Total maxillectomy


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Total maxillectomy

  1. 1. Total maxillectomy Amy L. Pittman, MD,a Chad A. Zender, MDb From the a Department of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois; and the b Department of Otolaryngology-Head and Neck Surgery, University Hospitals-Case Western Reserve Medical Center, Cleveland, Ohio. Tumors of the nasal cavity and paranasal sinuses are uncommon and represent both malignant and benign pathology. These neoplasms often present as locally advanced lesions. Depending on the extent of 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 from preservation of adjacent vital structures. Free tissue transfer provides many reconstructive options for the head and neck surgeon and is reliable for restoring near-normal functional recovery. © 2010 Elsevier Inc. All rights reserved. KEYWORDS Maxillectomy; Maxillary sinus tumors; Paranasal sinus tumors; Orbital exenteration Introduction and indications Tumors of the nasal cavity and paranasal sinuses are infre- quent in incidence, making up less than 10% of lesions in the head and neck region. Most of these tumors are epithe- lial in origin, with squamous cell carcinoma being the most common pathologic diagnosis. Tumors may also originate in the bone, salivary glands, or odontogenic apparatus. Un- fortunately, malignant lesions of the region tend to mimic benign disease, thus delaying diagnosis until the tumor becomes problematic and evident at an advanced stage. Surgical excision is often a component of, if not the primary modality in, treatment. This is related to the close proximity of the nasal cavity and paranasal sinuses to important struc- tures such as the orbit and brain. Exceptions to this rule would include lymphoma or other lesions that are respon- sive to chemotherapy or radiotherapy. Benign lesions usu- ally require excision alone, whereas malignant neoplasms are often treated with adjuvant therapy. When dealing with both benign and malignant lesions, the operation can be tailored to the tumor type and location. Inverted papillomas are an example of a benign tumor with the potential for malignant transformation. They can be treated with a medial maxillectomy removing the lateral nasal wall, medial orbital wall, and medial wall of the maxilla, preserving the hard palate. Another example is when treating tumors of the alveolus (eg, squamous cell carcinoma). An inferior maxillectomy removing the inferior portion of the maxilla and floor of the nose can be per- formed, preserving the orbital floor and medial components of the maxilla and nose. When tumors involve the orbital contents (orbital fat or ocular muscle involvement), an or- bital exoneration can be performed in conjunction with the maxillectomy. This article will describe a traditional max- illectomy with orbital preservation. Patient selection Advanced tumors may be unresectable when they begin to involve the lateral sphenoid sinus (cavernous sinus), intra- cranial contents, or carotid artery. Ohngren’s line is an imaginary line drawn from the angle of the mandible to the medial canthus on the ipsilateral side (Figure 1). The line divides the midface into an anteroinferior and posterosupe- rior quadrant, with the latter being typically more challeng- ing to treat and carrying a poorer prognosis. The extent of the tumor dictates the extent of the max- illectomy necessary for adequate resection. For example, an inferior or partial maxillectomy may be sufficient for neo- Address reprint requests and correspondence: Chad A. Zender, MD, Department of Otolaryngology-Head and Neck Surgery, UH Case Medical Center, 11100 Euclid Ave, Cleveland, OH 44106. E-mail address: Operative Techniques in Otolaryngology (2010) 21, 166-170 1043-1810/$ -see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2010.07.005
  2. 2. plasms confined to the inferior sinus or palate. Conversely, if there is extension into the skull base, pterygomaxillary fossa, or infratemporal fossa, then a combination of surgical approaches may be necessary. A total or complete maxil- lectomy is indicated for tumors that involve the floor of the orbit, inferior rim, or posterior maxillary wall. The extent of therapeutic surgical intervention is dictated by the general well being of the patient, with careful con- sideration of comorbid conditions, prognosis, and patient’s preference. Preoperative preparation History and physical examination, with emphasis placed on intraoral and intranasal anatomy, are essential. This in- volves assessment of the nasal cavity and nasopharynx with an endoscope. The integrity of the infraorbital nerve and malar soft tissue can reveal extension outside of the max- illary sinus. Preoperative biopsies of the tumor should be obtained for histologic confirmation of disease. All patients should be evaluated with a CT, MRI, or possibly both. CT will show bony anatomy, but may overestimate the margins of the tumor. MRI is superior in distinguishing tumor from surrounding soft tissue. A dental evaluation should be completed preoperatively to extract grossly infected teeth but also to take necessary impressions so that a surgical obturator can be made if soft tissue reconstruction is not planned. The device is inserted following excision with the intent of retaining operative packing and to facilitate postoperative swallowing and speech. Alternatively, soft tissue reconstruction of the midface defect can be planned with a reconstructive surgeon. A microvascular free flap or local–regional flap can be used, depending on anticipated needs postoperatively. This may include fasciocutaneous, myocutaneous (if bulk is required), or osseocutaneous flaps. Consultation by an ophthalmolo- gist may be helpful when determining the potential for involvement of the orbit. Surgical technique The procedure is completed under general anesthetic. A preoperative dose of a broad spectrum antibiotic is admin- istered to cover normal flora of the oral and nasal cavities. In addition, the author typically administers a 10-mg dose of Decadron, unless otherwise contraindicated. Tarsorrhaphy is used to protect the globe during the procedure and is removed immediately post procedure. Traditionally, the sur- gical approach used for a complete maxillectomy includes a lateral rhinotomy or a modified Weber–Ferguson incision. When not designed appropriately, these incisions can lead to unsightly scars; however, maintaining the incision within the borders of the facial subunits can minimize both distor- tion and functional impact. Although the initial incision for a complete maxillectomy is similar to that used for a partial maxillectomy or medial maxillectomy, a much wider expo- sure is essential. Supraciliary or subciliary incisions may be made if orbital exenteration is planned. Please illustrate (Dis- cuss why and when supraciliary and when subciliary). The lip splitting incision runs along the ipsilateral philtrum to respect the subunits of the upper lip. The incision is carried through the skin, subcutaneous tissue, and musculature of the upper lip and cheek (Figure 2). A cheek flap is then elevated at the level of the perios- teum of the anterior maxilla. An upper gingivolabial sulcus incision is also made intraorally to facilitate in flap elevation (Figure 3). The infraorbital nerve is encountered just infe- rior to the infraorbital rim and is divided. Elevation of the cheek flap extends to approximately 1 cm lateral to the lateral canthus. The orbicularis oris muscle is retracted ce- phalic to expose the orbital rim. A freer elevator is used to lift the periosteum posteriorly along the floor of the orbit. After the periorbita has been lifted inferiorly and medially, the lacrimal fossa, lamina papyracea, and lacrimal sac are identified. The sac and duct are transected, and the sac is marsupialized. Medial elevation must be carried above the frontoethmoid suture line, which can be identified by the anterior and posterior ethmoid arteries. These arteries can be clipped or bipolared, but care must be used when manipu- lating the posterior ethmoid artery because of it close prox- imity to the optic nerve (3–5 mm). The orbital plate of the maxilla should be exposed. The orbit is inspected for ex- tension of tumor, and, if involved, an exenteration is per- formed. Attention is then turned to the zygoma, where the attachments of the masseter are transected using electrocau- Figure 1 Ohngren’s line. 167Pittman and Zender Total Maxillectomy
  3. 3. tery. At this point, the orbital rim is transected at the trima- lar suture laterally. Medially, the maxilla is transected 2 mm below the frontoethmoid suture line to avoid entering the anterior cranial vault. A rongeur, osteotome, or high-speed cutting drill can be used to make these osteotomies, with all bony cuts first being marked out using electrocautery (Fig- ure 4). A malleable retractor is used to protect the orbital contents while the bones surrounding the globe are manip- ulated. Next, the oral cavity is exposed, and a vertical, gingival incision is made between the lateral incisor and canine. This is extended superiorly to meet the sulcus and lip incision and represents the anterior border of a total maxillectomy. The mucosal incision is then carried intraorally along the midline hard palate to the junction of the hard and soft palate. It is then turned laterally around the maxillary tu- bercle and superiorly up to the gingivobuccal sulcus. The lateral incisor is extracted to allow for the bony cuts of the palate to be performed. The palate is then divided with an osteotome or saw. If possible, the nasal septum should be left intact (Figure 5). At this point, the hemi-maxilla can be fractured anteri- orly–inferiorly and removed from the pterygoid plates with a curved osteotome. Bleeding can be problematic during this process and cannot be controlled until the specimen is removed entirely. Usually, this involves blindly cutting the soft tissue attachments posteriorly with curved Mayo scis- sors. Generally, the source of bleeding is the internal max- illary artery, which must be packed off until the artery can be identified and suture ligated or clipped. Good communi- cation with anesthesia is essential during this part of the procedure. Figure 4 The approach allows for the bony cuts to be made across the zygoma laterally, the floor of the orbit (roof of the maxilla), the medial orbital wall (2 mm below frontoethmoid suture line) and into the nasal cavity. Figure 2 The Weber–Ferguson incision. (A) The lateral rhino- tomy incision is incorporated in this approach. (B) The incision is extended inferiorly to include (if needed) a splitting of the upper lip in midline with sublabial gingivobuccal and palatal extensions. (C) Superiorly, the incision may be extended in a subciliary fash- ion or may include a contralateral Lynch extension to provide adequate access to the orbit. Figure 3 The Weber–Ferguson incision provides excellent ac- cess to the hard palate, lower half of the nasal cavity, maxilla, maxillary sinus, and infratemporal fossa, and allows adequate exposure if orbital exenteration is indicated. 168 Operative Techniques in Otolaryngology, Vol 21, No 3, September 2010
  4. 4. With the entire maxilla removed, the surgical defect can be examined. The entire maxillary component of the orbital floor should be absent, with the periosteum intact. The nasal cavity, pterygoid fossa, and nasopharynx are widely visible. The wound is then copiously irrigated. What about support for orbit? Is support even needed? What do you use? At this point, the defect may be either reconstructed surgically with a local what kind of local flap or free tissue transfer, or nonsurgically with an orthodontic prosthesis. The aim for either of these techniques is to create separation between the nasal and oral cavity. If an orthodontic prosthesis going to be used, a previously harvested split thickness skin graft is then used to line the raw edges of the defect. Xeroform gauze packing is used to secure the graft and prevent fluid collection beneath the graft. The orthodontic prosthesis is then inserted and secured with a lag screw or wired to the remaining teeth. Free tissue reconstruction Reconstruction of the maxillary suprastructure, the perior- bital region, and the lateral pyriform aperture can be per- formed at the time of oncological ablative surgery. There is a relative paucity of local vascularized soft tissue flaps that can support such a reconstruction. Because the local soft tissues do not lend themselves to pedicled or rotational transfer, the most commonly used vascularized tissue for midface reconstruction has been free tissue transfer. As previously stated, the purpose of this reconstruction in- cludes reestablishing a functional separation of the oral and nasal cavity, thus restoring speech and swallowing. The surgeon should also aim to re-create both the oral and nasal mucosa and to provide a watertight seal in doing so. By reconstructing in this manner, the flap can often be har- vested at the same time as the ablative procedure, and thus the patient leaves the hospital with a permanent, functional reconstruction. One possibility is the rectus abdominis flap. This partic- ular flap provides a large surface area of vascularized flap, which can actually be turned on itself to provide dual skin paddles. It has been used successfully in reconstructing palatal defects by supplying both an inner and outer lining. The stability of this flap allows the microvascular pedicle to survive in any number of environments, making it an espe- cially hardy flap. The anterolateral thigh also presents a po- tential donor for this particular type of head and neck defect. Its long vascular pedicle makes it useful in the reconstruction of the midface, and the flap provides an ample skin paddle. Defects that require bulk and the freedom to place epithelial surfaces in a number of different three-dimensional planes can be reconstructed using a free latissimus flap. This flap can also be used to create dual skin paddles. Several reports in the literature note the efficacy of the latissimus dorsi flap for complex and extensive defects of the midface and skull base. There are multiple osseous free tissue flaps that can be harvested to reconstruct lesions of the midface, including the fibula, iliac crest, and scapula. The vascular supply in each of these flaps will usually allow for osteotomies to be made, as the defect requires, with the ability to re-create a palate, nasal floor, or orbital floor. Depending on the thickness of the bone har- vested, dental implants can be used if necessary. Postoperative care Oral irrigations should be completed often throughout the day and postprandially. The patient should be instructed on the use of gentle saline irrigation of the nasal and exposed sinus cav- ities. After the second week, more aggressive saline irrigation is recommended and is often necessary until the mucosa heals. Adherence to oral exercises of the jaw is essential in preventing trismus and pain due to inflammation. The patient should also follow up with the primary surgeon for packing removal and also with the prosthodontist if a temporary obturator was used. Follow-up with radiation oncologist may be necessary, de- pending on the final pathology. Complications The close proximity of many vital anatomical structures to the nasal cavity and paranasal sinuses is responsible for possible complications due to local extension of the primary tumor or treatment (surgical resection and radiation ther- apy). Surgical complications include bleeding, cerebrospi- nal fluid leak, infection (skin and soft tissue infections, meningitis, intracranial abscess, osteomyelitis), pneumo- cephalus, blindness, and facial disfiguration due to exten- sive resection. Failure to restore the oral and nasal separa- tion adequately can lead to velopharyngeal insufficiency and nasal regurgitation during swallowing. Inadequate dacrocystorhinostomy during the excision can lead to per- sistent epiphora. Enophthalmos or hypophthalmos due to Figure 5 Intraoral and palatal incisions are made last because of the associated bleeding and difficulty in controlling the internal maxillary artery before the entire specimen is removed. The lateral incisor is removed to allow for the bony cut through the palate to be made. 169Pittman and Zender Total Maxillectomy
  5. 5. loss of orbital support can be prevented or minimized with appropriate reconstructive techniques. Discussion Surgery for tumors of the nasal cavity and paranasal sinuses can be technically challenging. However, ade- quate ablation via total maxillectomy can achieve cure in even locally advanced tumors. The difficulty lies in giv- ing the patient an oncologically sound resection while preserving important adjacent structures, without causing cosmetic deformity. Multiple free tissue transfer possi- bilities exist for reconstructing midface defects left by a complete maxillectomy and have been used successfully in the experience of this author as well as in the literature. 170 Operative Techniques in Otolaryngology, Vol 21, No 3, September 2010