Is the Canine Fossa Puncture Approach Really Necessary for the Severely Diseased Maxillary Sinus during Endoscopic Sinus Surgery?

Abstract

To evaluate the necessity of canine fossa puncture (CFP) by comparing the symptom scores and postoperative computed tomography (CT) findings between patients with severe maxillary sinus disease who underwent CFP and those who underwent maxillary sinus clearance through a middle meatal antrostomy (MMA). A prospective, randomized study. Fourteen patients met the inclusion criteria for each of the CFP and MMA groups. In both groups, all diseased sinuses were addressed in the same manner using the same surgical techniques; the only difference was management of the maxillary sinus. Most of the patients completed the Sinonasal Outcome Test 20 (SNOT-20) and visual analogue scales (VAS) for the six main symptoms preoperatively and 3, 6, and 12 months postoperatively. The Lund-Mackay scores for the maxillary sinus and for all sinuses were calculated from the preoperative CT scan and another scan taken 12 months postoperatively. The mucosal thickening as a percentage of the total volume of the maxillary sinus was also evaluated on the postoperative CT scans, and complications related to both procedures were investigated. Twenty-four patients completed the follow-up, questionnaires, and postoperative CT scans and were included in the analysis: 11 CFP patients and 13 MMA patients. All of the patients had chronic rhinosinusitis with nasal polyposis (NP). There were no significantdifferences in polyp extent or Lund-Mackay score for the maxillary sinus and for all sinuses on the pre- and postoperative CT scans between the groups. The volume of mucosal thickening also did not differ significantly between the groups on the postoperative CT scans. The SNOT-20 and VAS scores improved significantly 3, 6, and 12 months after the procedure in both groups. However, there were no significant differences between the two groups except for the VAS for postnasal drip 3 months postoperatively, which was better in the CFP group. Six of 11 patients in the CFP group experienced one or more complications after the procedure, although all of the symptoms resolved spontaneously within 3 months. In the MMA group, three patients had bleeding from the branches of the sphenopalatine artery during widening of the ostium, which was controlled intraoperatively with suction cauterization. We could not find any benefits of the CFP procedure over the conventional MMA method in the present study. Although CFP is a useful method for removing severe mucosal disease that cannot be reached through the MMA, it does not guarantee a better subjective or objective surgical outcome in patients who have accompanying NP.