SPECIALTY TECHNIQUES

Prelacrimal approach to the maxillary sinus

David K. Morrissey, MBBS (Hons), FRACS1 , Peter-John Wormald, MD, FRACS2 and Alkis J. Psaltis, MBBS
(Hons), PhD, FRACS2


C 2015 ARS-AAOA, LLC.

Key Words:
paranasal sinuses; paranasal sinus disease; endoscopic sinus surgery; maxillectomy; sinus surgery

he maxillary sinus is perhaps the mostly commonly

approached sinus in endoscopic sinus surgery. It is the
largest of the paranasal sinuses and is located within the
body of the maxilla. Taking the form of a 3-sided pyramid, it has anterolateral, posterior, and medial walls and
an apex extending into the zygomatic process of the maxilla. The roof is formed by the floor of the orbit, across
which traverses the infraorbital branch of the maxillary
nerve. The floor of the sinus is formed by the alveolar
and palatine processes of the maxilla. Located superiorly
on the medial wall of the maxillary sinus, the natural
ostium opens into the ethmoid infundibulum. In this region the wall of the maxillary sinus is thin and partially
membranous which may permit the formation of accessory
ostia.1
The unique anatomy of the maxillary sinus provides even
the experienced sinus surgeon with challenges in accessing all walls of the sinus.2, 3 Historically the sinus was approached via the Caldwell-Luc approach popularized over
100 years ago.4, 5 In recent times the importance of the
natural ostium of the sinus, coupled with enhancements in
equipment and visualization, has led to approaches including uncinectomy, maxillary antrostomy, and endoscopic
medial maxillectomy, which all incorporate the natural ostium into the new opening. Despite these advances, there
1 School

of Medicine, The University of Queensland, Brisbane, Australia;

of SurgeryOtorhinolaryngology, Head and Neck Surgery
University of Adelaide, Adelaide Australia

2 Department

Correspondence to: Peter-John Wormald, MD, FRACS, Department of

SurgeryOtorhinolaryngology, Head and Neck Surgery, The Queen
Elizabeth Hospital, 28 Woodville Rd, Woodville, SA 5011, Australia; e-mail:
peterj.wormald@adelaide.edu.au
Additional Supporting Information may be found in the online version of
this article.
Potential conflict of interest: P.J.W. receives royalties from Medtronic ENT
Integra and Scopis and is a consultant for Neilmed.
Received: 27 March 2015; Revised: 11 July 2015; Accepted: 4 August 2015
DOI: 10.1002/alr.21640
View this article online at wileyonlinelibrary.com.

How to Cite this Article:

Morrissey DK, Wormald PJ, Psaltis AJ. Prelacrimal approach to the maxillary sinus. Int Forum Allergy Rhinol.
2016;6:214218.

are still regions of the maxillary sinus that remain technically difficult to access in order to manage benign and
malignant disease of the maxillary sinus, pterygopalatine
fossa, and infratemporal fossa.
We elaborate on the prelacrimal approach to the maxillary sinus originally described by Zhou et al.6 Approaches
such as middle meatal antrostomy, mega-antrostomy, and
endoscopic medial maxillectomy are limited in their utility
because in many cases the surgeon can experience difficulty
in visualizing and accessing the anterior and anterolateral
walls of the maxillary sinus. The prelacrimal recess can
be an area of particular difficulty. The advantages of
utilizing a prelacrimal approach include the provision of wide access to all walls of the maxillary sinus
while still preserving the nasolacrimal duct and inferior
turbinate (Fig. 1). This approach to the maxillary sinus
also incorporates the prelacrimal recess, negating the
aforementioned difficulties and is particularly useful in
addressing pathology of the anterior wall of the maxillary
sinus (Fig. 2). It is also a useful aid when lateral access
to the pterygopalatine fossa or infratemporal fossa is
needed.
In our version of this procedure we emphasize the
importance of an uncinectomy and middle meatal antrostomy as well as removal of bone from the margin of the
piriform aperture in all cases. We feel that the addition of
the uncinectomy and wide middle meatal antrostomy facilitates improved surveillance of the maxillary sinus in the
postoperative period via the use of angled or flexible endoscopes. Removal of bone at the margin of the piriform
aperture permits improved access to the prelacrimal recess
and facilitates visualization of the anterior maxillary sinus
wall.
Beyond the standard complications of endoscopic
sinus surgery, potential complications of the prelacrimal
approach include damage to the nasolacrimal apparatus, nasal dryness, and facial numbness. The removal of
soft tissue attachments to the piriform aperture has been

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Prelacrimal approach to the maxillary sinus

FIGURE 1. The access available with the prelacrimal approach. The highlighted region indicates the potential operative field visualized with a
0-degree rigid endoscope.

FIGURE 2. The access window created through the prelacrimal recess into
the maxillary sinus via the prelacrimal approach. The nasolacrimal duct can
be seen to the left side of the image orientated vertically (1). To the right
of the nasolacrimal duct is the mucosa of the medial wall of the maxillary
sinus (2), and further to the right side of the image the anterior wall of the
maxillary sinus (3) can be identified.

proposed to potentially lead to collapse of the external

nasal valve and possibly cosmetic changes to the nasal
alar. Our experience has been that these specific complications are rare and in particular that the potential cosmetic and functional deficits have not been noted by our
unit.

Procedure
This procedure is conducted under a general anesthetic. The
nose is initially prepared via injection of local anesthetic
with adrenaline to the nasal septum, inferior turbinate,
and lateral nasal wall adjacent and anterior to the inferior turbinate. Topical vasoconstrictor is also applied via
neuropatties to the mucosa within the surgical field. The
procedure is shown in Supporting Video 1.

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FIGURE 3. The incision for the prelacrimal approach can be seen along
the superior edge of the inferior turbinate turning inferiorly at the anterior
head.

FIGURE 4. The mucosa is reflected down exposing the anterior bone of

the inferior turbinate and the ridge (black arrow) of the piriform aperture
where the osteotomies will be performed.

Initially an uncinectomy and middle meatal antrostomy

is performed, facilitating wide opening of the maxillary
sinus.7 An incision is then made on the lateral nasal wall
beginning at the anterior edge of the antrostomy onto
the frontal process of the maxilla (Fig. 3). This incision
is above the level of the inferior turbinate and should be
carried forward to a point anterior to the anterior end
of the inferior turbinate, where it turns inferiorly running down to the piriform aperture. The incision should
be carried down to the bone. The mucoperiosteum can
then be elevated via a suction Freer elevator with relative ease. Elevation of this mucosa is carried down onto
the medial surface of the inferior turbinate to visualize
the entire bony extent of the anterior inferior turbinate
and its attachment to the lateral nasal wall anteriorly
(Fig. 4).

Morrissey et al.

FIGURE 5. The osteotomies are placed such that 2 to 3 mm of bone at the

edge of the piriform aperture is removed.

FIGURE 6. The bone is removed exposing the mucosa of the maxillary

sinus anterior to the nasolacrimal duct.

FIGURE 8. The final osteotomies are performed in the posterior bony nasolacrimal duct.

FIGURE 9. The entire maxillary sinus can now be accessed while keeping
the nasolacrimal duct intact.

FIGURE 7. The nasolacrimal duct is retracted out of the bony nasolacrimal

duct, allowing the bone forming the posterior wall of the nasolacrimal duct
to be exposed.

FIGURE 10. The mucosa is repositioned and a dissolvable suture placed

to hold the mucosa in place during healing.

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The osteotomies begin at the piriform aperture with

an angled osteotomy across the aperture followed by a
vertical osteotomy, removing about 3 mm of the aperture
before another horizontal osteotomy at the level of the maxillary ostium (Fig. 5). This osteotomy is carried posterior
until the nasolacrimal duct is exposed (Fig. 6). The duct
is mobilized so that the posterior bone of the duct can be
visualized (Fig. 7) and an osteotomy performed (Fig. 8).
This allows removal of the bone of the head of the inferior turbinate and the bone around the nasolacrimal duct,
giving an anterior access around the nasolacrimal duct into
the maxillary sinus. It is important to recognize that the
anterior triangle of bone forming the piriform aperture is
removed for about 3 mm along the anterior face of the
maxilla and then the direction of dissection through the
bone with the chisel is in a posterior direction toward the
nasolacrimal duct (Fig. 5). It is quite easy for the surgeon
to become disorientated and inadvertently dissect farther
onto the cheek along the anterior face of the maxilla than
the 3 mm required. Further marginal bone removal as required around the aperture is completed with a Hajek Koeffler punch. Access has now been obtained to all walls
of the maxillary sinus and a clean line of sight is available to access laterally into the infratemporal fossa should
that be necessary (Fig. 9). At the conclusion of the procedure, the inferior turbinate is repositioned and the incision
sutured with 1 or more absorbable sutures (Fig. 10). No
packing is used within the nose following the procedure.
The surgical steps in a patient with inverted papilloma of
the anterior wall of the maxillary sinus are illustrated in
Figure 11.
Following the operation, the patient is managed with
simple analgesia and a 5-day to 10-day course of broadspectrum antibiotics. Nasal saline douches are commenced
on day 1 and are typically performed 4 times a day. The
patient is reviewed in the clinic at 2 and 6 weeks after the
operation, in most cases, unless the pathology dictates a
different approach.

Conclusion
The prelacrimal approach to the maxillary sinus provides
the rhinologist with a technique that allows access to all
aspects of the maxillary sinus while preserving the inferior
turbinate and nasolacrimal duct. The addition of a wide
maxillary antrostomy aids postoperative surveillance and
the penetration of topical medications into the maxillary
sinus.
FIGURE 11. (A-E) This patient presented with an inverted papilloma situated at the lateral aspect of the anterior wall of the maxillary sinus as seen
on these coronal and axial images (A, B). (C) Shows the access available to
the lesion via a prelacrimal approach. The inverted papilloma (1) can be visualized arising from the anterior wall of the maxillary sinus (2). The infraorbital
nerve can be seen traversing the roof of the sinus (*). (D) Shows the surgeon
operating a drill over the site of new bone formation at the base of the
papilloma on the anterior wall of the maxillary sinus, whereas (E) shows the
end result with complete macroscopic clearance of the disease. Monopolar
diathermy has been used for hemostasis over the site of bony drilling.

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Acknowledgments
Medical illustrations provided by Mr. Nicholas Wormald
with thanks.

Morrissey et al.

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