Surgical Treatment

The type of surgical resection required for tumors of the nasal cavity and paranasal sinuses is dictated by each lesion's anatomic location and sites of extension. Tumors originating in the maxillary sinus are removed by some form of maxillectomy. Several different subtypes of maxillectomy have been described, each characterized by the extent of the maxilla resected with tumor. Although terms such as limited, partial, medial, subtotal, total, radical, and extended have been used to differentiate these types of maxillectomy, there is still a lack of a standard nomenclature and some confusion exists between terms. To clarify these discrepancies, a classification system was recently described which categorized maxillectomies into limited, subtotal, and total max-

illectomies.51 The limited maxillectomy removes primarily one wall of the maxilla, while the subtotal maxillectomy removes at least two walls, including the palate. Total maxillectomy is a term reserved for procedures resecting the entire maxilla. This system of classification requires that the soft-tissue approach to the maxilla, as well as the specific portion of bone removed, be described for limited and subtotal maxillectomies. Any extension of the resection to include adjacent structures such as the orbit should also be clarified.

The limited maxillectomy is most frequently performed with either resection of the medial wall or the floor of the maxillary sinus. Medial maxillec-tomy is appropriate for limited, low-grade tumors of the medial wall of the maxillary sinus, nasal cavity, and ethmoid sinus, such as inverted papilloma. The entire medial maxillary wall, lamina papyracea and ethmoid sinus are removed in this procedure (Figures 11-6 and 11-7). The infraorbital nerve is preserved, along with the majority of the anterior maxillary wall, orbital floor, and entire lateral maxillary wall and floor. The fragile nature of the ethmoid air cells, lamina papyracea, and lateral nasal wall makes the en bloc removal of an entire medial maxillec-tomy specimen challenging.52

Malignancies of the floor and lower half of the maxillary sinus may extend inferiorly into the hard palate or alveolar ridge. If such tumors are limited in extent and anteriorly located, they may be resected by a limited maxillectomy of the maxillary floor by an approach through the open mouth (Figures 11-8 and 11-9). Intraoral mucosal incisions are made on the hard palate and extended into the gingival-buccal sulcus, allowing elevation of the cheek soft tissues off the anterior maxillary wall. Osteotomies along the inferior maxilla are then made with a high-speed power saw and osteotome.

Larger tumors of the maxillary sinus may be resected by subtotal maxillectomy, a procedure that removes at least two walls of the sinus including a portion of the hard palate. The tumor location determines the particular subtotal variant that is appropriate. Total maxillectomy is the least common maxillary resection, and is defined as the complete removal of the maxilla (Figures 11-10 and 11-11). Orbital exentera-tion may be included, and has been performed in up to 71 percent of cases requiring total maxillectomy.51 Extensions of total maxillectomy are more common and may involve any number of adjacent sites.

The choice of soft-tissue approach depends on the type of maxillectomy being performed. Limited max-illectomy for small lesions of the hard palate or floor of the maxillary sinus may occasionally be approached transorally without the need for any facial incisions. A midface degloving or Denker's approach offers better inferior maxillary exposure while also avoiding any external skin incisions. Medial maxillec-tomy requires a lateral rhinotomy incision with a Lynch extension for improved ethmoid exposure superiorly. Larger nasal cavity and maxillary lesions require a Weber-Ferguson incision. Total maxillec-tomy requires a much wider lateral exposure with a full elevation of the cheek flap and division of the infraorbital nerve. This exposure may be achieved by a Weber-Ferguson incision with a subciliary or transconjunctival extension. An alternate approach for total maxillectomy is a Weber-Ferguson incision with an extended Lynch extension curving superiorly and laterally across the brow. This incision, when combined with gentle orbital retraction laterally, permits adequate lateral exposure for total maxillectomy without requiring either a subciliary or transconjunctival extension. A combination subciliary and supraciliary extension of the Weber-Ferguson incision is indicated for total maxillectomy with orbital exenteration.52

Figures 11-6 and 11-7. Anteroposterior and oblique views of a skull delineating the osteotomies required for a medial maxillectomy.

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