What is the current state of endoscopic medial maxillectomy (EMM) in terms of indications, technique, and outcomes?

Endoscopic Medial Maxillectomy: Current Indications, Techniques, and Outcomes

Endoscopic medial maxillectomy (EMM) is currently the procedure of choice for treating maxillary sinus inverted papillomas with excellent surgical access and outcomes, particularly when enhanced with techniques like the transseptal approach for anterolateral lesions. 1

Indications for EMM

• EMM is primarily indicated for benign sinonasal neoplasms, particularly inverted papillomas (IPs) originating from the maxillary sinus 1, 2
• EMM has proven effective for chronic maxillary sinusitis refractory to standard medical and endoscopic surgical management, including cases that failed prior Caldwell-Luc procedures 3
• EMM can be used to treat mucoceles of the maxillary sinus, especially those occurring after previous Caldwell-Luc operations 4
• EMM has largely replaced traditional open approaches (like Caldwell-Luc) due to decreased morbidity and comparable or better outcomes 2

Technical Evolution and Approaches

Standard EMM Technique

• Traditional EMM involves removal of the medial wall of the maxillary sinus, which typically includes resection of the inferior turbinate and nasolacrimal duct 4
• The procedure provides excellent visualization of the maxillary sinus, particularly when using angled endoscopes (70-degree) and specialized instrumentation 1

Modified EMM Techniques

• Endoscopic Modified Medial Maxillectomy (EMMM) preserves the inferior turbinate and nasolacrimal duct while maintaining equivalent surgical access 4
• This preservation technique is important as the inferior turbinate has critical functions in conditioning nasal airflow, and preserving the nasolacrimal duct reduces the risk of epiphora 4
• For anterolateral maxillary sinus lesions (previously thought to require external approaches), transseptal surgical access can provide enhanced visualization without requiring a Caldwell-Luc approach 1

Surgical Outcomes

Efficacy for Inverted Papillomas

• EMM demonstrates significantly lower recurrence rates compared to non-endoscopic techniques (11.8% vs 44.4%) 2
• Studies show no recurrences with mean disease-free intervals of 29 months for anterolateral maxillary sinus IPs treated with EMM 1
• EMM with preservation of the nasolacrimal duct and inferior turbinate has shown good outcomes with no recurrences in selected IP cases during follow-up periods averaging 30.8 months 5

Efficacy for Inflammatory Disease

• MEMM has proven both safe and effective for chronic maxillary sinusitis refractory to standard medical and endoscopic surgical management 3
• Success rates are high even in patients who have failed previous sinus surgeries, including Caldwell-Luc procedures 3

Complications and Functional Outcomes

• Complication rates are low, with nasolacrimal duct injury being a potential but uncommon complication 3
• Postoperative complaints are typically minor, including temporary hemorrhagic discharge and crusting in the first few weeks 5
• Preservation techniques (EMMM) provide better functional outcomes by maintaining the physiological functions of the inferior turbinate and preventing epiphora 4, 5

Special Considerations

• Proper patient selection is critical for success, particularly when using preservation techniques 5
• The attachment site of lesions (particularly for IPs) should be carefully evaluated preoperatively to determine the optimal surgical approach 5
• For lesions in challenging locations (anterolateral wall), specialized techniques like the transseptal approach can avoid the need for external procedures 1
• Surgeons should be experienced in advanced endoscopic techniques and comfortable with angled endoscopes and instrumentation 1

Comparison to Traditional Approaches

• EMM has largely replaced open approaches like Caldwell-Luc procedures, which were associated with longer hospitalization and recovery times 6
• The endoscopic approach provides better visualization, reduced morbidity, and comparable or better oncologic outcomes for benign sinonasal tumors 2
• For inflammatory conditions, EMM offers effective treatment even for cases that have failed previous conventional approaches 3