return to: Paranasal Sinus Surgery Protocols
Note: last updated before 2013
GENERAL CONSIDERATIONS
- Indications
- Juvenile nasopharyngeal angiofibroma
- Nasopharyngeal, sphenoid, clivus tumors
- Inverting papilloma, Myxoma, adenoma
- Pterygomaxillary space tumors
- Neuroma
- Contraindications
- Young children with juvenile dentition
PREOPERATIVE PREPARATION
- Additional Preoperative Evaluations
- CT scans, MRI, possible angiograms based on tumor type
- Panorex dental film to document preoperative occlusion
- Consent Inclusions
- General risks including bleeding, infection, and reaction to anesthesia
- Specific risks including possible nerve injury (cranial nerve V2)
- Transfusion
- Recurrence with the need for further surgery or adjuvant therapy based on tumor type
- Dental numbness, nonunion, tooth injury
- Malocclusion
- Palate necrosis partial or complete (very rare)
NURSING CONSIDERATIONS
- Room Setup
- See Basic Soft Tissue Room Setup
- Back table x 2
- See Basic Soft Tissue Room Setup
- Instrumentation and Equipment
- Standard
- Special
- Rowe disimpaction forceps
- Richards double-fork retractors
- KLS Free Flap Implant - Instrument Tray
- Rhoton Micro Bayo, bipolar forceps, regular tip 8, 5 in x 1 mm
- Suction coagulator, 10 Fr
- Cautery electrode, ENT/IMA, guarded
- Bone wax
- Throat pack
- Medications (specific to nursing)
- 1% lidocaine with 1:100,000 epinephrine
- Ocular lubricant ointment, ophthalmic
- Balanced salt solution (BSS) 15 ml dropper
- Prep and Drape
- Intraoral prep
- Drape:
- Head drape
- Towels to square off entire face
- Split sheet
- Drains and Dressings
- Xeroform gauze
- Special Considerations
- Blood loss may be rapid, have double suctions available.
ANESTHESIA CONSIDERATIONS
- General Anesthesia
- Tube position: Wired to inferior molars of contralateral side, placed in dental gap to avoid biting during dropdown
- Paralysis: Will aid in exposure
- Systemic Medication
- Antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
- Steroids: Decadron 8 mg IV
- Positioning
- Supine
- Estimated Blood Loss
- Based on tumor type: 1000 cc (300 to 3000)
- Type and cross for 4 units
OPERATIVE PROCEDURE
- Pertinent Anatomy
- It is important to know the location of dental roots and undescended maxillary teeth.
- The internal maxillary artery inters the pterygomaxillary space laterally as it hooks around the neck of the mandibular condyle.
- The internal carotid artery will provide a blood supply to the tumor via the maxillary and vidian canal.
- The pterygoid plates are attached to the maxilla by a bony bridge just posterior to the maxillary alveolar pad posterior to the third molar.
- Nasal and Oral Preparation
- Inject local anesthesia (1% lidocaine with 1:100,000 epinephrine) along the upper gingival buccal sulcus and intranasal along the nasal floor, septum, and nasal sidewall.
- Nasal packing with Afrin bilaterally
- Opening
- Incise 1 cm above gum line, from third molar to third molar.
- Identify the location of bone cuts above roots of teeth extending from the nasal passage (piriform aperture) to the pterygoid plates.
- With the maxilla intact, place bilateral medial and lateral maxillary buttress reconstruction miniplate 1.5 mm (2.0 plate may fit on the posterior buttress in larger children and adult patients), X-, Y-, or L-shaped plates, with ideally at least three screw holes remaining available on each side of the bone cuts (remove). Care must be taken not to bend these plates once removed.
- Make bone cuts along maxillary face, septal cuts, lateral nasal wall cuts (inferior to inferior turbinate).
- Fracture pterygomaxillary bone union with curved osteotome.
- Down fracture lower maxilla with palate using disimpaction forceps.
- Place hinged smooth-tipped self-retaining retractors in the maxillary bony opening to retain the down fractured position. Take care not to occlude the transoral endotracheal tube or compress the upper lip in the retractors.
- Visualize nasopharynx and pterygopalatine fissures. Complete the septal and lateral nasal wall cuts if needed.
- Remove tumor.
- Closure
- Replate maxilla at completion of operation.
- Confirm normal occlusion.
- Close wound with interrupted 3-0 vicryl, followed by running 3-0 chromic.
- Nasal Packing
- Xeroform gauze roll cut into long 1-in-wide strips is packed transnasally into the defect, to include the sphenoid and maxillary sinuses if opened during the surgery.
- Drains
- None
- Dressing
- Nasal drip pad
POSTOPERATIVE CARE
- General Considerations
- Continue antibiotics until packing out
- Bedside humidification
- Dressings
- Change as needed
- Monitoring
- Palate viability
- PO intake
- Packing Removal
- Postoperative day five to seven
- In the operating room in young children
- Follow-Up
- Weekly follow-up until healing complete and then follow-up based on tumor type.
REFERENCES
Brown, DH. The LeFort I maxillary osteotomy approach to surgery of the skull base. J Otolaryngol. 1989;18:289-292.
Drommer RD. The history of the "LeFort I osteotomy." J Max Fac Surg. 1986;14: 119-122.