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Operative Techniques in Otolaryngology (2010) 21, 166-170

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otal maxillectomy

my L. Pittman, MD,a Chad A. Zender, MDb

rom the aDepartment of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois;nd theDepartment of Otolaryngology-Head and Neck Surgery, University Hospitals-Case Western Reserve Medical Center,

leveland, Ohio.

Tumors of the nasal cavity and paranasal sinuses are uncommon and represent both malignant andbenign pathology. These neoplasms often present as locally advanced lesions. Depending on the extentof the disease, a total maxillectomy has been traditionally used for eradication of disease successfully.Although radiation therapy may be an option, patients treated with surgical excision benefit frompreservation of adjacent vital structures. Free tissue transfer provides many reconstructive options forthe head and neck surgeon and is reliable for restoring near-normal functional recovery.© 2010 Elsevier Inc. All rights reserved.

KEYWORDSMaxillectomy;Maxillary sinustumors;Paranasal sinustumors;Orbital exenteration

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ntroduction and indications

umors of the nasal cavity and paranasal sinuses are infre-uent in incidence, making up less than 10% of lesions inhe head and neck region. Most of these tumors are epithe-ial in origin, with squamous cell carcinoma being the mostommon pathologic diagnosis. Tumors may also originaten the bone, salivary glands, or odontogenic apparatus. Un-ortunately, malignant lesions of the region tend to mimicenign disease, thus delaying diagnosis until the tumorecomes problematic and evident at an advanced stage.urgical excision is often a component of, if not the primaryodality in, treatment. This is related to the close proximity

f the nasal cavity and paranasal sinuses to important struc-ures such as the orbit and brain. Exceptions to this ruleould include lymphoma or other lesions that are respon-

ive to chemotherapy or radiotherapy. Benign lesions usu-lly require excision alone, whereas malignant neoplasmsre often treated with adjuvant therapy.

When dealing with both benign and malignant lesions,he operation can be tailored to the tumor type and location.nverted papillomas are an example of a benign tumor withhe potential for malignant transformation. They can be

Address reprint requests and correspondence: Chad A. Zender,D, Department of Otolaryngology-Head and Neck Surgery, UH Caseedical Center, 11100 Euclid Ave, Cleveland, OH 44106.

iE-mail address: Chad.Zender@UHhospitals.org.

043-1810/$ -see front matter © 2010 Elsevier Inc. All rights reserved.oi:10.1016/j.otot.2010.07.005

reated with a medial maxillectomy removing the lateralasal wall, medial orbital wall, and medial wall of theaxilla, preserving the hard palate. Another example ishen treating tumors of the alveolus (eg, squamous cell

arcinoma). An inferior maxillectomy removing the inferiorortion of the maxilla and floor of the nose can be per-ormed, preserving the orbital floor and medial componentsf the maxilla and nose. When tumors involve the orbitalontents (orbital fat or ocular muscle involvement), an or-ital exoneration can be performed in conjunction with theaxillectomy. This article will describe a traditional max-

llectomy with orbital preservation.

atient selection

dvanced tumors may be unresectable when they begin tonvolve the lateral sphenoid sinus (cavernous sinus), intra-ranial contents, or carotid artery. Ohngren’s line is anmaginary line drawn from the angle of the mandible to theedial canthus on the ipsilateral side (Figure 1). The line

ivides the midface into an anteroinferior and posterosupe-ior quadrant, with the latter being typically more challeng-ng to treat and carrying a poorer prognosis.

The extent of the tumor dictates the extent of the max-llectomy necessary for adequate resection. For example, an

nferior or partial maxillectomy may be sufficient for neo-

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167Pittman and Zender Total Maxillectomy

lasms confined to the inferior sinus or palate. Conversely,f there is extension into the skull base, pterygomaxillaryossa, or infratemporal fossa, then a combination of surgicalpproaches may be necessary. A total or complete maxil-ectomy is indicated for tumors that involve the floor of therbit, inferior rim, or posterior maxillary wall.

The extent of therapeutic surgical intervention is dictatedy the general well being of the patient, with careful con-ideration of comorbid conditions, prognosis, and patient’sreference.

reoperative preparation

istory and physical examination, with emphasis placed onntraoral and intranasal anatomy, are essential. This in-olves assessment of the nasal cavity and nasopharynx withn endoscope. The integrity of the infraorbital nerve andalar soft tissue can reveal extension outside of the max-

llary sinus. Preoperative biopsies of the tumor should bebtained for histologic confirmation of disease. All patientshould be evaluated with a CT, MRI, or possibly both. CTill show bony anatomy, but may overestimate the marginsf the tumor. MRI is superior in distinguishing tumor fromurrounding soft tissue.

A dental evaluation should be completed preoperativelyo extract grossly infected teeth but also to take necessarympressions so that a surgical obturator can be made if softissue reconstruction is not planned. The device is inserted

Figure 1 Ohngren’s line.

ollowing excision with the intent of retaining operative a

acking and to facilitate postoperative swallowing andpeech.

Alternatively, soft tissue reconstruction of the midfaceefect can be planned with a reconstructive surgeon. Aicrovascular free flap or local–regional flap can be used,

epending on anticipated needs postoperatively. This maynclude fasciocutaneous, myocutaneous (if bulk is required),r osseocutaneous flaps. Consultation by an ophthalmolo-ist may be helpful when determining the potential fornvolvement of the orbit.

urgical technique

he procedure is completed under general anesthetic. Areoperative dose of a broad spectrum antibiotic is admin-stered to cover normal flora of the oral and nasal cavities.n addition, the author typically administers a 10-mg dose ofecadron, unless otherwise contraindicated. Tarsorrhaphy

s used to protect the globe during the procedure and isemoved immediately post procedure. Traditionally, the sur-ical approach used for a complete maxillectomy includes aateral rhinotomy or a modified Weber–Ferguson incision.

hen not designed appropriately, these incisions can lead tonsightly scars; however, maintaining the incision withinhe borders of the facial subunits can minimize both distor-ion and functional impact. Although the initial incision forcomplete maxillectomy is similar to that used for a partialaxillectomy or medial maxillectomy, a much wider expo-

ure is essential. Supraciliary or subciliary incisions may beade if orbital exenteration is planned. Please illustrate (Dis-

uss why and when supraciliary and when subciliary). The lipplitting incision runs along the ipsilateral philtrum to respecthe subunits of the upper lip. The incision is carried through thekin, subcutaneous tissue, and musculature of the upper lip andheek (Figure 2).

A cheek flap is then elevated at the level of the perios-eum of the anterior maxilla. An upper gingivolabial sulcusncision is also made intraorally to facilitate in flap elevationFigure 3). The infraorbital nerve is encountered just infe-ior to the infraorbital rim and is divided. Elevation of theheek flap extends to approximately 1 cm lateral to theateral canthus. The orbicularis oris muscle is retracted ce-halic to expose the orbital rim. A freer elevator is used toift the periosteum posteriorly along the floor of the orbit.fter the periorbita has been lifted inferiorly and medially,

he lacrimal fossa, lamina papyracea, and lacrimal sac aredentified. The sac and duct are transected, and the sac isarsupialized. Medial elevation must be carried above the

rontoethmoid suture line, which can be identified by thenterior and posterior ethmoid arteries. These arteries can belipped or bipolared, but care must be used when manipu-ating the posterior ethmoid artery because of it close prox-mity to the optic nerve (3–5 mm). The orbital plate of theaxilla should be exposed. The orbit is inspected for ex-

ension of tumor, and, if involved, an exenteration is per-ormed. Attention is then turned to the zygoma, where the

ttachments of the masseter are transected using electrocau-

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168 Operative Techniques in Otolaryngology, Vol 21, No 3, September 2010

ery. At this point, the orbital rim is transected at the trima-ar suture laterally. Medially, the maxilla is transected 2 mmelow the frontoethmoid suture line to avoid entering thenterior cranial vault. A rongeur, osteotome, or high-speedutting drill can be used to make these osteotomies, with allony cuts first being marked out using electrocautery (Fig-re 4). A malleable retractor is used to protect the orbitalontents while the bones surrounding the globe are manip-lated.

Next, the oral cavity is exposed, and a vertical, gingivalncision is made between the lateral incisor and canine. Thiss extended superiorly to meet the sulcus and lip incisionnd represents the anterior border of a total maxillectomy.he mucosal incision is then carried intraorally along theidline hard palate to the junction of the hard and soft

alate. It is then turned laterally around the maxillary tu-ercle and superiorly up to the gingivobuccal sulcus. Theateral incisor is extracted to allow for the bony cuts of thealate to be performed. The palate is then divided with ansteotome or saw. If possible, the nasal septum should beeft intact (Figure 5).

At this point, the hemi-maxilla can be fractured anteri-rly–inferiorly and removed from the pterygoid plates withcurved osteotome. Bleeding can be problematic during

igure 2 The Weber–Ferguson incision. (A) The lateral rhino-omy incision is incorporated in this approach. (B) The incision isxtended inferiorly to include (if needed) a splitting of the upperip in midline with sublabial gingivobuccal and palatal extensions.C) Superiorly, the incision may be extended in a subciliary fash-on or may include a contralateral Lynch extension to provide

sdequate access to the orbit.

his process and cannot be controlled until the specimen isemoved entirely. Usually, this involves blindly cutting theoft tissue attachments posteriorly with curved Mayo scis-ors. Generally, the source of bleeding is the internal max-llary artery, which must be packed off until the artery cane identified and suture ligated or clipped. Good communi-ation with anesthesia is essential during this part of therocedure.

igure 4 The approach allows for the bony cuts to be madecross the zygoma laterally, the floor of the orbit (roof of theaxilla), the medial orbital wall (2 mm below frontoethmoid

igure 3 The Weber–Ferguson incision provides excellent ac-ess to the hard palate, lower half of the nasal cavity, maxilla,axillary sinus, and infratemporal fossa, and allows adequate

xposure if orbital exenteration is indicated.

uture line) and into the nasal cavity.

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169Pittman and Zender Total Maxillectomy

With the entire maxilla removed, the surgical defect cane examined. The entire maxillary component of the orbitaloor should be absent, with the periosteum intact. The nasalavity, pterygoid fossa, and nasopharynx are widely visible.he wound is then copiously irrigated. What about support

or orbit? Is support even needed? What do you use? At thisoint, the defect may be either reconstructed surgically withlocal what kind of local flap or free tissue transfer, or

onsurgically with an orthodontic prosthesis. The aim forither of these techniques is to create separation between theasal and oral cavity. If an orthodontic prosthesis going toe used, a previously harvested split thickness skin graft ishen used to line the raw edges of the defect. Xeroformauze packing is used to secure the graft and prevent fluidollection beneath the graft. The orthodontic prosthesis ishen inserted and secured with a lag screw or wired to theemaining teeth.

ree tissue reconstruction

econstruction of the maxillary suprastructure, the perior-ital region, and the lateral pyriform aperture can be per-ormed at the time of oncological ablative surgery. There isrelative paucity of local vascularized soft tissue flaps that

an support such a reconstruction. Because the local softissues do not lend themselves to pedicled or rotationalransfer, the most commonly used vascularized tissue foridface reconstruction has been free tissue transfer. As

reviously stated, the purpose of this reconstruction in-ludes reestablishing a functional separation of the oral andasal cavity, thus restoring speech and swallowing. Theurgeon should also aim to re-create both the oral and nasalucosa and to provide a watertight seal in doing so. By

econstructing in this manner, the flap can often be har-

igure 5 Intraoral and palatal incisions are made last because ofhe associated bleeding and difficulty in controlling the internalaxillary artery before the entire specimen is removed. The lateral

ncisor is removed to allow for the bony cut through the palate toe made.

ested at the same time as the ablative procedure, and thus s

he patient leaves the hospital with a permanent, functionaleconstruction.

One possibility is the rectus abdominis flap. This partic-lar flap provides a large surface area of vascularized flap,hich can actually be turned on itself to provide dual skinaddles. It has been used successfully in reconstructingalatal defects by supplying both an inner and outer lining.he stability of this flap allows the microvascular pedicle tourvive in any number of environments, making it an espe-ially hardy flap. The anterolateral thigh also presents a po-ential donor for this particular type of head and neck defect. Itsong vascular pedicle makes it useful in the reconstruction ofhe midface, and the flap provides an ample skin paddle.

Defects that require bulk and the freedom to place epithelialurfaces in a number of different three-dimensional planes cane reconstructed using a free latissimus flap. This flap can alsoe used to create dual skin paddles. Several reports in theiterature note the efficacy of the latissimus dorsi flap foromplex and extensive defects of the midface and skull base.

There are multiple osseous free tissue flaps that can bearvested to reconstruct lesions of the midface, including thebula, iliac crest, and scapula. The vascular supply in each of

hese flaps will usually allow for osteotomies to be made, as theefect requires, with the ability to re-create a palate, nasal floor,r orbital floor. Depending on the thickness of the bone har-ested, dental implants can be used if necessary.

ostoperative care

ral irrigations should be completed often throughout the daynd postprandially. The patient should be instructed on the usef gentle saline irrigation of the nasal and exposed sinus cav-ties. After the second week, more aggressive saline irrigations recommended and is often necessary until the mucosa heals.dherence to oral exercises of the jaw is essential in preventing

rismus and pain due to inflammation. The patient should alsoollow up with the primary surgeon for packing removal andlso with the prosthodontist if a temporary obturator was used.ollow-up with radiation oncologist may be necessary, de-ending on the final pathology.

omplications

he close proximity of many vital anatomical structures tohe nasal cavity and paranasal sinuses is responsible forossible complications due to local extension of the primaryumor or treatment (surgical resection and radiation ther-py). Surgical complications include bleeding, cerebrospi-al fluid leak, infection (skin and soft tissue infections,eningitis, intracranial abscess, osteomyelitis), pneumo-

ephalus, blindness, and facial disfiguration due to exten-ive resection. Failure to restore the oral and nasal separa-ion adequately can lead to velopharyngeal insufficiencynd nasal regurgitation during swallowing. Inadequateacrocystorhinostomy during the excision can lead to per-

istent epiphora. Enophthalmos or hypophthalmos due to

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170 Operative Techniques in Otolaryngology, Vol 21, No 3, September 2010

oss of orbital support can be prevented or minimized withppropriate reconstructive techniques.

iscussion

urgery for tumors of the nasal cavity and paranasal

inuses can be technically challenging. However, ade- i

uate ablation via total maxillectomy can achieve cure inven locally advanced tumors. The difficulty lies in giv-ng the patient an oncologically sound resection whilereserving important adjacent structures, without causingosmetic deformity. Multiple free tissue transfer possi-ilities exist for reconstructing midface defects left by aomplete maxillectomy and have been used successfully

n the experience of this author as well as in the literature.