How To: Transseptal Approach to the Maxillary Sinus and Pterygopalatine Fossa

We begin by raising a “U”-shaped mucoperichondrial flap of the ipsilateral nasal floor and part of the inferior meatus mucosa that is extended medially to the nasal septum (Figure 1, A). The incision is extended superiorly along the nasal septum so that the mucosal flap can be pushed posteriorly. Next, an inferior turbinate resection is performed. On the contralateral side, an incision is made along the choana and brought forward through the nasal floor. The mucoperichondrial flap is elevated conventionally. No superior incision is made, leaving the flap superiorly attached. This mucoperichondrial flap is sutured to the lateral nasal wall at the level of the alar vestibule to hold it in place (Figure 1, B). The septal cartilage is then removed and kept in saline for the septal reconstruction (Figure 1, C). After this, we pass the scope through the transseptal approach to widely expose the posterior wall of the maxillary sinus (Figure 1, D). With this wide approach and enhanced visualization, we perform four-handed dissection and bilateral instrumentation to achieve en bloc resection of the tumor with straight instrumentation. After resection of the tumor, the “U”-shaped flap is repositioned along the nasal floor covering part of the medial maxillectomy defect. The septal cartilage is wrapped in Gelfoam and repositioned to aid in mucosal healing and prevent a postoperative septal perforation. The mucoperichondrial flap is repositioned and closed conventionally with 4–0 chromic sutures, and Doyle splints are placed to prevent adhesion formation and are removed two weeks postoperatively.

Results

Through this approach, the inverted papilloma was resected en bloc and the patient’s recovery was uneventful. Three months postoperative nasal endoscopy showed a well-healed septum with no residual septal deviation or septal perforation.

This transseptal technique allows a wide window exposure with enhanced visualization of the maxillary sinus, which enables a straight four-handed dissection and bilateral instrumentation, as well as clear visualization. Our instruments can reach more laterally compared to a unilateral approach, as evidenced by closeness to the proximal aspect of the infraorbital nerve within the maxillary sinus exhibited on intraoperative imaging. We demonstrate our septal repair, and postop nasal endoscopy five months after surgery reveals a well-healed straight nasal septum without septal perforation. The supporting video illustrates the key points of the operative technique used to remove the lesion and reconstruct the nasal septum.