the maxillary sinus. J Laryngol Otol. 2015;129:159–63.
9. Jurado-Ramos A, Jodas JG, Romero FR, etal. Endoscopic medial maxillectomy as a procedure of choice to treat inverted papillomas. Acta Otolaryngol. 2009;129:1018–25.
10. Kennedy DW, Adappa ND.Endoscopic maxillary antrostomy: not just a simple procedure.
Laryngoscope. 2011;121(10):2142–5.
11. Thamboo A, Ayoub N, Maul X, etal. The inferior turbinate: role in normal respiration and
airway obstruction. Curr Otorhinolaryngol Rep. 2021;9:383–8.
12. Chastain JB, Cooper MH, Sindwani R.The maxillary line: anatomic characterization and clinical utility of an important surgical landmark. Laryngoscope. 2005;115(6):990–2.
13. Greater palatine canal: Ayoub N, Thamboo A, Hwang PH, Walgama ES. Radioanatomic
Study of the Greater Palatine Canal relevant to endoscopic endonasal surgical landmarks.
Otolaryngol Head Neck Surg 2017;157(4):731–736.
14. Iwanaga J, Wilson C, Lachkar S, Tomaszewski KA, Walocha JA, Tubbs RS.Clinical anatomy of
the maxillary sinus: application to sinus oor augmentation. Anat Cell Biol. 2019;52(1):17–24.
15. Loftus CA, Yoo F, Desiato VM, Schlosser RJ, Soler ZM.Treatment of recalcitrant maxillary
sinusitis with endoscopic modied medial maxillectomy: a systematic review of safety and
efcacy. Am J Rhinol Allergy. 2020;34(1):127–33.
16. Cho DY, Hwang PH.Results of endoscopic maxillary mega-antrostomy in recalcitrant maxillary sinusitis. Am J Rhinol. 2008;22:658–62.
17. Costa ML, Psaltis AJ, Nayak JV, Hwang PH. Long-term outcomes of endoscopic maxillary mega-antrostomy for refractory chronic maxillary sinusitis. Int Forum Allergy Rhinol.
2015;5:60–5.
18. Wang EW, etal. Modied endoscopic medial maxillectomy for recalcitrant chronic maxillary
sinusitis. Int Forum Allergy Rhinol. 2011;1(6):493–7.
19. Woodworth BA, Parker RO, Schlosser RJ.Modied endoscopic medial maxillectomy for
chronic maxillary sinusitis. Am J Rhinol. 2006;20:317–9.
20. Thulasidas P, Vaidyanathan V.Role of modied endoscopic medial maxillectomy in persistent
chronic maxillary sinusitis. Int Arch Otorhinolaryngol. 2014;18:159–64.
21. Wong EH, Cavada MN, Orgain CA, et al. The modied medial maxillectomy as a radical or extended,-yet still functional,-technique in sinus surgery. Am J Rhinol Allergy.
2023;37(4):476–84.
22. Illing EA, Woodworth BA.Management of the upper airway in cystic brosis. Curr Opin Pulm
Med. 2014;20(6):623–31.
23. Virgin FW, etal. Extensive surgical and comprehensive postoperative medical management for
cystic brosis chronic rhinosinusitis. Am J Rhinol Allergy. 2012;26(1):70–5.
24. Siu J, Dong J, Inthavong K, Shang Y, Douglas RG.Quantication of airow in the sinuses following functional endoscopic sinus surgery. Rhinology. 2020;58(3):257–65.
25. Talmadge J, Nayak JV, Yao W, Citardi MJ.Management of postsurgical empty nose syndrome.
Facial Plast Surg Clin North Am. 2019;27(4):465–75.
26. Saibene AM, Felisati G, Pipolo C, Bulfamante AM, Quadrio M, Covello V.Partial preservation
of the inferior turbinate in endoscopic medial maxillectomy: a computational uid dynamics
study. Am J Rhinol Allergy. 2020;34(3):409–16.
27. Gras-Cabrerizo JR, Martel-Martin M, Montserrat-Gili JR, et al. Endoscopic medial maxillectomy with preservation of inferior turbinate: assessing results by acoustic rhinometry. J
Craniofac Surg. 2019;30(4):996–9.
35
Endoscopic Denker’s Approach
JustinP.McCormick andJivianneT.Lee
Key Points
• Chronic rhinosinusitis is a complex inammatory disease with a surgical revi-
sion rate of up to 15–20%.
• The modied endoscopic Denker’s approach is classically described for address-
ing tumors involving the anterior or lateral wall of the maxillary sinus, but also
is an option for the management of recalcitrant chronic rhinosinusitis.
• This surgical technique utilizes an endonasal maxillotomy without the need for
separate external incisions.
• The modied endoscopic Denker’s approach allows for complete exposure of the
anterior and medial maxilla and may be a useful adjunct procedure in patients
with severe recalcitrant chronic rhinosinusitis.
4
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 89191- 5_4.
J. P. McCormick
Department of Head and Neck Surgery and Communication Sciences, Rutgers Robert Wood
Johnson Medical School, New Brunswick, NJ, USA
J. T. Lee (
Division of Rhinology & Endoscopic Sinus and Skull Base Surgery, Department of Head and
Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
e-mail: JTLee@mednet.ucla.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee etal. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_4
*)
37
38
J. P. McCormick and J. T. Lee
Background
Chronic rhinosinusitis (CRS) is an inammatory disease of the paranasal sinuses
which causes symptoms of nasal obstruction, thick nasal drainage, smell dysfunction, and facial pain or pressure for a time period of greater than 12weeks [1]. The
management of CRS begins with medical therapy which can include a combination of large volume saline irrigations, intranasal corticosteroids, oral corticosteroids, and/or antibiotics depending on the phenotype/endotype of the CRS,
typically for a 3–4week period [1]. The response rate to medical therapy alone is
quite varied and has been reported to be 37.5–90% [2, 3]. When patients fail to
respond to appropriate medical therapy, which can be dened as persistence of
symptoms with ndings of sinonasal inammation on radiography or endoscopy,
they can be offered sinus surgery.
The goals of endoscopic sinus surgery (ESS) have been similar since its introduction in the 1980s. ESS seeks to reestablish sinus ventilation and improve access
for delivery of topical medications [4]. Despite adequate ESS and post-operative
medical management, a subset of patients will develop recurrent or refractory symptoms. Several large database studies have reported overall revision rates after ESS
of 15–20% [5–7]. Reasons for primary surgical failure have been suggested to
include postoperative scarring, neo-osteogenesis, inadequate postoperative management, or incomplete primary surgical extirpation. After initial surgical failure,
extended approaches may be required to improve access for long-term topical therapies. The maxillary sinus has several extended approaches that may be employed to
address recalcitrant chronic maxillary sinusitis [8].
A standard middle meatal maxillary antrostomy involves resecting the uncinate
process to expose the natural ostium of the maxillary sinus, followed by widening
of the natural ostium. The appropriate maxillary ostium size is a topic of debate;
however, it is the preference of the authors to perform a wide maxillary antrostomy
during primary ESS to facilitate in-ofce monitoring and management. The primary
maxillary antrostomy may involve extending the natural ostium from the nasolacrimal duct anteriorly to the posterior wall of the maxillary sinus, and opening the
sinus superiorly to the orbital oor and inferiorly to the attachment of the inferior
turbinate. There are several extended surgical approaches to the maxillary sinus.
The endoscopic maxillary mega-antrostomy involves resection of the mid-portion
of the inferior turbinate, and extends the antrostomy inferiorly to the oor of the
nasal cavity [9]. The modied endoscopic medial maxillectomy, which involves
more aggressive resection of the inferior turbinate and extends the antrostomy anterior and inferior to Hasner’s valve to expose the more anterior aspect of the maxillary sinus. The Caldwell-Luc approach utilizes an intraoral incision to perform an
anterior maxillotomy allowing access to the far anterior-lateral aspect of the maxillary sinus [10]. Recently, an endoscopic modication to the standard Denker’s
approach has been described to address tumors of the maxillary sinus; however, it
may also be adapted to address recalcitrant maxillary sinusitis, as the standard
Denker’s approach has been used previously [11].
4 Endoscopic Denker’s Approach
39
Surgical Technique
The standard Denker’s approach involves a sublabial incision that exposes a wide
area of the anterior maxillary wall. An anterior maxillotomy is then performed and
extended laterally to the infraorbital foramen and superiorly to the orbital rim. The
lateral nasal wall is then incised and resected to the oor of the nasal cavity, including resection of the inferior turbinate. This allows exposure of the ethmoid sinuses
where complete sphenoethmoidectomy can be performed, and the middle turbinate
is resected. The nasolacrimal duct is then identied and sharply transected near the
lacrimal sac. Once the sinuses have been widely opened, forceps are used to the
remove the mucosa of sinus cavities [12].
Recently the Denker’s approach has been modied to allow for similar access via
a completely endoscopic approach (Table4.1) [11]. An endoscopic medial maxillectomy is performed. Electrocautery with a guarded needle tip [Megadyne, Draper,
UT] is used to make a mucosal incision at the junction of the nasal oor and lateral
nasal wall through the periosteum. The incision is then extended along the head of
the inferior turbinate at the edge of the pyriform aperture. Then, a subperiosteal dissection is performed with a suction freer elevator [Olympus ENT, Southborough,
MA] to expose the anterior aspect of the maxilla, the infraorbital foramen, and its
neurovascular bundle. A high-speed drill is utilized to create a bony window into the
anterior wall of the maxillary sinus, taking care to stay inferior to the infraorbital
foramen and preserve the anterior superior alveolar nerve. Further drilling of the
pyriform aperture is performed to connect the anterior maxillotomy to the inferior
portion of the endoscopic medial maxillectomy. This exposure allows access to the
anterior-lateral, and anterior-inferior medial portion of the maxillary sinus (Fig.4.1).
At the end of the procedure, the nasolacrimal duct is identied and is sharply
obliquely transected to prevent stenosis (Video 4.1).
Table 4.1 Steps to perform the modied endoscopic Denker’s approach
Step 1 Perform an endoscopic medial maxillectomy by completing a standard
maxillary antrostomy and then excising the middle portion of the inferior
turbinate allowing the medial maxillary sinus wall to be resected to the
nasal oor.
Step 2 Using monopolar electrocautery, make a mucosal incision at the pyriform
aperture extending from the oor of the nose to the superior portion of the
inferior turbinate
Step 3 Using a suction elevator, dissect in a subperiosteal plane along the anterior
aspect of the maxilla until the infraorbital neurovascular bundle is
identied
Step 4 A high speed drill is used to create a bony window into the anterior wall of
the maxillary sinus, taking care to stay inferior to the infraorbital foramen
Step 5 Further drilling of the medial aspect of the pyriform aperture is performed
to connect the anterior maxillotomy to the inferior portion of the
endoscopic medial maxillectomy
Step 6 The nasolacrimal duct is then identied within the mucosal of the lateral
nasal wall, and the lumen is cut obliquely to prevent stenosis
(Fig. 4.2)
(Fig. 4.3)
(Fig. 4.4)
(Fig. 4.5)
(Fig. 4.6)
40
Fig. 4.1 Completion of
the endoscopic Denker’s
approach allows for full
visualization of all walls of
the maxillary sinus
Fig. 4.2 To begin the
endoscopic Denker’s
approach, a mucosal
incision is made with a
monopolar cautery at the
pyriform aperture
J. P. McCormick and J. T. Lee
Role oftheDenker’s Approach inRecalcitrant CRS
The Denker’s approach for treatment-resistant maxillary sinusitis was rst reported
in the 1990s by a group in the Netherlands. Kerrebijn etal [12] reviewed their series
of 56 patients with treatment resistant chronic rhinosinusitis with nasal polyps
(CRSwNP). All patients underwent thestandard Denker’s approach and had at least
36months offollow-up. Long term results after radical surgery demonstrated resolution of nasal discharge in 82% of patients, restored sense of smell in 89% of
patients, and resolution of headaches in 87% of patients. Despite these positive