Clinical Research On The Surgical Treatment Of Complex Maxillary Sinus Diseases By Pyriform Aperture Extend Prelacimal Recess Approach

objective:TO design a surgical method for the resection of complex lesions located in alveolar recess,zygomatic recess and anterior wall of maxillary sinus which is more minimally invasive than open surgery and more thorough than endoscopic surgery.Methods: 23 patients with complex lesions of maxillary sinus were evaluated by imaging before operation,and the lesions were confirmed to be located in the anterior wall of maxillary sinus,alveolar recess and zygomatic recess during operation.All patients underwent maxillary sinus surgery via piriform foramen enlargement of anterior lacrimal recess.The amount of bleeding during operation and regular follow-up were recorded,general examination,nasal endoscopy and sinus CT examination were performed,and MRI examination was performed as needed.The postoperative reactions and complications of each patient were observed and recorded: facial swelling,numbness and pain;pain,numbness and weakness of upper teeth on the diseased side;and complications such as nasal and facial scar,collapse and deformation,reduction of anterior nostril,overflowing of tears and so on.The intraoperative blood loss,postoperative reaction,complications and curative effect were counted and analyzed.Results: All the 23 patients of maxillary sinus lesion were successfully treated by piriforamen enlarged anterior lacrimal recess approachall.There were 12 cases of papilloma,according to the Krouse clinical stage,all the lesions were T3,according to the tumor root base of Tongren Hospital,11 cases of stage 3,1 case of stage 2,7 cases of recurrentpapilloma.There were 5 cases of maxillary sinus carcinoma,including 3cases of squamous cell carcinoma and 2 cases of adenoid cystic carcinoma.There were 2 cases of maxillary cyst,including 1 case of dental cyst and 1 case of nasopalatine cyst;There other's 1 case of moderate atypical hyperplasia,1 case of fibroangioma,1 case of neurilemmoma and 1 case of maxillary sinus osteoma.The bases of the lesions in 23 cases were located in the special part of the maxillary sinus or more widely.The approach to enlarge the anterior lacrimal recess through the piriform foramen can be handled very well.The lesions in various parts of the maxillary sinus can remove the inner wall,anterior wall,posterior outer wall,parietal wall and bottom wall of the maxillary sinus under direct vision,which ensures the thoroughness of the operation.The intraoperative bleeding was198.9ml±34.7ml.One case of maxillary sinus carcinoma injured the maxillary artery while dealing with the base of the tumor,resulting in turbulent bleeding.Because of the convenient approach,the bleeding was stopped quickly.All the operations were performed through the piriform foramen incision to avoid the injury of the labial gingival sulcus incision and the severe trauma of the nasal incision;7 patients had slight facial swelling and disappeared in 3 to 5days,and 8 patients had facial numbness.among them,there was no significant improvement in 3 cases of preoperative numbness,5 cases of postoperative numbness recovered or improved in 3 ~ 6 months after operation,and no complications such as nasal and facial scar,collapse and deformation,reduction of anterior nostril,tears overflow and toothache were found in 23 cases.Sometimes it is difficult to evaluate the lesion base by preoperative imaging,or it is found that the lesion base during the operation is inconsistent with the preoperative evaluation,and the step-by-step operation plan is followed,which effectively avoids the wrong enlargement of the operation,and 3 cases of lesions that cannotdetermine the nature of good or evil during the operation.by using this method,it is difficult to make decisions and medical risks caused by the difficulty of thorough minimally invasive surgery and severe injury caused by open surgery.The tissue structure and physiological function were protected while the lesions were completely removed.All cases were followed up to January 2020 and there was no recurrence.Conclusion: 1.Surgical indications for enlarged anterior lacrimal recess via piriform foramen:(1)it is difficult to completely remove the benign tumors of the maxillary sinus through the anterior lacrimal recess approach;(2)it is difficult to determine the benign and malignant tumors by pathological examination during the operation;(3)it is limited to the maxillary sinus or only breaks through the medial wall of the maxillary sinus.(4)the jaw cystic lesions of the cyst bone wall can not be completely removed by the anterior lacrimal recess approach.2.The operation of enlarging the anterior lacrimal recess through the piriform foramen can provide enough operation space to thoroughly remove the complex lesions of the maxillary sinus whose base is located in the anterior wall,alveolar recess,zygomatic recess and various parts.Third,the operation of expanding the anterior lacrimal recess through the piriform foramen minimizes the surgical incision,avoids the serious trauma of tissue structure,mild postoperative reaction and few complications.Fourth,the step-by-step operation plan can avoid the enlargement of the operation and resolve the confusion of the choice of operation and the risk of operation.