The Prelacrimal Recess Approach: A Review of Surgical Applications, Outcomes, and Recent Advances

Yeon Hee Im; Soo Whan Kim; Chan-Soon Park; Dong-Hyun Kim

doi:10.18787/jr.2024.00041

J Rhinol > Volume 32(1); 2025

Im, Kim, Park, and Kim: The Prelacrimal Recess Approach: A Review of Surgical Applications, Outcomes, and Recent Advances

Review

Journal of Rhinology 2025;32(1):17-27.

Published online: March 21, 2025

DOI: https://doi.org/10.18787/jr.2024.00041

The Prelacrimal Recess Approach: A Review of Surgical Applications, Outcomes, and Recent Advances

Yeon Hee Im, MD¹

, Soo Whan Kim, MD, PhD²

, Chan-Soon Park, MD, PhD³

, Dong-Hyun Kim, MD, PhD⁴

¹Department of Otorhinolaryngology-Head and Neck Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea

²Department of Otorhinolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

³Department of Otorhinolaryngology-Head and Neck Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea

⁴Department of Otorhinolaryngology-Head and Neck Surgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea

Address for correspondence: Yeon Hee Im, MD, Department of Otorhinolaryngology-Head and Neck Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 271 Cheonbo-ro, Uijeongbu 11765, Republic of Korea
Tel: +82-31-820-5267, Fax: +82-31-820-5267, E-mail: younheeim@naver.com

Received November 26, 2024 Revised January 19, 2025 Accepted February 3, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The prelacrimal recess approach (PLRA) has advanced endoscopic sinonasal surgery by providing improved access to the maxillary sinus and adjacent anatomical regions while preserving critical structures such as the inferior turbinate (IT) and nasolacrimal duct (NLD). First introduced in 2013, the PLRA has become an important technique for addressing various sinonasal pathologies. This review comprehensively evaluates the advancements, applications, and outcomes associated with the PLRA. The PLRA enables superior visualization and access to regions that are traditionally difficult to reach with conventional techniques. Standardized surgical steps emphasize meticulous preservation of the NLD and IT, while technical modifications have broadened its feasibility in patients with narrow prelacrimal recesses. Applications of the PLRA span diverse pathologies, including sinonasal inverted papilloma, fungal infections, odontogenic cysts, and tumors of the lacrimal system, orbit, and skull base. Anatomical studies reveal significant variations in prelacrimal recess dimensions across populations, affecting surgical feasibility. Sex-specific differences, ethnic variations, and age-related factors are important in patient selection. Clinical outcomes from multiple investigations validate the PLRA’s efficacy in maintaining sinonasal function while achieving comprehensive lesion removal. Comparative analyses with traditional approaches underscore the PLRA’s advantages in reducing postoperative morbidity and recurrence rates. Integration of the PLRA with complementary surgical approaches further expands its therapeutic applications while maintaining favorable safety profiles. The PLRA is a safe and effective surgical method that offers favorable outcomes in disease management, symptom resolution, and anatomical preservation. With ongoing innovations and refinements, the PLRA is poised to remain a cornerstone of minimally invasive sinonasal surgery, enabling the precise and safe treatment of complex pathologies.

KEY WORDS: Prelacrimal recess approach; Endoscopic sinus surgery; Paranasal sinuses; Nasolacrimal duct

INTRODUCTION

The surgical management of the maxillary sinus and adjacent anatomical structures has evolved significantly with advances in endoscopic techniques. Among these innovations, the prelacrimal recess approach (PLRA), first described by Zhou et al. [1] in 2013, represents a pivotal development in endoscopic sinonasal surgery. This technique preserves the nasolacrimal duct (NLD) through careful dissection of the prelacrimal recess (PLR) and overcomes the limitations of traditional methods such as the Caldwell-Luc approach (CLA) and endoscopic medial maxillectomy (EMM). Unlike CLA and EMM, the PLRA provides access to all regions of the maxillary sinus while preserving the inferior turbinate (IT) and the anterior wall of the maxillary sinus. This preservation maintains nasal physiologic functions, including humidity and temperature regulation and mucociliary clearance, while avoiding complications associated with canine fossa puncture [1].

The PLRA also offers superior visualization and access to areas that are challenging to reach via conventional endoscopic techniques such as middle meatal antrostomy or inferior meatal antrostomy. This technique has proven particularly effective for lesions in the anterior, inferior, and lateral aspects of the maxillary sinus, while simultaneously providing access to deeper structures including the pterygopalatine fossa, infratemporal fossa, orbital floor, and skull base regions [2-4].

This comprehensive review examines the current scientific literature on the PLRA, including modifications in surgical methodology, its diverse clinical applications across various pathological conditions, and outcome comparisons with conventional surgical approaches.

SURGICAL TECHNIQUES

The PLRA requires meticulous attention to surgical technique and anatomical landmarks. Since its initial description by Zhou et al. [1], multiple technical refinements and procedural modifications have improved both its safety profile and efficacy. The surgical procedure for the PLRA is depicted schematically in Fig. 1.

Standard surgical steps

The procedure begins with the administration of a 1% lidocaine solution containing 1:100,000 epinephrine, followed by a precise incision along the lateral nasal wall anterior to the IT, extending downward from its attachment to the nasal floor. Elevation of the mucoperiosteal flap exposes the pyriform aperture. An osteotomy of the medial wall of the PLR is then performed with careful preservation of the NLD. The IT-NLD flap is created and retracted medially, ultimately exposing the maxillary sinus cavity [1].

The procedure concludes with the precise reconstruction of the surgical corridor. The mucoperiosteal flap is repositioned and secured, with particular attention to maintaining the anatomical positions of the NLD and IT to promote optimal healing and avoid postoperative crusting and adhesions [5].

Technical variations

Research by Tran et al. [6] demonstrated a refined approach for cases with a narrow PLR, in which controlled thinning of the anterior medial NLD bony canal surface with a diamond burr, followed by removal of the thinned bony canal, enables NLD preservation. For patients lacking suitable PLR anatomy, an alternative method involves separating the NLD from its bony canal using a 1-mm Kerrison punch [7]. Vinciguerra et al. [8] proposed an enhanced technique that involves complete circumferential (360°) removal of the bone surrounding the NLD combined with a comprehensive prelacrimal window removal and medial NLD transposition, which maximizes maxillary sinus exposure. Their findings indicated that this modification increased the feasibility of the PLRA without elevating the risk of epiphora.

Special considerations

Mucosal incisions should be made anterior to the osteotomy line to avoid creating an unintended fistula between the nasal cavity and the maxillary sinus [9]. To optimize postoperative healing, the use of cold instruments such as a sickle knife rather than electrosurgical devices is preferred for mucosal incisions [10].

During the osteotomy, employing a chisel instead of drills can help prevent thermal injury and promote improved healing [10]. When extending the osteotomy to include the pyriform aperture and anterior maxillary sinus wall, at least 5 mm of the inferior portion should be preserved to prevent nasal ala retraction and injury to the anterior superior alveolar nerve (ASAN) [11]. Kashlan and Craig [12] reported that the PLR width at the inferior level was significantly wider—averaging 8.4 mm—compared to the middle (7.6 mm) and superior (6.5 mm) levels. These findings support initiating medial wall access from the inferior aspect during PLRA procedures. For facilitating postoperative endoscopic surveillance and maintaining sinonasal drainage, several authors recommend routinely combining the procedure with a middle meatal antrostomy [10,13].

SUITABLE PATHOLOGIES FOR THE PRELACRIMAL RECESS APPROACH

The capacity of PLRA to maintain anatomical integrity while providing extensive exposure has established it as a valuable approach for addressing a range of anatomical regions and pathological conditions.

Lesions in the lacrimal system and orbit

The PLRA has proven feasible in managing pathologies of the lacrimal system and orbital structures. One documented case reported the complete excision of lacrimal sac squamous cell carcinoma using the PLRA in conjunction with an external approach [14]. For orbital lesions, Li et al. [3,15] confirmed the feasibility of accessing the inferior intraconal space and orbital floor via this corridor, thus broadening its application to orbital pathologies. A recent cadaveric study further confirmed that all critical structures within the infraorbital region can be visualized and accessed through the orbital floor using the PLRA without compromising the optic nerve; however, the authors cautioned against using this approach for lesions located superior to the optic nerve [16].

Lesions in the maxillary sinus

The maxillary sinus is the primary target for the PLRA, with applications encompassing various pathologies. Reports on PLRA applications primarily involve sinonasal inverted papilloma, along with other conditions such as neoplasms, rhinosinusitis, antrochoanal polyps, odontogenic cysts, fungal balls, and foreign bodies [5,6,8,17-22]. This approach enables comprehensive visualization of the maxillary sinus using a 0º rigid endoscope, which is particularly beneficial for managing lesions in the lateral or anterior regions of the maxillary sinus or alveolar recess—areas typically difficult to address with standard endoscopic sinus surgery (ESS) techniques such as middle meatal antrostomy and inferior meatal antrostomy [1,8,23].

Lin et al. [24] proposed a strategy for selecting appropriate surgical procedures based on the specific characteristics of unilateral maxillary sinus disease. For uncomplicated inflammation, such as sinusitis or fungal sinusitis without polyps or allergic mucin, they recommended middle meatal antrostomy as sufficient treatment. However, for more complex cases involving diffuse polyposis, allergic mucin, or tumors affecting the alveolar or PLRs, they advocated for the use of the CLA, PLRA, or maxillectomy.

Lesions in the lateral sphenoid recess

Li et al. [25] demonstrated the technical viability of the PLRA for accessing lateral sphenoid sinus recesses, even in cases of significant lateral pneumatization, while preserving the vidian nerve and pterygopalatine ganglion. Additional research by Ahmadzada et al. [26] documented successful reconstruction of lesions—including encephalocele, meningocele, and meningoencephalocele—within the lateral sphenoid recess using the PLRA, noting only transient V2 paresthesia as a postoperative complication.

Lesions in the pterygopalatine fossa and infratemporal fossa

The PLRA has expanded access to the pterygopalatine and infratemporal fossae, regions that have traditionally been challenging to approach. Zhou et al. [27] documented positive outcomes in managing schwannomas in these areas, achieving successful results without necessitating sphenopalatine and vidian arterial ligation or vidian nerve resection. Cadaveric studies have also shown that the PLRA provides access to the pterygopalatine fossa and infratemporal fossa, exposing regions such as the Eustachian tube area, the petrous apex, the upper pharyngeal space, the temporomandibular joint, and the temporalis muscle [2,28]. Further research indicates that the PLRA provides approximately 9.55 cm² of exposure of the posterior maxillary sinus wall—a measurement comparable to that achieved with the CLA—underscoring its utility in managing lesions in these areas [29]. Reported clinical cases include the successful removal of a pterygopalatine fossa schwannoma in a 6-year-old pediatric patient without postoperative complications using the PLRA [30] and the excision of extensive tumor masses in the anterolateral infratemporal fossa using a combination of the PLRA and vestibular sulcus incision techniques [31].

Skull base lesions

Applying the PLRA to skull base lesions represents a significant advancement in minimally invasive skull base surgery. Li et al. [32] conducted a cadaveric study to analyze the feasibility of accessing the middle cranial fossa through the anterolateral triangle corridor using the PLRA. Their research demonstrated successful exposure of middle cranial fossa structures—including critical landmarks such as the middle meningeal artery, greater superficial petrosal nerve, superior petrous sinus, and arcuate eminence—while maintaining the structural integrity of the vidian nerve, greater palatine nerve, lateral nasal wall, and NLD across all specimens.

COMBINED APPROACHES

When the PLRA is performed as a standalone procedure, postoperative endoscopic examination of the maxillary sinus can be challenging. To address this limitation and ensure adequate drainage between the maxillary sinus and nasal cavity, surgeons frequently incorporate a middle meatal antrostomy during the primary procedure [23]. Khong et al. [33] improved access to challenging regions such as the alveolar recess, zygomatic recess, and orbital floor during PLRA by employing 45º forceps inserted through a trans-septal window.

Lee et al. [34] introduced a two-port technique that combined the PLRA with the CLA to effectively manage tumors in the infratemporal fossa. Similarly, Cao et al. [35] described a case in which a schwannoma in the infratemporal fossa was successfully removed by integrating the PLRA, CLA, and a distal intraoral approach. These combined approaches allowed for separate insertion paths for the endoscope and surgical instruments, thereby creating a clearer surgical field and improving instrument maneuverability [34,35].

Shi et al. [36] reported positive outcomes in treating malignant tumors of the lacrimal drainage system by combining the PLRA with a minor external incision along the inferior medial eyelid for en bloc resection in 12 patients. Wu et al. [37] further demonstrated that, for trigeminal schwannomas, a strategic combination of approaches—including the PLRA, translamina papyracea approach, trans-Meckel’s cave approach, and transclival approach—tailored to the tumor’s size and location enabled successful tumor removal using endonasal techniques alone.

Integrating the PLRA with other surgical techniques has expanded the scope of minimally invasive sinonasal surgery, particularly for complex and extensive lesions. Understanding the advantages and limitations of each combined approach is crucial for optimal surgical planning and outcomes.

POSTOPERATIVE COMPLICATIONS

Although the PLRA is generally safe and effective, careful attention must be paid to potential complications and their management. In addition to the complications associated with traditional ESS, those specific to the PLRA include injury to the NLD, nasal mucosal dryness, and facial paresthesia [13].

A systematic review and meta-analysis conducted by Machado et al. [23] identified several postoperative morbidities associated with the PLRA. Reported complications included epiphora in 0.56% of cases, dry nose in 0.32%, epistaxis or infections requiring intervention in 0.63%, and facial or gingival numbness in 12.11% of cases. In addition, postoperative synechiae formation has been reported at rates ranging from 5% to 25%, while temporary facial swelling has been observed in approximately 10% of cases [10,20,38,39].

Long-term or persistent facial numbness following the PLRA has been reported in 2.5% to 52.4% of cases [10,18,20,40,41]. The meta-analysis conducted by Machado et al. [23] revealed that among patients experiencing postoperative numbness, 73.5% reported temporary symptoms that resolved within six months, while 26.5% experienced persistent symptoms. Facial or gingival numbness may result from injury to the ASAN or from manipulation of the surrounding bone or soft tissue [41].

In rare instances, mild alar collapse may occur due to an incision placed too close to the nostril or as a consequence of excessive suction or drilling, which can damage soft tissues and lead to contracture [42]. Intraoperative injury to branches of the lateral nasal artery may cause bleeding that compromises visibility during the procedure. Surgeons should carefully manage intraoperative bleeding and use intranasal packing at the conclusion of the procedure to maintain visibility and minimize blood loss [23].

PREDICTIVE FACTORS FOR THE FEASIBILITY OF PLRA

Understanding the limiting factors of the PLRA is crucial for appropriate patient selection and surgical planning. Recent anatomical studies have provided significant insights into the factors influencing the feasibility of this approach, particularly the width of the PLR.

The width and anatomical configuration of the PLR play crucial roles in surgical accessibility. Simmen et al. [43] classified the PLR into three types based on its width: type I (0–3 mm), type II (>3–7 mm), and type III (>7 mm). They found that the PLRA is most feasible in type III cases (12.5%), whereas type II cases (56.5%) typically require dislocation of the lacrimal sac, and type I cases (31.5%) are the least feasible, often necessitating additional bone work along with lacrimal sac dislocation. However, Tran et al. [6] demonstrated that even in type I cases the PLRA can be performed safely without damaging the NLD by meticulously thinning and removing the bony canal with a diamond burr.

A retrospective review of computed tomography (CT) scans from 150 patients revealed that individuals with hyperplastic maxillary sinuses had significantly greater PLR width and pyriform aperture angle, which decreased with age. In type III cases, the medial wall of the PLR was thinner, and the pyriform aperture angle, maxillary sinus volume, and the angle between the NLD and the hard palate were significantly larger than in type I and II cases [44]. Similarly, Duman and Gumussoy [45] found that maxillary sinus hypoplasia was associated with a shorter PLR width (3.11 mm) compared to normal sinuses (4.77 mm), as observed on cone-beam CT. Additionally, a recent study demonstrated that a well-pneumatized maxillary sinus correlates with a wider PLR [46].

Andrianakis et al. [47] suggested that an antero-medial maxillary sinus angle wider than 70° limits visibility and access, highlighting the maxillary sinus angle as an additional factor influencing PLRA feasibility. Conversely, Arosio et al. [10] reported that patients with postoperative maxillary paresthesia had narrower pyriform notch angles, indicating that a narrower angle may require more extensive bone removal, potentially affecting the ASAN. Further research by Koo and Lee [48] revealed that Asian patients with reduced posterior angulation of the anterior maxillary walls relative to the coronal plane typically exhibited increased PLR dimensions, indicating enhanced PLRA feasibility. They proposed that a lower frequency of Simmen type I cases among Asian populations compared to Western cohorts may reflect characteristic Asian craniofacial morphology, specifically shorter, flatter cranial configurations that result in reduced anterior maxillary wall angulation.

Sex-specific anatomical variations also significantly influence procedural feasibility. Andrianakis et al. [49] documented substantial differences in surgical accessibility between male and female patients, with female subjects demonstrating notably reduced PLR dimensions and requiring increased bone work and NLD mobilization to achieve adequate access. Analysis of adult cone-beam CT imaging revealed PLR presence in 81.5% of the maxillary sinuses, without significant gender-based prevalence differences. However, PLR prevalence declined in subjects under 55 years and increased in those over 55 years [50]. Male subjects also exhibited significantly greater medial PLR wall thickness compared to females, with wall thickness inversely correlating with PLR width measurements [51].

Ethnic variations in anterior maxillary wall anatomy have also emerged as an important consideration. These findings build upon research by Lock et al. [52], who documented the distributions of Simmen classifications in Asian populations (type I: 39.5%, type II: 53.5%, type III: 39.5%), indicating a higher feasibility rate for the PLRA compared to that reported by Simmen et al. [43].

The management of pediatric cases requires special consideration, as highlighted by Yaylacı and Alparslan’s analysis [53] of anatomical relationships in the pediatric population. They noted that 45.9% of children under 18 years had a PLR width exceeding 3 mm, rendering them suitable for the PLRA. Male pediatric subjects demonstrated a significantly greater PLR width (3.10±2.55 mm) compared to females (2.48±2.26 mm). Their findings established a 55% feasibility rate in the 9- to 17-year age group, leading them to recommend nine years as the cut-off age for PLRA feasibility.

The presence of specific pathological conditions may also contraindicate the approach. Lesions involving the medial maxillary sinus wall or the NLD may preclude the use of the PLRA, and alternative approaches should be considered, particularly for tumorous lesions [20,33].

Understanding these limiting factors is essential for achieving optimal surgical outcomes. Careful preoperative evaluation of anatomical parameters, consideration of patient-specific factors, and recognition of technical limitations allow for appropriate patient selection and necessary modifications to the surgical approach.

OUTCOMES AND EVIDENCE-BASED RESULTS

In a retrospective study of 40 patients undergoing the PLRA for maxillary sinus lesions, complete restoration of the lateral nasal wall was achieved in all cases. Minor complications, including temporary and permanent paresthesia (10% and 2.5%, respectively), supported the technique’s favorable risk-benefit profile [20]. Analysis of 12 recurrent antrochoanal polyp cases managed via the PLRA revealed that, despite NLD compromise in two instances, epiphora did not develop and no recurrences occurred during follow-up periods ranging from 8 to 21 months [38]. Further evidence of PLRA efficacy emerged from significant improvements in Sino-Nasal Outcome Test-22 scores among 25 patients (13 with antrochoanal polyps, 10 with maxillary sinus fungal balls, and 2 with migrated teeth) following surgical intervention [5].

Suzuki et al. [18] investigated 51 cases of the maxillary sinus inverted papilloma managed through a modified EMM via the PLRA, preserving the IT and NLD. Recurrence was documented in only one patient during follow-up periods ranging from 2 to 138 months. Complications such as epiphora, nasal dryness, persistent crusting, or external nasal deformities were not observed, although seven patients experienced temporary numbness that resolved within approximately one year. Zhou et al. [19] conducted a multicenter study of 71 patients undergoing the PLRA for inverted papilloma, reporting a recurrence rate of 7.04% and mild complications such as perinasal numbness (7.04%) and nasal alar retraction (5.63%) during follow-up periods ranging from 13 to 134 months. Yu et al. [22] analyzed 20 cases of the maxillary sinus inverted papilloma managed via the PLRA and documented a single recurrence, with no patients reporting postoperative complications. The retrospective review conducted by Hildenbrand et al. [41] of 17 PLRA procedures for maxillary sinus inverted papilloma revealed no significant complications or recurrences during a median follow-up period of 45.9 months, although four patients experienced postoperative hypoesthesia, with resolution in one case.

Kim et al. [42] conducted a systematic review and meta-analysis investigating the effectiveness of the PLRA in managing maxillary sinus inverted papilloma and documented recurrence, postoperative facial numbness, and alar collapse rates of 3.13%, 9.02%, and 3.39%, respectively. In a recent 15-year investigation, Liang et al. [54] demonstrated a 3.28% recurrence rate during follow-up periods ranging from 13 to 192 months for maxillary sinus inverted papilloma cases following PLRA intervention. While 23.77% of patients experienced postoperative facial paresthesia, symptoms typically resolved within one year. Additionally, visual analog scale nasal symptom scores showed significant postoperative improvement.

An analysis categorizing maxillary sinus pathologies and comparing postoperative symptom modifications revealed significant improvements in Sino-Nasal Outcomes Test-22 and visual analog scale scores among non-papilloma cases. In contrast, patients with sinonasal inverted papilloma demonstrated improvement that did not reach statistical significance and exhibited higher rates of transient numbness postoperatively [40].

Cumulative evidence supports the PLRA as a reliable and effective surgical methodology, demonstrating favorable outcomes in disease control, functional preservation, and postoperative morbidity management. Table 1 summarizes studies documenting the efficacy and safety of the PLRA.

COMPARATIVE ANALYSIS WITH OTHER APPROACHES

The clinical utility of the PLRA is further elucidated by systematic comparisons with traditional surgical techniques. Recent comparative studies have highlighted the relative advantages and limitations of the PLRA compared to conventional methods, particularly the CLA and EMM.

Although the CLA and Denker’s approaches provide extensive access to the maxillary sinus, they are associated with higher postoperative morbidity risks, including persistent facial numbness, cheek discomfort, and edema [22,55]. In contrast, the PLRA achieves comprehensive maxillary sinus exposure while preserving the integrity of the IT and NLD and avoiding injury to the anterior maxillary wall structures, canine fossa periosteum, and infraorbital nerve [22,34]. However, the PLRA does present specific considerations, including direct NLD exposure with potential injury risk and possible facial paresthesia resulting from ASAN compromise [38,41].

A retrospective analysis of the maxillary sinus inverted papilloma management revealed that during an average follow-up period of 46 months, recurrence occurred in 3 of 18 patients treated with conventional procedures (maxillary sinus antrostomy or CLA), whereas no recurrences were observed among 27 patients treated with the PLRA. Kaplan-Meier analysis confirmed significantly higher recurrence rates in the conventional treatment groups compared to the PLRA cohorts [17]. The systematic review and meta-analysis conducted by Kim et al. [42] demonstrated significantly reduced recurrence rates for patients undergoing the PLRA compared to those treated with conventional approaches (EMM, ESS, and CLA), although complication rates—including facial paresthesia, epistaxis, and periorbital edema—did not differ significantly.

The comprehensive comparison of surgical morbidity conducted by Vinciguerra et al. [56] between the PLRA and EMM in cases of the maxillary sinus inverted papilloma revealed significantly reduced postoperative pain and lower rates of epistaxis, infections requiring intervention, and epiphora with the PLRA. However, rates of ASAN-related numbness and recurrence of inverted papilloma remained comparable between the two approaches.

Lee et al. [34] compared the PLRA and traditional CLA for benign maxillary sinus tumors (including inverted papilloma, ameloblastoma, and ossifying fibroma) and documented no recurrences in either group during an average follow-up period of 13 months. While postoperative cheek numbness occurred with similar frequency in both groups, its duration was significantly shorter in PLRA cases compared to those managed by CLA.

A recent comparative investigation by Kondo et al. [57] examining endoscopic modified medial maxillectomy versus the PLRA for maxillary sinus neoplasia management revealed no significant differences in postoperative morbidity rates—including facial paresthesia, maxillary sinus dysfunction, and adhesions requiring surgical intervention—suggesting comparable safety profiles between the approaches. A prospective analysis of antrochoanal polyp management comparing middle meatal antrostomy and PLRA groups during a one-year postoperative follow-up demonstrated equivalent complication rates but significantly different recurrence rates (50% versus 8%, respectively) [39].

A recently published systematic review and meta-analysis comparing the PLRA with traditional approaches (EMM, CLA, and ESS) for maxillary sinus pathologies demonstrated significantly lower lesion recurrence rates following the PLRA, while rates of epiphora, paresthesia, epistaxis, and infection remained comparable [23].

Comparative studies focusing on access to the pterygopalatine and infratemporal fossae have also emerged. A cadaveric investigation comparing the PLRA with Denker’s approach for access to the pterygopalatine and inferior temporal fossae demonstrated comparable visualization capabilities; however, the area permitting unrestricted surgical instrument manipulation was significantly greater with Denker’s approach [4].

A cadaveric comparison of the PLRA with transethmoid approaches for access to the medial intraconal space revealed that the transethmoid approach was superior for visualizing regions superior to the medial rectus muscle. Both approaches provided effective exposure inferior to the superior border of the medial rectus muscle. Notably, the PLRA enabled adequate visualization of the posterior region at this level without necessitating transection of the medial rectus muscle [58]. Table 2 summarizes the results of comparative studies illustrating the efficacy and safety of the PLRA relative to other surgical techniques [17,22,34,39,56,57,59], and Table 3 outlines the benefits and limitations of the CLA, EMM, and PLRA.

CONCLUSION

The PLRA represents a significant advancement in endoscopic sinonasal surgery, providing improved access to traditionally challenging areas while preserving critical anatomical structures. This review highlights the technique’s versatility in addressing a variety of pathologies—including maxillary sinus lesions, orbital conditions, and skull base tumors—with favorable outcomes and manageable complications. Comparative analyses validate the PLRA’s effectiveness in disease control and its safety profile with minimal postoperative morbidity, while integration with other techniques further expands its utility. Understanding the anatomical and technical considerations is crucial for optimizing outcomes and minimizing risks. Future advancements in surgical tools and techniques will likely further enhance the feasibility and effectiveness of the PLRA in complex sinonasal operations.

Notes

Ethics Statement

Not applicable

Availability of Data and Material

The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.

Conflicts of Interest

Yeon Hee Im who is on the editorial board of the Journal of Rhinology was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.

Author Contributions

Conceptualization: Yeon Hee Im. Data curation: Soo Whan Kim, Chan-Soon Park, Dong-Hyun Kim. Formal analysis: Soo Whan Kim. Investigation: Dong-Hyun Kim. Methodology: Chan-Soon Park. Resources: Dong-Hyun Kim. Supervision: Yeon Hee Im. Validation: Chan-Soon Park. Writing—original draft: Yeon Hee Im. Writing—review & editing: Yeon Hee Im.

Funding Statement

None

Acknowledgments

Fig. 1 was created with the assistance of Research Factory (https://www.rfactory.kr/). We thank for their contribution to the design of Fig. 1.

Fig. 1.

Schematic diagram of the surgical steps in the prelacrimal recess approach. A: Following the injection of 1% lidocaine with 1:100,000 epinephrine, an incision is made anterior to the IT and extended downward. B: A mucoperiosteal flap is elevated, and the pyriform aperture is exposed. C: Osteotomy is performed on the medial wall of the prelacrimal recess. D: The IT-NLD duct flap is retracted medially, providing access to the MS. E: After the lesion is removed, the flap is repositioned, and the incision site is sutured. IT, inferior turbinate; MT, middle turbinate; NS, nasal septum; MS, maxillary sinus; NLD, nasolacrimal duct.

Table 1.

Prior studies reporting the efficacy and safety outcomes of the prelacrimal recess approach

Study	Study type	Number of patients (M/F)	Mean or median age (yr)	Follow-up periods (mon; mean or median)	Pathology (n)	Complications, n (%)	Recurrence, n (%)	Other outcomes
Zhou et al. [1] (2013)	Retrospective cohort study	17 (NA)	NA	7–60	Recurrent MS IP (10)	Epiphora: 0 (0.0%)	1 in MS IP (5.9%)
					Nasal polyp in the MS (2)	Dry nose: 0 (0.0%)
					MS cyst (4)	Numbness: 0 (0.0%)
					Postoperative bleeding (1)
Comoglu et al. [38] (2016)	Retrospective cohort study	12 (7/5)	22.0±5.7	8–21 (14.2)	Antrochoanal polyp (12)	NLD injury: 2 (16.7%)	0 (0.0%)
						Epiphora: 0 (0.0%)
						Synechia requiring removal: 1 (8.3%)
Suzuki et al. [18] (2017)	Retrospective cohort study	51 (30/21)	58.7±12.6	2–138	MS IP (51)	Epiphora: 0 (0.0%)	1 (2.0%)
						Dry nose: 0 (0.0%)
						Numbness: 7 (13.7%)
						Prolonged numbness: 0 (0.0%)
						External nasal deformities: 0 (0.0%)
						Persistent crusting: 0 (0.0%)
Zhou et al. [19] (2018)	Retrospective cohort study	71 (42/29)	52.2±12.1	13–134 (37.3)	MS IP (71)	NLD injury: 0 (0.0%)	5 (7.0%)
						Numbness: 11 (15.5%)
						Prolonged numbness: 5 (7.0%)
						Nasal alar retraction: 4 (5.6%)
Lin et al. [24] (2018)	Retrospective cohort study	15 (12/3)	49.5±15.3	6–28 (16.5)	Tumor in the MS (12)	NLD injury: 0 (0.0%)	1in sinonasal inflammation (6.7%)
Lin et al. [24] (2018)	Retrospective cohort study	15 (12/3)	49.5±15.3	6–28 (16.5)	Sinonasal inflammation (3)
Hildenbrand et al. [41] (2019)	Retrospective cohort study	17 (13/4)	54.3	24–69 (45.9)	MS IP (17)	Numbness: 4 (23.5%)	0 (0.0%)
						Epiphora: 0 (0.0%)
						Prolonged numbness: 3 (17.6%)
						Nasal alar retraction: 0 (0.0%)
						Persistent crusting: 0 (0.0%)
Lin and Chen [40] (2020)	Retrospective cohort study	21 (16/5)	51.7±14.5	1.4–41.5 (12.7)	Sinonasal papilloma in the MS (9)	Epistaxis: 1 (4.8%)	0 (0.0%)	SNOT-22 and VAS scores significantly improved among non-papilloma cases but not in papilloma cases.
					Other tumors involving MS (7)	Numbness: 11 (52.4%)
					Mucocele in the MS (1)	Prolonged numbness: 0 (0.0%)
					Orbital wall fracture (1)
					Sinonasal inflammation (3)
Tomoum et al. [5] (2020)	Prospective cohort study	25 (10/15)	37.0±12.0	6–14 (10.9)	Antrochoanal polyp (13)	NLD injury: 0 (0.0%)	1 in antrochoanal polyp (4.8%)	All patients showed significant improvement in SNOT-22 scores.
					Fungal ball in the MS (10)
					Displaced tooth in MS (2)
Seresirikachorn et al. [20] (2023)	Retrospective cohort study	40 (15/25)	52.8±17.0	(50.1± 25.2)	Pyriform aperture stenosis (2)	Epiphora: 0 (0.0%)	NA
					Antrochoanal polyp (2)	Numbness: 4 (10.0%)
					Mucocele in the MS (1)	Synechia requiring removal: 2 (5.0%)
					Fungal ball in the MS (4)	External nasal deformities: 0 (0.0%)
					Rhinosinusitis (8)
					Neoplasms (20)
Vinciguerra et al. [8] (2023)	Retrospective cohort study	50 (27/23)	48.8±16.5	(22.8±13.9)	MS IP (26)	Epiphora: 1 (2.0%)	0 (0.0%)
					Odontogenic cyst (17)	Numbness: 9 (18.0%)
					Antrochoanal polyp (6)	Epistaxis: 1 (2.0%)
					V2 Schwannoma (1)
Liang et al. [54] (2024)	Retrospective cohort study	122 (68/54)	50.8±12.8	13–192 (86.6)	MS IP (122)	Numbness: 29 (23.8%)	4 (3.3%)	VAS scores showed significant postoperative improvement.
Liang et al. [54] (2024)	Retrospective cohort study	122 (68/54)	50.8±12.8	13–192 (86.6)		Prolonged numbness: 5 (4.1%)		VAS scores showed significant postoperative improvement.

M, male; F, female; NA, not available; MS, maxillary sinus; IP, inverted papilloma; V2, maxillary branch of cranial nerve V; NLD, nasolacrimal duct; SNOT-22, Sino-Nasal Outcome Test-22; VAS, visual analog scale

Table 2.

Prior studies comparing the PLRA with other surgical techniques

Study	Study type	Number of patients (M/F)	Mean or median age (yr)	Follow-up periods (mon; mean or median)	Pathology (n)	Complications, n (%)	Recurrence, n (%)	Other outcomes
Yu et al. [22] (2018)	Retrospective cohort study	71 (44/27)	52	37–73	MS IP (71)	Epiphora: PLRA – 0 (0.0%), MMA+CLA – 0 (0.0%), EMM – 1 (3.3%), MMA – 0 (0.0%)	PLRA – 1 (5.0%)
		• PLRA–20				Dry nose: PLRA – 0 (0.0%), MMA+CLA – 0 (0.0%), EMM – 1 (3.3%), MMA – 0 (0.0%)	MMA+CLA – 1 (14.3%)
		• MMA+CLA – 7				Numbness: PLRA – 0 (0.0%), MMA+CLA – 1 (14.3%), EMM – 0 (0.0%), MMA – 0 (0.0%)	EMM – 2 (6.7%)
		• EMM – 30				Epistaxis: PLRA – 0 (0.0%), MMA+CLA – 0 (0.0%), EMM – 1 (3.3%), MMA – 1 (7.1%)	MMA – 2 (14.3%)
		• MMA – 14					MMA – 2 (14.3%)
Lee et al. [34] (2019)	Retrospective cohort study	40 (32/8)	• PLRA – 53.6±10.7	(12.4±11.7)	MS IP (38)	Epiphora: PLRA – 0 (0.0%), CLA – 0 (0.0%)	PLRA – 0 (0.0%)	The duration of numbness was significantly shorter in the PLRA group.
		• PLRA – 10	• CLA – 53.7±14.2		Ameloblastoma in the MS (8)	Numbness: PLRA – 3 (30.0%), CLA – 11 (36.7%)	CLA – 0 (0.0%)
		• CLA – 30			Ossifying fibroma in the MS (1)	Facial pain: PLRA – 0 (0.0%), CLA – 2 (6.7%)
		• CLA – 30			Ossifying fibroma in the MS (1)	Epistaxis: PLRA – 0 (0.0%), CLA – 0 (0.0%)
Nakayama et al. [17] (2020)	Retrospective cohort study	45 (34/11)	• PLR – 54.1±12.9	16–104 (45.3±22.9)	MS IP (45)	NLD injury: PLRA – 0 (0.0%), ESS±CLA – 0 (0.0%)	PLRA – 0 (0.0%)	A Kaplan-Meier plot revealed a significantly lower risk of recurrence for PLRA than for ESS±CLA.
		• PLRA – 27	• ESS±CLA – 55.1±15.6			Epiphora: PLRA – 0 (0.0%), ESS±CLA – 0 (0.0%)	ESS±CLA – 3 (16.6%)
		• ESS±CLA^* – 18	• ESS±CLA – 55.1±15.6			Numbness: PLRA – 1 (3.7%), ESS±CLA – 1 (5.6%)
Mohankumar et al. [39] (2022)	Prospective cohort study	60 (NA)	NA	12 (12)	Maxillary sinusitis (24)	Epiphora: PLRA – 3 (10.0%), MMA – 0 (0.0%)	PLRA – 1 in antrochoanal polyp (3.3%)	No significant difference in improvement in SNOT-22 scores between the groups
		• PLRA – 30			Allergic fungal sinusitis (8)	Numbness: PLRA – 1 (3.3%), MMA – 0 (0.0%)	MMA – 6 in antrochoanal polyp (20.0%)
		• MMA – 30			Antrochoanal polyp (24)	Facial swelling: PLRA – 3 (10.0%), MMA – 1 (10.0%)
		• MMA – 30			Dentigerous cyst (4)	Facial pain: PLRA – 5 (16.7%), MMA – 3 (10.0%)
Vinciguerra et al. [56] (2023)	Retrospective cohort study	52 (29/23)	• PLRA – 57.5±11.1	(29.5±14.4)	MS IP (52)	Epiphora: PLRA – 1 (3.8%), EMM – 10 (38.5%)	PLRA – 0 (0.0%)
		• PLRA – 26	• EMM – 57.7±14.4			Dry nose: PLRA – 1 (3.8%), EMM – 13 (50.0%)	EMM – 1 (38.5%)
		• EMM – 26				Numbness: PLRA – 6 (23.1%), EMM – 8 (30.8%)
						Nasal crusting: PLRA – 3 (11.5%), EMM – 14 (53.8%)
						Epistaxis/infection requiring intervention: PLRA – 1 (3.8%), EMM – 6 (23.1%)
Kondo et al. [57] (2024)	Retrospective cohort study	140 (68/72)	• PLRA – 52.9±17.9	3–132 (32.6±29.3)	Tumor in the MS (140)	Epiphora: PLRA – 0 (0.0%), EMMM – 0 (0.0%)	NA
		• PLRA – 44	• EMMM – 52.4±18.5			Numbness: PLRA – 4 (9.1%), EMMM – 14 (14.6%)
		• EMMM – 96				Prolonged numbness: PLRA – 1 (2.3%), EMMM – 5 (5.2%)
						Synechia requiring removal: PLRA – 2 (4.5%), EMMM – 4 (4.2%)
						Nasal cavity stenosis: PLRA – 0 (0.0%), EMMM – 0 (0.0%)
Abdulla et al. [59] (2024)	NA	30 (18/12)	39.5±11.5	11–23 (14.3)	Antrochoanal polyp (4)	Epiphora: MMA+PLRA – 1 (6.7%), MMA – 0 (0.0%)	MMA+PLRA – 0 (0.0%)	Postoperative improvement in VAS score and Lund-Kennedy Endoscopic scores were significantly higher in the MMA+PLRA group.
		• MMA+PLRA – 15			Mucocele in the MS (12)	Epiphora: MMA+PLRA – 1 (6.7%), MMA – 0 (0.0%)	MMA – 4 (26.7%)
		• MMA – 15			Allergic fungal sinusitis (14)	Anterior nasal synechia: MMA+PLRA – 1 (6.7%), MMA – 0 (0.0%)	MMA – 4 (26.7%)

^* ESS was performed via middle and/or inferior meatus antrostomy with or without the CLA.

M, male; F, female; NA, not available; PLRA, prelacrimal recess approach; MMA, middle meatal antrostomy; CLA, Caldwell-Luc approach; ESS, endoscopic sinus surgery; EMM, endoscopic medial maxillectomy; EMMM, endoscopic modified medial maxillectomy; MS, maxillary sinus; IP, inverted papilloma; NLD, nasolacrimal duct; SNOT-22, Sino-Nasal Outcome Test-22; VAS, visual analog scale

Table 3.

Comparison of benefits and limitations of the Caldwell-Luc approach, endoscopic medial maxillectomy, and the prelacrimal recess approach

	Caldwell-Luc approach	Endoscopic medial maxillectomy	Prelacrimal recess approach
Benefits	• All areas of the maxillary sinus can be accessed [17]	• All areas of the maxillary sinus can be accessed [1]	• All areas of the maxillary sinus can be accessed with preserving inferior turbinate and nasolacrimal duct, maintaining nasal physiologic function [1,23,33]
Benefits	• Useful when the two-port technique is necessary, such as for tumors in infratemporal fossa [34]	• Suitable for tumorous lesions involving medial maxillary sinus wall or nasolacrimal duct [20,33]	• Lesions placed in the lateral or anterior wall of the maxillary sinus, or the alveolar recess can be manipulated [43]
Limitations	• Persistent facial numbness, discomfort, or edema, mucocele, and neo-osteogenesis can develop [1,5,23,34]	• Inferior turbinate and nasolacrimal duct are sacrificed, potentially causing empty nose syndrome, dry nose, epiphora, lacrimal pathway obstruction, and dacryocystitis [1,17]	• Nasolacrimal duct is directly exposed and susceptible to potential injury [38,41]
	• Infraorbital nerve or artery can be injured [34]		• Facial paresthesia due to injury of anterior superior alveolar nerve, and nasal mucosa dryness can develop [13,38,41,42]
	• Canine fossa puncture site may serve as a potential pathway for tumor spreading [34]		• Superomedial wall of the maxillary sinus is difficult to manage [34]
	• Lesions of anterior wall of the maxillary sinus, prelacrimal recess, and alveolar recess are difficult to manage [17,34,41]		• Access might be challenging if the prelacrimal recess is narrow or absent [23, 43]
			• Tumorous lesions involving the medial maxillary sinus wall or nasolacrimal duct might not be appropriate [20,33]

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