Maxillectomy a review

Dr T Balasubramanian Otolaryngology online 1

History  Concept described by Lazars in 1826 Syme first performed it in 1829 Portman described sublabial transoral approach in 1927 Smith described extended maxillectomy in 1954 Fairbanks & Barbosa described infratemporal fossa approach for advanced maxillary sinus tumors in 1961 Midfacial degloving approach was popularized in 1970 Otolaryngology online 2

Dangers - Historic  Bleeding was the most common danger Complications due to anesthesia Post op sepsis Secondary deformity due to poor prosthesis support Otolaryngology online 3

Indications  Malignant tumors involving maxilla Benign tumors of maxilla causing extensive bone destruction (fibrous dysplasia) May be performed as a part of combined resection of skull base neoplasm May be needed in patients with extensive fungal / granulomatous infections (rare) Malignant tumors of oral cavity with extensive involvement of palate Otolaryngology online 4

Tips  Not indicated in the management of lymphoreticular tumors which are better managed medically Tumors involving inferior aspect of maxillary sinus can be managed by performing partial maxillectomy Rehabilitation and prosthesis issues should be planned well in advance in consultation with dental surgeons Otolaryngology online 5

Contraindications  Poor general condition of the patient Bilateral tumors with bilateral orbital involvement Malignant tumors with skull base extension. Patient not consenting to undergo the procedure Systemic disorders like uncontrolled diabetes / poor cardio respiratory reserve Otolaryngology online 6

Bilateral tumors  Involvement of orbits on both sides – This could compromise the vision because orbital exenteration will have to be performed Removing bilateral tumors is not only a surgical challenge but also a challenge to design appropriate prosthesis. Since it is rather difficult to design prosthesis for patients who undergo bilateral total maxillectomy it is a relative contraindication Otolaryngology online 7

Imaging  Both axial and coronal CT scans will have to be performed in order to ascertain the extent of lesion MRI will have to be performed in patients with erosion of skull base to rule out intracranial extension Imaging helps in deciding osteotomy location. Superior osteotomy above the level of frontoethmoidal suture line will result in intracranial injury and CSF leak Otolaryngology online 8

CT Otolaryngology online 9

Ocular evaluation  Vision should always be tested before taking the patient up for surgery Tumor involvement of orbit is an indication of orbital exenteration If orbital exenteration is planned appropriate prosthesis should be designed to fill up the defect Otolaryngology online 10

Complications  Bleeding Infection Epiphora Break down of skin graft Numbness of cheek area Atrophic rhinitis Otolaryngology online 11

Bleeding  Can be minimized by coagulating bleeders Angular vessels should be secured properly Breaking maxilla from pterygoid process will cause bleeding from internal maxillary artery. Simple hot packs will help in reducing bleeding during this stage When lip splitting incision is used bleeding from labial vessels is common and should be secured at the earliest Otolaryngology online 12

Infection  Can be minimized by following strict asepsis Avoiding undue use of cautery will minimize tissue necrosis / infection Post op antibiotics By conserving skin as much as possible without compromising tumor margins Otolaryngology online 13

Epiphora  Nasolacrimal duct is transected during maxillectomy thus causing epiphora Simple transection of nasolacrimal duct rarely causes epiphora unless followed by stricture which usually occurs following radiotherapy Insertion of silicone tube after transection of nasolacrimal duct Marsupialization of nasolacrimal duct Otolaryngology online 14

Numbness of cheek area  Caused due to transection of infraorbial nerve Infraorbital nerve can be conserved if not involved by the tumor Otolaryngology online 15

Otolaryngology online 16

Consent issues  Dental extraction Tracheostomy Prosthesis issues Cosmetic defects Otolaryngology online 17

Surgical steps  General anaesthesia Infiltration with 1% xylocaine with 1 in 100,000 adrenaline Marking incision site Reflection of skin flap over maxilla Bone cuts Disarticulation of maxilla Otolaryngology online 18

Incision   Weber Ferguson’s incision is used  Lateral rhinotomy incision with horizontal infraorbital component and midline lip split Otolaryngology online 19

Sublabial component   Sublabial incision is performed after splitting upper lip in midline  This facilitates elevation of flap from anterior wall of maxilla  Extends through entire bucco gingival sulcus up to maxillary tuberosity Otolaryngology online 20

Infraorbital component   This is the horizontal component of weber Ferguson’s incision  Made about 1 mm below the infraorbital rim Otolaryngology online 21

Flap Otolaryngology online 22

Bone cuts  Otolaryngology online 23

Palatal cut  Otolaryngology online 24

Zygoma cut  Otolaryngology online 25

Maxilla removal  Otolaryngology online 26

Prosthesis  Otolaryngology online 27

Specimen  Otolaryngology online 28

Closure  Otolaryngology online 29

Eye protection  Temporary tarsorraphy Corneal shield Significant laceration of periorbita should be sutured Otolaryngology online 30

Otolaryngology online 31

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Maxillectomy a review

by Balasubramanian Thiagarajan on Oct 30, 2011

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Maxillectomy a review — Presentation Transcript