1. MAXILLECTOMY.pptx

MAXILLECTOMY

1. Maxillectomy Department: ORL MUHAS/MNH Presenter: Resident 3 Omary Mhochi Thuo Samuel Supervisor: Dr. Henry Swai 8 th November , 2021

2. Outline Introduction Surgical anatomy Types of maxillectomy and their indications Preoperative evaluation Surgical techniques Complications Controversies References

3. INTRODUCTION Maxillectomy A surgical procedure to resect the maxilla. It can be partial or total resection of the maxilla. Historical background In 1826, Lazars first described the concept of maxillectomy. In 1829, Syme to performed the first maxillectomy. Bleeding and infection caused high morbidity and mortality. In 1927 Portmann & Retrouvey suggested sublabial-transoral approach to remove maxilla. In 1950s Weber Ferguson came out with lateral rhinotomy incision which caused very little cosmetic deformity.

4. INTRODUCTION In 1954 Smith combined total maxillectomy with orbital exenteration. In 1961, Fairbanks & Barbosa described infratemporal fossa approach to resect advanced malignancies of maxilla. Earlier these tumors were considered to be inoperable. Maxillectomy has potential complications by injury to orbital contents, lacrimal drainage, optic nerve, ethmoid arteries, intracranial contents and may be accompanied bleeding.

5. SURGICAL ANATOMY Bony anatomy Vasculature Nerves

6. SURGICAL ANATOMY. 1.Bony anatomy

7. SURGICAL ANATOMY. 2. Vasculature The significant vein encountered during maxillectomy is from Angular vein .

8. SURGICAL ANATOMY. 2. Vasculature The possible arteries may encountered during maxillectomy are Facial artery (external maxillary artery) and Internal maxillary artery passes through pterygomaxillary fissure enter the pterygopalatine fossa.

9. SURGICAL ANATOMY. 3. Nerves The V2 nerve enters the pterygopalatine fossa via foramen rotundum. The only branch of surgical significance is the infraorbital nerve. It runs in the floor of the orbit/roof of the antrum to exit from the infraorbital foramen. The only other major nerve to be considered during maxillectomy is the optic nerve.

10. INDICATIONS OF MAXILLECTOMY Neoplasm involving maxilla Malignant tumors involving the maxilla. Benign tumors of maxilla with extensive bone destruction. Oral cavity neoplasm extending into the hard palate. Orbital tumors extending into the maxilla. Skull base neoplasm . As part of combined excision of skull base. Nasal tumors Involving lateral wall extending to the maxilla. Fungal infections extensive destruction of sinus. Chronic granulomatous diseases involving nose and sinus.

11. Contraindications Maxillectomy Patient refusal to consent Poor general medical condition of the e.g. uncontrolled diabetes mellitus, poor cardiorespiratory system Tumors extending to the brain Bilateral tumors with bilateral orbital involvement , surgical challenges, challenge to design appropriate prosthesis Malignancies which are highly responsive to chemotherapy and or radiotherapy (e.g. lymphomas, rhabdomyosarcomas) Advanced disease whereby surgery has no gain in life expectancy or quality of life

12. TYPES OF MAXILLECTOMY a) Partial maxillectomy 1. Medial Maxillectomy 2. Infrastructure Maxillectomy 3. Suprastructure Maxillectomy b) Total maxillectomy c) Extended total maxillectomy - Orbital exenteration - Sphenoidectomy - Resection of the pterygoid plates

13. a. PARTIAL MAXILLECTOMY 1. Medial maxillectomy Resection of the media wall of the maxillary sinus , ethmoid sinuses & medial part of the orbital floor, but the eye and hard palate are preserved. Indication : Tumours involving the medial wall of the maxilla, lacrimal sac and ethmoid sinus May be combined with either infra/supra structures maxillectomy Approaches Lateral rhinotomy/Weber-Ferguson

14. PARTIAL MAXILLECTOMY… 2. Infrastructure Maxillectomy resection of the hard palate and alveolar ridge but the orbital floor is preserved. Indication - Tumors limited to the hard palate, floor of the maxillary sinus and nasal cavity Oral tumors extending to the hard palate Maxillary odontogenic tumors Approaches sublabial incision / midfacial de-gloving approach.

15. PARTIAL MAXILLECTOMY… 3. Suprastructure maxillectomy Resection of the orbital floor (+/- exenteration) and ethmoids, the inferior structures (hard palate) are preserved. Indication Tumors limited to the roof of the maxilla Orbital tumors involving the upper part of the maxilla Approaches Lateral rhinotomy/Weber-Ferguson

16. b. TOTAL MAXILLECTOMY Resection of the entire maxilla and the ethmoid sinuses Indication Tumors involving the entire maxilla

17. c. EXTENDED TOTAL MAXILLECTOMY Total maxillectomy may extend to malar complex, sphenoid sinus, cribriform plate (craniofacial resection), contralateral maxilla, skin or orbital contents. Indication Maxillary tumors extending to particular structures

18. PREOPERATIVE CONSIDERATIONS Basic investigations: Hematology – FBP Biochemistry – RFTs Serology : - HIV Hepatitis panel Chest X-ray Specific investigations: Biopsy Imaging – CT scan, MRI (for Dx and surgical planning)

19. PREOPERATIVE CONSIDERATIONS Role of Prosthodontist To design an optimal prosthesis for the maxillary defect. Role of Ophthalmologist Help in ruling out ocular involvement If the orbit is involved- maxillectomy + orbital exenteration

20. PREOPERATIVE CONSIDERATIONS Preoperative consent includes discussing the need for a tracheostomy, facial Scar/Deformity loss of sensation in the infraorbital nerve distribution, diplopia, epiphora , enophthalmos, telecanthus , potential injury to the optic nerve, and visual loss CSF leak.

21. PREOPERATIVE CONSIDERATIONS Pre op antibiotics Reduce post op infection It should be broad spectrum covering normal flora of nose and oral cavity Tarsorraphy Performed on side of the lesion Protect the eye from injury Eye ointment may applied before tarsorraphy to prevent excessive drying of the cornea.

22. PREOPERATIVE CONSIDERATIONS Anaesthesia General anesthesia Preferred Hypotensive Anesthesia to minimize blood loss Orotracheal intubation is preferred secured opposite site to lesion site. Position Supine, with head turned 180 degree from the anesthetist. Jungle juice is injected along the planned skin incision Nasal decongestion with a topical vasoconstrictor.

23. PREOPERATIVE CONSIDERATIONS NGT NGT in position will help in feeding the patient during the initial post-operative period Probable bleeding sites encountered during this incision 1. Angular vein close to the inner canthus of eye. 2. Superior labial artery, When lip is being split 3. Infra orbital vessels when infraorbital limb of the incision made

24. TOTAL MAXILLECTOMY

25. SURGICAL TECHNIQUE The operation may be considered in 3 stages: 1.Soft tissue dissection & bone exposure. Lateral rhinotomy/ Sublabial mucosa/ Midfacial degloving /Weber Ferguson approach 2.Bone resection. The extent of the bony resection is dependent on the primary tumour. 3. Closure/ reconstruction. objectives are to prevent epiphora , to separate the oral cavity from the nose and orbit, to preserve the facial contours, to minimise enophthalmos and diplopia, to maintain nasal airway, and to restore dentition.

26. 1. SOFT TISSUE DISSECTION Approaches…. Lateral rhinotomy Provides better access to medial wall of the orbit and the ethmoid. Weber-Ferguson Lateral rhinotomy + upper lip split + lower eye lid Mid-facial degloving Avoids facial scars

27. Incision… Skin Incision made by a scalpel and remainder of soft tissues by electrocautery. The angular vessels are cauterized or ligated adjacent to the medial canthus of the eye. In Weber Ferguson approach- The sublabial mucosa is incised with electrocautery along the gingivobuccal sulcus onto the maxilla and extended all the way to the maxillary tuberosity. The lower lid incision is placed close to the palpebral margin. The lower lid skin is elevated down to the inferior orbital rim

28. Flap elevation… The soft tissues of the face are elevated off the face of the maxilla using cautery or an elevator. Expose the entire face of the maxilla. Transect infraorbital nerve and vessels with cautery.

29. Flap elevation… Strip the tissues all the way around the maxilla up to the pterygo -maxillary fissure and the zygoma . Don’t use sharp dissection beyond the fissure to avoid transecting internal maxillary artery Sequentially identify the medial canthal ligament, anterior lacrimal crest, lacrimal sac in the lacrimal fossa, and posterior lacrimal crest

30. Flap elevation… Divide the medial canthal ligament. Elevate the lacrimal sac from its fossa. Transect the sac as distally as possible with a scalpel so as to facilitate dacryocystorhinostomy.

31. Flap elevation… Next the medial and inferior orbit is exposed . Strip the orbital contents in a subperiosteal plane from the lamina papyracea and frontal bone

32. Flap elevation… Identify the frontoethmoidal suture: a crucial surgical landmark, corresponding with the level of the cribriform plate and the anterior and posterior ethmoidal foramina . Gently retract the orbital contents laterally and identify the anterior ethmoidal artery, ligate and dissect it ; providing access to the posterior ethmoidal artery . Now strip along the floor of the orbit in a subperiosteal plane, not to tear the periosteum

33. Flap elevation… Next free the soft tissues from the bone up to the anterior free margin of the nasal aperture with diathermy. Retract the nasal ala and incise the lateral wall of the nasal vestibule to expose the ipsilateral nasal cavity and inferior turbinate

34. Flap elevation… Using a tonsil gag in the mouth to retract the tongue, visualise the hard and soft palates . Identify the maxillary tuberosity and the bony spines of the pterygoid plates immediately posterior to the tuberosity. Palpate and define the posterior edge of the hard palate and divide the attachment of the soft palate to the hard palate with electrocautery, thereby entering the nasopharynx. NB :This marks the end of tissue dissection. The bone dissection can now be done

35. 2. BONE RESECTION The extent of the bony resection is tailored to the primary tumour and may include the lateral wall of the orbit and zygoma . Sequence of osteotomies is planned to reserve troublesome bleeding to the end of the procedure.

36. Osteotomies.. Osteotomy through inf. Orbital rim and along the orbital floor Cut through malar buttress lateral to the antrum then posteriorly to the orbital floor aiming for the infraorbital fissure. Osteotomy through frontal process of maxilla and lacrimal bone. kerrison ronguer used due to thick bone. Directed towards but few mm below frontoethmoidal suture line.

37. Osteotomy through the lamina papyracea and anterior ethmoids Gentle tapping by osteotome to enter ethmoid air cells Few mm below fronto ethmoidalsuture line Stops short of the post.ethmoid aa and directed inf. Towards orbital floor to protect optic nn Palatal osteotomy Cut made vertically through the superior alveolus and hard palate . The placement of this osteotomy is dependent on the palatal extent of the tumour. Extended to the post.margin of the hard palate

38. Osteotomy of nasal septum This is only required when the palatal osteotomy is placed across the midline. The nasal septum is then divided parallel to the nasal floor with an osteotome or heavy scissors .

39. Osteotomy to separate maxillary tuberosity from pterygoid plates This is the final osteotomy Tapping done in the groove btn maxillary tuberosity and pterygoid bone Superiorly the cut ends in the pterygomaxillary fissure and pterygopalatine fossa.

40. The maxillectomy specimen can now be gently down-fractured. The internal maxillary artery tethers the specimen laterally and is clipped and divided where it enters the pterygomaxillary fissure. The specimen is removed plus inspected to determine the adequacy of the tumour resection and taken for histological evaluation.

41. Maxillectomy defect

42. 3. CLOSURE/RECONSTRUCTION. Objectives of closure and reconstruction Separate oral cavity from the nose and orbit Prevent epiphora Prevent facial contour. Minimize enophthalmos and diplopia Maintain nasal airway Restore dentition

43. Oronasal separation Dental obturator Split thickness skin graft lined in the inner aspect of maxillectomy. Kept in place by gauze pack –removed on day 5 Obturator fashioned to fill the defect and restore dentition. Remoulded as cavity heals and contracts

44. Oronasal separation … FLAPS Temporalis free flap supplied by deep temporal artery. Anterolateral free thigh flap - Has good bulk and palatal skin cover Scapula tip flap used but bone is suboptimal for dental implants. Free fibula flap Excellent option as it permits dental implants

45. Closure cont …. Epiphora - lacrimal sac is slit along its length and marsupialised by suturing edges to the surrounding soft tissue (dacrocystorhinostomy). Facial contour- Achieved by use of flaps and obturator. Enophthalmos and diplopia - suture periorbita tears and reconstruction of medial wall/ floor of the orbit.

46. ORBITAL EXENTERATION Resection of the orbital contents including the globe. Indications Involvement of orbital apex and/or orbital nerve Involvement of extraocular muscles Involvement of bulbar, conjunctiva or sclera Lid involvement beyond possible reconstruction Involvement of peri-orbital fat.

47. POST OPERATIVE CARE Antibiotics Analgesics Nasal douching Wound care - The patient has to be recalled for nasal toilet upon discharge.

48. COMPLICATIONS Complications Anesthetic Surgical Anesthetic complications Hypersensitivity reaction to anesthetic agents Injury to oral and oropharyngeal tissues Pulmonary edema

49. SURGICAL COMPLICATIONS Early complications Intra op Hemorrhage Nasolacrimal duct injury Injury to the optic nerve Injury to orbital structure CSF leak Late complications Epiphora (stenosis of nasolacrimal duct) Diplopia Enophthalmos Loss of vision Trismus due to scaring Wound infection Facial deformity Meningitis

50. CONTROVERSIE s Bilateral tumor with bilateral orbital involvement (Maxillectomy - S. JIMSON , LAKSHMI KRISHNAN et al 2015) Considered a contraindication to maxillectomy as it will potentially lead to total blindness and also poses a challenge in filling the resultant defect. It is a surgical challenge and also a challenge to design appropriate prosthesis .

51. Controversies …….. Palatal obturators vs Microvascular free flaps (Mauricio A et al- 2010) Both are used to address maxillectomy defects However the optimal techniques remain controversial Palatal obturator – can cause hypernasal speech, repeat prosthesis, hard to obdurate in large defects-heavy n difficult to retain but has shorter post-op hosp.stay and shorter op time. Microvascular flap – more complications, can delay diagnosis of recurrence and longer op time. However can be performed after maxillectomy as one procedure and transfer of bone offers option of dental restoration via implants.

52. Controversies… Classification of maxillary defects: 1.Armany’s Classification 6 categories, based upon the relationship of the defect with the abutment teeth. 2. Spiro Classification -Limited, subtotal and total 3. Liverpool Classification -according to the vertical and horizontal dimensions of the defect 4.Cordeiro’s Classification -Limited, subtotal, total and orbito-maxillectomy

53. Controversies… Maxillectomy + Reconstruction Procedures oncologic safety. “The oncologic safety of these procedures is still debated, and conclusive evidence in this regard has not emerged yet. Management of the orbit is also not yet addressed properly. Tissue engineering, that has been hyped to be one of the possible solutions for this vexing reconstructive problem, has not come out with reliable and reproducible results so far”. ( Maxillary reconstruction: Current concepts and controversies Subramania Iyer and Krishnakumar Thankappa 2014 )

54. REFERENCES Johan Fagan, Open Access Atlas of Otorhinolaryngology, Head & Neck Operative Surgery 2017. Maxillectomy by S. JIMSON 1 , LAKSHMI KRISHNAN 1 , SUDHA JIMSON 2 , B. ANANDH 1 and B. LOKESH. 2015. DOI: http://dx.doi.org/10.13005/bpj/669 Cumming otorhinolaryngology, Head & Neck surgery, 6 th edition David M et al. External medial maxillectomy. Operative technique in Otolaryngology, (2010) 21, 107-110 Bailey, Byron J. Johnson, Jonas T. Newlands, Shawn D. Head & Neck Surgery - Otolaryngology, 4th Edition