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Maxillectomy

last modified on: Tue, 02/27/2024 - 08:57

return to: Paranasal Sinus Surgery Protocols

Note: last updated before 2013

GENERAL CONSIDERATIONS

  1. Indications
    1. Removal of malignant and benign tumors of the nose and paranasal sinuses
    2. Removal of malignant and benign tumors of the oral cavity that extend into the hard palate
    3. As part of the treatment of fulminant invasive fungal sinusitis
  2. Contraindications
    1. General patient infirmity
    2. Tumor extent requiring bilateral orbital exenteration is generally held to be a contraindication
    3. Tumor eroding or invading through the skull base requires a craniofacial resection rather than maxillectomy in isolation

PREOPERATIVE PREPARATION

  1. Evaluation
    1. Essential for most cases
      1. Axial and coronal CT scan
      2. Oculoplastic/Ophthalmology Service consultation may assist with decisions regarding orbital involvement
      3. Dental Service consultation for fashioning an obturator when palatal sacrifice is anticipated. In patients not undergoing palatal removal and in whom radiation therapy is anticipated postoperatively. Dental consultation may also be needed to address the need for dental extraction.
      4. For palatal lesions that cross the midline of the palate, a prosthetic repair may not be possible. Reconstruction may require a pedicled soft tissue flap from the temporalis muscle or a free tissue transfer.
  2. Consent
    1. Description
      1. Remove the teeth, palate, sinus, and possibly eye (in selected cases) through an incision under the lip and/or along the side of the nose, possibly splitting the lip. This may be followed by a tracheotomy and the need for prosthesis, nasal packing, and skin graft. A tube may be placed in the tear drainage system.
      2. A preoperative decision should be made on how the eye is to be managed, if involvement is identified at the time of surgery.
    2. Potential complications
      1. Bleeding
      2. Infection
      3. Epiphora
      4. Breakdown of skin graft
      5. Atrophic rhinitis
      6. Numbness of cheek

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Basic Soft Tissue Room Setup
      1. Back table x 2
      2. Audio-visual unit (for possible endoscopy procedure)
      3. Fibertopic light source
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
      4. Nasal Prep Tray
      5. Nasal Sharp Tray
      6. Bien Otologic Electric Drill Tray
      7. Padgett Dermatome Instrument Tray
      8. Sinus Tray
      9. Rongeur Tray, Large
      10. Rongeur Tray, Small
      11. Hall Micro Sagittal Saw Tray (Pneumatic)
    2. Special
      1. Sphenoid Punch Tray
      2. Woodruff Screw Implant - Instrument Tray
        (used to secure palatal prosthesis)
      3. Zimmer hand drill (used with Woodruff screws)
      4. Smith-Petersen osteotomes
      5. Telescope (Storz), Hopkins straight, forward, 0°
      6. Storz fiberoptic light cable, 3.5mm x 230cm
      7. Tracheotomy Tray
      8. Extraction Tray
      9. Obwegeser Retractor Tray 2
      10. Gilgi saws
      11. Dentistry awls and 25-gauge wire for circumzygomatic wires
      12. Jorgenson scissors, curved, 9 in
      13. Cummings retractor, large
      14. Syringe, Luer tip, 30 cc x 2 and needle, blunt, 18-gauge, x 2 to use for irrigation while drilling
      15. Cautery electrode needle, guarded
      16. McKesson mouth prop, large and small
      17. Neurosurgical cottonoids 1/2 x 3 in
      18. Throat pack
      19. Corpak feeding tube
  3. Medications (specific to nursing)
    1. Antibiotic ointment
    2. 1% lidocaine with 1:100,000 epinephrine
    3. Oxymetazoline HCL spray, 0.05%
    4. Balanced salt solution (BSS), 15 ml sterile drop-tainer, x 2
    5. Ocular lubricant ointment, ophthalmic
    6. FRED (fog reduction elimination device)
  4. Prep and Drape
    1. Standard preparation
      1. Prep face with half-strength providone iodine diluted with saline, 1:1
      2. Prep skin graft site with 10% providone iodine
    2. Drape
      1. Head drape
      2. Towels around face and neck and skin graft site
      3. Split sheet
  5. Drains and Dressings
    1. Xeroform gauze, 4 in x 3 yd
    2. Adaptic, large
    3. Nasal endoscopy equipment may also be needed
  6. Special Considerations
    1. Tarsorrhaphy suture may be placed
    2. Oculoplastics instrumentation may be needed, including instruments/supplies for lacrimal stenting depending on the extent of the excision.

ANESTHETIC CONSIDERATIONS

  1. Intubation achieved either via an oral endotracheal tube or via a nasal tube in the contralateral nostril.
  2. Type and save 2 units of blood for a maxillectomy; blood does not need to be prepared for a medial maxillectomy.
  3. Head of the bed elevated
  4. Systemic medications
    1. Decadron, 8mg, IV
    2. See Antibiotic Prophylaxis in Head and Neck Surgery protocol

OPERATIVE PROCEDURE

  1. Local Injection (1% lidocaine with 1:100,000 epinephrine)
    1. Subciliary, paranasal and sublabial regions prior to prep
  2. Incisions/Approaches
    1. Lateral rhinotomy: indicated for medial maxillectomy without palate or orbit involvement.
    2. Weber-Ferguson (including lip split): provides enhanced exposure of alveolus, facilitating partial palatectomy. Lip split not usually necessary without palate involvement.
    3. Diefenbach (subciliary) extension: best exposure for orbital and/or lateral wall involvement.
    4. Facial degloving: rhinoplastic release; no external scar; permits bilateral exposure; best for pediatric patients with fibro-osseous tumors of the medial maxillae or selected cases of inverting papilloma. This may be combined with a subciliary incision (for orbital floor access) or a Lynch incision (for medial orbital wall access). This minimizes facial incisions (see Facial Degloving Approach protocol).
  3. Mucosal Incisions
    1. Incise entire length of gingivobuccal sulcus and posteriorly around maxillary tuberosity, as dictated by tumor extent.
    2. Detach soft palate.
    3. Incise palatal mucosa with attention to preserving as much mucosa as possible to drape over bone.
  4. Raise Cheek Flap
    1. Usually cut infraorbital nerve, unless tumor is clearly limited to the maxillary infrastructure.
    2. May extend around lateral maxillary sinus to identify and clip inferior maxillary artery to decrease subsequent bleeding.
  5. Explore Floor of Orbit
    1. Decision regarding orbital exenteration is made based on findings of floor and medial wall exploration.
  6. The principles of performing the bloodiest cuts last should be observed, in that hemostasis is most readily effected with the specimen removed. An external ethmoidectomy approach (see separate protocol) permits exploration of the periorbita and separation of the sinuses from the eye early in the dissection with minimal bleeding.
  7. Bone Cuts (Bloodiest Bone Cuts Made Last)
    1. Medial maxillectomy
      1. Anterior wall of maxillary sinus is removed with osteotome and rongeurs. This may leave the medial buttress (piriform aperture strut) intact, if not involved or not hindering exposure. Alternatively, this bone can be removed en bloc and later plated back.
      2. Osteotome is used to cut horizontally through lateral nasal wall inferiorly at level of nasal floor (inferior meatus). Cut extends from medial maxillary buttress to posterior limit of sinus.
      3. Vertical cut is made from anterior floor to anterior ethmoid cells just posterior to medial maxillary buttress and nasolacrimal duct (if not involved).
      4. Orbital contents retracted laterally, as horizontal cut is made through the anterior ethmoid labyrinth, extending from the previous vertical cut anteriorly to the anterior ethmoid artery. The artery is ligated and divided for further posterior extension. Cut is made below frontoethmoidal suture line that marks the level of the cribriform plate.
      5. Right-angled scissors are used to make final cut vertically from posterior floor to posterior tip of superior turbinate and postethmoid cells. This cut is typically between palatine bone and pterygoid process of sphenoid bone. Scissors are introduced through nasal cavity and lateral blade passed through inferior bone cut. Gentle bimanual rocking motion (two fingers) frees bone segment posteriorly, permitting delivery through maxillary sinus or nasal cavity.
    2. For palate involvement (subtotal maxillectomy)
      1. Remove central or (preferably) lateral incisor with bone cut to be made directly through center of extraction site.
      2. With Gigli saw placed around posterior end of hard palate, with one end through the nose and the other through the mouth, palatal cut is rapidly accomplished with care to preserve as much palatal mucosa as possible. This approach with the Gigli saw is rapidly effected and is a reasonable approach; a careful contoured bone cut is not required. The Midas-Rex drill is a more sophisticated bone cutting tool that is currently used more frequently for this bone cut than the Gigli saw.
    3. For orbit involvement
      1. Consider orbital exenteration, if periorbita involved.
      2. Transect orbital floor with osteotome as laterally as necessary. It is best to preserve anterior zygomatic arch for facial contour, but tumor extent may require its sacrifice (which permits greater exposure to the IMA, infratemporal fossa, and pterygoid plates).
    4. For lateral wall involvement, entire maxillary sinus is removed en bloc with transection of pterygoid plates.
    5. Brisk bleeding is expected and controlled with large lap packs initially, then with bipolar cautery and figure-of-eight suture ligatures through pterygoid muscles.
  8. Insertion of Nasolacrimal Stent (if required)
  9. Support for Orbit (Options)
    1. Skin graft to periorbita
    2. Temporalis flap: transect coronoid process low on mandible, swing temporalis medially, and wire coronoid to frontal process nasal bones.
    3. Titanium mesh and skin graft reconstruction
  10. Skin graft is placed on undersurface of cheek flap and any other raw surfaces capable of accepting skin graft, including exposed bone (0.015 in).
  11. Secure Surgical Prosthesis
    1. Modify previously-fabricated surgical obturator
      1. If prosthesis is not made, may use 4 x 4 gauze soaked in bacitracin ointment to obturate defect.
      2. May alternatively adapt dentures as obturator.
    2. The Woodruff screw technique is now obsolete and mentioned primarily for historical purposes. The KLS 2.0 mm titanium screws (usually x2) are used to secure the prosthesis to the palatal bone.
    3. The Woodruff screw technique
      1. Place obturator intraorally. Identify optimal site for screw hole(s). Remove obturator and drill hole (7/64 in) through proposed site. Replace obturator and, with 4 x 4 gauze in mouth to catch plastic tailings from obturator, drill through bone to adequate depth to engage screw (8/64 in). Length of screw is determined by placing 25-gauge needle (on syringe) through hole in place, mucosa, and depth of hole in bone. Screw hole into bone, securing plate.
      2. With unstable screw(s) or inadequate bone, secure prosthesis with circumzygomatic wires.
  12. Pack wound on top of surgical obturator with Furacin gauze, Xeroform gauze, or 0.5 in Iodoform gauze soaked in Bacitracin.
  13. Consider
    1. NG feeding tube
    2. Nasal airway placement through middle of packing
    3. Trach

POSTOPERATIVE CARE

  1. Admission to Hospital
  2. Oral Care
    1. Salt and soda rinses, beginning when patient awakens
    2. Begin oral feedings as soon as tolerated
    3. Remove surgical prosthesis on postoperative day 6 to 8
    4. Oronasal irrigations QID as soon as obturator removed
  3. Continue antibiotics while the wound is packed.
  4. Close attention is paid to modifications of interim obturators by Oto-Dental-Prosthodontics.
  5. Most cancers will receive radiotherapy (all T3 and T4, selected T1 and T2, based on clinical/pathologic features).

REFERENCES

Montgomery WW. Surgery of the Maxillary Sinus. In: Montgomery WW, ed. Surgery of the Upper Respiratory System. Vol. 1. Philadelphia, Pa: Lea & Febiger. 1971;169-194.

Schramm VL, Myers EN. How I do it-head and neck: a targeted problem and its solution, lateral rhinotomy. Laryngoscope 1978;88:1042-1045.

Sessions RB, Larson DL. En bloc ethmoidectomy and medical maxillectomy. Arch Otolaryngol. 1977;103:195-202