Download Endoscopic medial maxillectomy

Operative Techniques in Otolaryngology (2010) 21, 111-116
Endoscopic medial maxillectomy
Kelly Cunningham, MD, Kevin C. Welch, MD
From the Department of Otolaryngology - Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois.
KEYWORDS
Inverted papilloma;
Medial maxillectomy;
Endoscopic sinus
surgery;
Maxillary sinus;
Ethmoid sinus;
Minimally invasive
surgery
Historically, neoplastic processes of the lateral nasal wall and maxillary sinus have been treated with
external procedures. Advances in endoscopic sinus surgery have enabled some of these same disease
processes to be treated using endoscopic techniques. Endoscopic medial maxillectomy may be used as
an alternative to more invasive external approaches while maintaining similar cure rates. In this article,
the authors describe the endoscopic medial maxillectomy for neoplastic diseases involving the maxillary sinus.
© 2010 Elsevier Inc. All rights reserved.
Before the era of endoscopic sinus surgery, neoplastic
disease (such as inverted papilloma or malignant neoplasms) of the maxillary sinus was traditionally accessed
surgically with open procedures. Although the the lateral
rhinotomy with medial maxillectomy resulted in excellent
exposure of the lateral nasal wall and maxillary sinus with
good surgical cure rates, the procedure often resulted in
external scars with significant patient morbidity. The midface degloving procedure was first suggested by Portmann1
in 1927 as a means of obviating the shortcomings presented
by the lateral rhinotomy approach. However, the prolonged
postoperative healing and complications detract from the
utility of the procedure.
With the advances in endoscopic techniques, many now
advocate minimally invasive management of neoplasms involving the lateral nasal wall and maxillary sinus to limit the
morbidity historically associated with open techniques.
Technological advances, such as stereotactic image-guided
surgery and powered endoscopic tools, coupled with angled
lenses and instrumentation, have made the endoscopic medial maxillectomy a workhorse for the minimally invasive
treatment of maxillary sinus neoplastic disease. Sukenik and
colleagues2 have demonstrated that endoscopic evaluation
has a higher specificity when differentiating diseased and
Address reprint requests and correspondence: Kevin C. Welch,
MD, Department of Otolaryngology - Head and Neck Surgery, Loyola
University Medical Center, 2160 S. First Ave, Maywood, IL 60153.
E-mail address: [email protected].
1043-1810/$ -see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2010.06.002
normal mucosa. More significantly, this minimally invasive
technique in selected disease processes, such as inverted
papilloma, has been shown to have cure rates comparable
with traditional open approaches.3-6
In this article, the authors describe the indications as well
as operative technique for endoscopic medial maxillectomy.
Whereas others7 have described the use of the endoscopic
medial maxillectomy for refractory inflammatory sinus disease, we will focus on the use of the endoscopic medial
maxillectomy for neoplastic disease involving the lateral
nasal wall and maxillary sinus.
Indications
Indications for endoscopic medial maxillectomy are comparable to those of an open or external approach medial
maxillectomy. These indications include sinonasal neoplasms, inverted papilloma, as well as intractable inflammatory disease. However, in dealing with malignancies, the
same oncological principles used in open procedures, such
as complete resection, as well as margin control must be
applied to the endoscopic technique. Application of this
principle often precludes an endoscopic medial maxillectomy given the difficulty of visualizing, in particular, the
anterior maxillary sinus wall. Involvement of soft tissue
beyond the sinonasal cavity may preclude an endoscopic
approach as well. Therefore, detailed examination of the
tumor and the surrounding anatomy must be undertaken
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defer biopsy until in the operating room. As previously
mentioned, if a patient is selected to undergo an endoscopic medial maxillectomy, we inform all patients that
an adjuvant open procedure or conversion to open procedure may be necessary to ensure the complete removal
of the lesion.
Surgical technique
Figure 1 A coronal CT scan of a patient with inverted papilloma. A soft tissue mass (*) can be seen filling the infundibulum,
middle meatus, and nasal cavity. Although the transition between
tumor and inspissated secretions cannot be seen on this scan, focal
bony thickening (arrow) medial to the infraorbital canal (arrowhead) can be seen. This focal thickening suggests tumor attachment.
before recommending an endoscopic approach. Despite the
recent advances in hand instruments and angled telescopes,
sinus anatomy or tumor location may limit the applicability
of the endoscopic approach. Therefore, the patient is always
informed of the possibility of performing an adjuvant combined open approach, such as the Caldewell-Luc or midfacial degloving procedure. However, the superior image provided by the endoscope can still aid with visualization and
identification of diseased mucosa to preserve as much
healthy mucosa as possible if the procedure must be converted to an open approach.
Preoperative planning
When a neoplastic process, such as an inverted papilloma, is
suspected, both computed tomography (CT) and magnetic
resonance imaging (MRI) should be performed. The CT
provides crucial information regarding the status of the bone
surrounding the lesion. The CT should be examined for the
location of the tumor and for any focal bony hyperostosis or
erosion (Figure 1). Hyperostosis may indicate a site of
attachment for inverted papilloma, and a close inspection
along the lamina papyracea and walls of the maxillary sinus
is performed. Evidence of bone erosion is concerning for
malignancy. The addition of an MRI helps the surgeon
distinguish tumor from inspissated secretions or polypoid
mucoperiosteal thickening and reveals the status of extranasal tissue when sinus bone is eroded.
If possible, a biopsy is performed in the clinical setting;
if a vascular tumor is suspected, the surgeon may choose to
Endoscopic medial maxillectomy is performed under general anesthesia using total intravenous anesthesia (TIVA).8,9
The use of TIVA has been shown to decrease intraoperative
blood loss and may be beneficial when blood loss might be
expected to be high.9 The nose is decongested topically with
1% oxymetazoline and 4% topical cocaine, and the mucosa
of the inferior turbinate and lateral nasal wall is injected
with 1% lidocaine with 1:100,000 epinephrine. A transoral
pterygopalatine injection can be performed by inserting a
25-gauge needle into the greater palatine foramina, which is
located opposite the second molar, to provide additional
hemostasis.
After initial inspection with the 0-degree telescope, the
resection is primarily performed with a 4-mm, 30-degree
telescope. The middle turbinate is reflected toward the septum, and the middle meatus is inspected (Figure 2). The
initial step involves debulking the tumor to locate the site of
attachment. If it extends from the ethmoid into the maxillary
sinus or vice versa, debulking is performed with the microdebrider. All sinonasal contents are collected in a suction
trap to be sent to pathology. Care is taken to avoid injury to
the septum and the inferior turbinate. We periodically stop
and inspect the cavity to determine whether there are any
attachment sites along these aforementioned structures. This
point cannot be underscored because the tumor in its entirety, including attachment point, must be resected. This
principle is followed during the entire surgery.
The next step is to identify and visualize the maxillary
ostium. The uncinate process is resected with a backbiting
instrument and the natural os of the maxillary sinus is
identified. The natural ostium is widened with throughcutting forceps or the microdebrider. Again, we stop to
inspect the cavity to determine whether the tumor is attached or pedicled off any of these structures. Once a wide
anstrostomy is performed, Hasner’s valve is identified in the
inferior meatus. The valve is located approximately 30-35
mm posterior to the limen nasi and must be identified before
performing the maxillectomy; otherwise, the surgeon risks
injury to the lacrimal apparatus.
An inferior turbinectomy is performed next using the
endoscopic scissors. Although a total turbinectomy may be
performed, we often find total removal unnecessary and
prefer to remove the middle third only, when permitted. The
inferior turbinate, therefore, is incised between the anterior
one-third and the posterior two-thirds of the turbinate, just
behind Hasner’s valve (Figure 3). If tumor involves the
nasolacrimal duct, it is sacrificed and a dacryocystorhinostomy is performed at the conclusion of the procedure to
Cunningham and Welch
Endoscopic Medial Maxillectomy
113
instrumentation. This is performed with a backbiting instrument until the anterior wall of the maxillary sinus is reached
near the piriform aperture. Stereotactic navigation is very
helpful in confirming the local anatomy and the location of
the tumor during this exposure. If tumor is known preoperatively or intraoperatively to involve the medial maxillary
wall just lateral to the lacrimal duct, this region cannot be
addressed endoscopically unless the duct is resected or an
adjuvant canine fossa puncture is performed for access and
surgical manipulation.
Once opened (Figure 5), the maxillary sinus is inspected
thoroughly to evaluate for a possible site of attachment and
any unaddressed tumor. This is done with the 30- and
70-degree telescopes. Stereotactic probes are used to correlate the endoscopic view with the CT images to confirm the
completeness of the resection. When present, tumor is extirpated from the maxillary sinus along with surrounding
mucosa. When dealing with inverted papilloma, cautery is
performed to fulgurate nests of inverted papilloma. Inverted
papilloma may infiltrate the underlying bone at the site of
Figure 2 Endoscopic view with a 0-degree telescope of a left
maxillary sinus inverted papilloma. The middle turbinate (*) is
reflected toward the septum (S). A key distinction between inverted papillomas and benign sinonasal polyps is the lobulated
papillomatous appearance of inverted papilloma.
prevent epiphora. The incision of the turbinate is carried up
toward the antrostomy, just posterior to the lacrimal duct.
Finally, the posterior portion of the turbinate is incised near
the pterygoid plates.
The mucosa of the inferior meatus and nasal cavity floor
is elevated toward the septum. Through-cutting instruments
are used to resect the medial maxillary wall down to the
nasal floor. If needed, a high-speed irrigating drill can be
used to remove bone too thick for through-cutting punches
(Figure 4). At this point, the maxillary sinus opens directly
onto the floor of the nasal cavity, and the medial maxillary
wall has been removed nearly completely. Because Hasner’s valve is situated in the superior aspect of the inferior
meatus, the medial maxillary wall inferior to the valve can
be resected to provide additional exposure and room for
Figure 3 The inferior turbinate is reflected superiorly to identify
Hasner’s valve. Using endoscopic scissors, the inferior turbinate
(IT) is excised just posterior to Hasner’s valve (arrowhead).
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irrigation bur. The ability to closely inspect the remainder of
the ethmoid cavity and the frontal recess highlights the
advantages the endoscopic approach has over the open or
external approaches to the medial maxillary wall).
Margins around the sites of attachment are taken to
ascertain the completeness of the resection. If a margin
cannot be obtained using endoscopic instruments, a decision
must be made regarding whether to perform an adjuvant
open procedure. At the termination of the procedure, a final
inspection is performed, and the maxillary sinus is irrigated
and filled with a hemostatic agent. Light packing is placed
within the ethmoid cavity.
Figure 4 Following a wide maxillary antrostomy, the medial
maxillary wall is taken down using a combination of throughcutting instruments as well as the suction–irrigation diamond
bur drill. In this figure, the posterior third of the IT, Hasner’s
valve (arrowhead), and maxillary sinus (MS) is identified. Tumor (T) is identified along the floor of the maxillary sinus in
this patient.
attachment10; therefore, this bone must be removed. Highspeed suction–irrigation diamond burs are used to thin the
bone along the attachment site of the tumor to address these
histologic nests.
Ethmoid involvement is addressed simultaneously during this approach, and this represents the superior-most
aspect of the resection. When necessary (eg, tumor involvement), the middle turbinate is excised. In doing so, the
turbinate should be removed in such a fashion to avoid
postoperative lateralization and obstruction of the frontal
recess (Figure 6). If the tumor is attached to any degree to
the lamina papyracea, the site is resected along with the
bone itself to expose the periorbita; bone may be removed
with hand instruments or drilled down with the suction–
Figure 5 Surgical defect viewed with a 30-degree telescope.
When complete, the defect permits complete visualization of the
entire maxillary sinus. Surveillance can be performed with 30- and
70-degree telescopes. In this figure, the posterior choana (PC),
inferior turbinate stump (IT), and MS are visualized.
Cunningham and Welch
Endoscopic Medial Maxillectomy
115
disease, it is inferior to endoscopic technique in differentiating between disease and normal mucosa. Their
study found that CT was 69% sensitive and only 20%
specific; however, intraoperative endoscopic examination
had the same sensitivity but superior specificity (68%),
further illustrating the capability of endoscopy to provide
superior tumor delineation.
The endoscopic technique does maintain key oncological
principles by performing complete resection of the tumor
pedicle and allowing adequate margin control using frozen
sections intraoperatively.5,17 There may be portions of disease that may have to be removed piecemeal to allow better
visualization of the tumor attachment site; however, complete tumor removal should still be the guiding principle.4 In
the present cost-conscience health care environment in
which operative time and hospital stay are two important
considerations in surgical planning, endoscopic medial
maxillectomy offers advantages.3,18
Conclusions
Figure 6 When the middle turbinate is excised, the turbinate
should be excised in a manner that prevents postoperative lateralization and obstruction of the frontal recess. The dotted line indicates a proposed incision line. Close monitoring of the frontal
recess is advised during the postoperative setting.
Discussion
The endoscopic medial maxillectomy is rapidly replacing
open medial maxillectomy, which has traditionally been
considered the gold standard treatment for neoplastic disease involving the lateral nasal wall and maxillary sinus.
The underlying principles of functional endoscopic sinus
surgery aim to preserve as much normal mucosa to maintain
sinonasal physiology. Endoscopic techniques offer decreased morbidity while maintaining comparable recurrence
rates. The recurrence rate for external approaches for the
inverted papilloma varies from 0% to 36%,11-14 whereas the
recurrence rate of endoscopic approach for the inverted
papilloma varies from 0% to 25%.4-6,15,16
The endoscopic technique offers several advantages to
open techniques for patients and surgeons. For patients,
the lack of facial scars is appealing cosmetically, but, for
the surgeons, the endoscope also offers superior visualization of the tumor bed, allowing more accurate mapping and resection of the tumor. A study performed by
Sukenik and Casiano2 found that, although preoperative
CT imaging is adequate for detecting the presence of
When used appropriately, the endoscopic medial maxillectomy is a viable option for the treatment of refractory
maxillary sinus disease and sinonasal neoplasms. Patients
undergoing this treatment experience less morbidity
when compared with traditional approaches and similar
cure rates. Despite the advantages provided by the endoscopic approach, the authors strongly caution that oncological principles always be followed and that adjuvant
external procedures be performed when necessary to
completely eradicate any disease present.
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