CARCINOMA MAXILLA clinical features and managment.ppt

Seminar of malignancy of Maxilla

1. CARCINOMA MAXILLACARCINOMA MAXILLA
PRESENTER:DR.SANTHOSH PRESENTER:DR.SANTHOSH
VELU.P.VVELU.P.V
MODERATOR:DR.T.D.PRAKASHMODERATOR:DR.T.D.PRAKASH
1/12/20081/12/2008

2. EPIDEMIOLOGYEPIDEMIOLOGY
•0.2-0.8% of all carcinomas0.2-0.8% of all carcinomas
•Only 3% of aerodigestive tract Only 3% of aerodigestive tract
(osguthorpe,1994)(osguthorpe,1994)
•In USA & UK incidence is 10/million In USA & UK incidence is 10/million
population/yearpopulation/year
•In japan & africa it is >twiceIn japan & africa it is >twice
•Upto 44% of sinonasal neoplasm are attributed Upto 44% of sinonasal neoplasm are attributed
to occupationto occupation

3. Statistics in INDIAStatistics in INDIA
•0.44% of all body cancers0.44% of all body cancers
•Male: 0.5% female: 0.44%Male: 0.5% female: 0.44%
•Incidence in year 2000 was 0.3/100000 Incidence in year 2000 was 0.3/100000
populationpopulation
•HistologyHistology : 80% are SCC, followed by : 80% are SCC, followed by
adenocarcinomaadenocarcinoma
adenoid cystic carcinomaadenoid cystic carcinoma
melanoma & others.melanoma & others.

4. Risk factors for sinonasal cancerRisk factors for sinonasal cancer
•Hardwood dust (adenocarcinoma)Hardwood dust (adenocarcinoma)
•Softwood dust (squamous cacinoma)Softwood dust (squamous cacinoma)
•Nickel refining; chromium workersNickel refining; chromium workers
•Boot, shoe & textile workersBoot, shoe & textile workers
•Isopropyl oil; volatile hydrocarbonsIsopropyl oil; volatile hydrocarbons
•SnuffSnuff
•Human papilloma virus may be a cofactorHuman papilloma virus may be a cofactor
•Male :female=2:1Male :female=2:1
•Mean age 55 yearsMean age 55 years
retrospective cohort study of nickel-refining workers in wales, retrospective cohort study of nickel-refining workers in wales,
norway & canada ----risk increased 100 times & rises with length norway & canada ----risk increased 100 times & rises with length
of exposure & in inverse proportion to the age at first exposureof exposure & in inverse proportion to the age at first exposure

5. Ethmoid(5%)
•Frontal/sphenoid(2%)
•Nasal walls (45%)
Maxillary(30%)
•Uncertain due to disease extent(18%)
Site incidence of cancer of the nose
& sinuses

6. CLASSIFICATION OF MAXILLARYCLASSIFICATION OF MAXILLARY
NEOPLASMNEOPLASM
•CarcinomaCarcinoma
1.squamous cell carcinoma1.squamous cell carcinoma
2.adenocarcinoma2.adenocarcinoma
3.adenoidcystic carcinoma3.adenoidcystic carcinoma
4.mucoepidermoid ca4.mucoepidermoid ca
5.anaplastic ca5.anaplastic ca
6.transitional cell ca6.transitional cell ca
•SarcomaSarcoma
1.osteogenic sarcoma1.osteogenic sarcoma
2.chondrosarcoma2.chondrosarcoma
3.fibrosarcoma 3.fibrosarcoma
•Odontogenic tumourOdontogenic tumour
1.ameloblastoma1.ameloblastoma
2.odontoma2.odontoma
•OthersOthers
1.melanoma1.melanoma
2.lymphoma2.lymphoma

7. OHNGREN’S CLASSIFICATIONOHNGREN’S CLASSIFICATION
•Suprastructure tumour carrySuprastructure tumour carry
poor prognosis because of poor prognosis because of
proximity to orbit & proximity to orbit &
pterygoid regionpterygoid region
difficulty in resectiondifficulty in resection

8. LEDERMAN’S CLASSIFICATIONLEDERMAN’S CLASSIFICATION
•SuprastructureSuprastructure
•MesostructureMesostructure
•infrastructuresinfrastructures

9. AJCC CLASSIFICATIONAJCC CLASSIFICATION
It is only for sq.cell ca of nose & PNS ,does not include other It is only for sq.cell ca of nose & PNS ,does not include other
tumourstumours
Histologically sq.cell ca is further graded into Histologically sq.cell ca is further graded into
1.well differentiated1.well differentiated
2.moderately differentiated2.moderately differentiated
3.poorly differentiated3.poorly differentiated
Note should also be made of perineural & vascular invasionNote should also be made of perineural & vascular invasion
as well.as well.

10. HARRISON’S CLASSIFICATIONHARRISON’S CLASSIFICATION
T1- T1- bony erosion without involvement of facial skin, orbit,bony erosion without involvement of facial skin, orbit,
ethmoids or PPF.ethmoids or PPF.
TT2- 2- involvement of facial skin, orbit,ethmoidsinvolvement of facial skin, orbit,ethmoids
TT3- tumour extension to NP,SS,CP,PMF.3- tumour extension to NP,SS,CP,PMF.
Others : Others : SISSON’SSISSON’S / /RUBIN’SRUBIN’S / /ESCHWNG’SESCHWNG’S / /AMERICANAMERICAN &&
JAPANESE JOINT COMMITEES PROPOSAL

11. CLINICAL FEATURESCLINICAL FEATURES
1.1.NasalNasal
.epistaxis: profuse, unprovoked,painless.epistaxis: profuse, unprovoked,painless
.nasal obstruction: unilateral, intermittent & progressive.nasal obstruction: unilateral, intermittent & progressive
.anosmia.anosmia
.mass in nasal cavity: friable with irregular surface, bleeds on touch & sensitive to .mass in nasal cavity: friable with irregular surface, bleeds on touch & sensitive to
touchtouch
.foul smelling discharge.foul smelling discharge
2.2.OrbitOrbit
.oedema of eyelid.oedema of eyelid
.proptosis.proptosis
.epiphora.epiphora
.restricted eye movement (advanced stage).restricted eye movement (advanced stage)
.decreased vision & loss of vision.decreased vision & loss of vision
.direct reflex absent ( advanced stage).direct reflex absent ( advanced stage)
.consensual reflex present.consensual reflex present

12. 3.Anterolateral wall3.Anterolateral wall
. paraesthesia of maxillary region due to involvement of . paraesthesia of maxillary region due to involvement of
the infraorbital nervethe infraorbital nerve
.facial swelling.facial swelling
.ulceration of skin in terminal stages.ulceration of skin in terminal stages
4.Posterior wall4.Posterior wall
.trismus.trismus
.swelling in infratemporal fossa.swelling in infratemporal fossa

13. 5.Floor5.Floor
dentures are illfittingdentures are illfitting
paraesthesia of upper molars/premolarsparaesthesia of upper molars/premolars
tingling in upper molars/premolarstingling in upper molars/premolars
reffered pain in molars/premolars (pain increases in reffered pain in molars/premolars (pain increases in
recumbent position)recumbent position)
loosening of toothloosening of tooth
alteration in tooth alignmentalteration in tooth alignment
persistent oroantral fistulapersistent oroantral fistula
swelling of the oral cavityswelling of the oral cavity
ulceration of the palateulceration of the palate
bleedingbleeding

14. 6.Neck node6.Neck node
.nodes seen in the drainage pathway of maxilla.nodes seen in the drainage pathway of maxilla
.usually submandibular group is involved.usually submandibular group is involved
Characteristics of nodeCharacteristics of node
.firm to hard in consistency.firm to hard in consistency
.smooth surface.smooth surface
.margins defined.margins defined
.mobile or fixed.mobile or fixed
.tender or nontender.tender or nontender
.r/o involvement of carotid artery.r/o involvement of carotid artery
7.Metastasis to lungs & spine7.Metastasis to lungs & spine
.lungs—cough & haemoptysis.lungs—cough & haemoptysis
.spine—pain.spine—pain
8.Hearing loss8.Hearing loss due to secondary otitis media with effusion due to secondary otitis media with effusion
9.Cranial nerve palsies—II,III,IV,V,& VI9.Cranial nerve palsies—II,III,IV,V,& VI depending on involvement depending on involvement

15. INVESTIGATIONSINVESTIGATIONS
CT scanCT scan --1.both coronal & axial sections1.both coronal & axial sections
2. contrast & high contrast bone algorithm2. contrast & high contrast bone algorithm
3.PNS & chest screen3.PNS & chest screen
4.site & extent of disease-intracranial/PMF/ITF/ 4.site & extent of disease-intracranial/PMF/ITF/
eye involvementeye involvement
5.CT guided aspiration cytology 5.CT guided aspiration cytology in deep tumour in deep tumour
of antrum & in medial orbit. of antrum & in medial orbit.
critical areascritical areas : posterior ethmoid,sphenoid : posterior ethmoid,sphenoid
sinus,nasopharynx,orbital apex,cribriform plate, PMF, intracranial sinus,nasopharynx,orbital apex,cribriform plate, PMF, intracranial
extensionextension

16. •Disadvantage of CT scanDisadvantage of CT scan
 limitation in soft tissue delineation in areas of high limitation in soft tissue delineation in areas of high
contrastcontrast
intracranial extensionintracranial extension
By CT scan 30% overestimated,due to surrounding By CT scan 30% overestimated,due to surrounding

oedemaoedema

17. MRIMRI
soft tissue extension & delineationsoft tissue extension & delineation
distinguish tumour from sinusitis distinguish tumour from sinusitis
sinusitissinusitis --T1W isointense --T1W isointense
T1W with enhanncement &T2W hyperintense.T1W with enhanncement &T2W hyperintense.
Inverted papillomaInverted papilloma: T1W & T1W with enhancement,both will be isotense: T1W & T1W with enhancement,both will be isotense
•Subtle perineural extension,cavernous sinus involvementSubtle perineural extension,cavernous sinus involvement
•Determining the extent of the tumour relative to the orbitDetermining the extent of the tumour relative to the orbit
•INTRACRANIAL SPREADINTRACRANIAL SPREAD:: bone erosion at the sinus-dural interface(ct scan) bone erosion at the sinus-dural interface(ct scan)
• MRI to evaluate tumour spread beyond the early cortical invasion.the overlying MRI to evaluate tumour spread beyond the early cortical invasion.the overlying
dura will appear thickened & enhanced when tumour invades the duradura will appear thickened & enhanced when tumour invades the dura

the earliest of brain invasion is enhancement of the surface of brain & localised the earliest of brain invasion is enhancement of the surface of brain & localised
edema of the same regionedema of the same region

18. •Orbital involvement:Orbital involvement: erosion of cortical bone erosion of cortical bone
& displacement of the extraocular fat& displacement of the extraocular fat
•MRI/CT combinationMRI/CT combination —evaluating involvement —evaluating involvement
of lacrimal bone, lacrimal sac, NLD.of lacrimal bone, lacrimal sac, NLD.
•Perineural spreadPerineural spread:: enlargement of the enlargement of the
nerve,obliteration of soft tissue plane around nerve,obliteration of soft tissue plane around
the nerve.erosion of facial or skull base along the nerve.erosion of facial or skull base along
the course of involved nerve.the course of involved nerve.
•MRI with paramagnetic contrast materialMRI with paramagnetic contrast material & &
often with fat suppression technique is bestoften with fat suppression technique is best

19. Laboratory investigationLaboratory investigation

Routine blood investigationRoutine blood investigation

Special lab investigationSpecial lab investigation

myelomamyeloma –electrophoresis,bence jones –electrophoresis,bence jones
proteinprotein

olfactory neuroblastomaolfactory neuroblastoma – catecholamines – catecholamines

CSFCSF - - ββ2 transferrin2 transferrin

20. IMMUNOHISTOCHEMISTRYIMMUNOHISTOCHEMISTRY
•Melanoma:Melanoma: s-100;vimentin;HMB-45 s-100;vimentin;HMB-45
•EsthesioneuroblastomaEsthesioneuroblastoma; sustentacular pattern S-; sustentacular pattern S-
100;neuroendocrine markers100;neuroendocrine markers
•Lymphoma:Lymphoma: common leukocyte antigen common leukocyte antigen
•Muscle derivedMuscle derived: muscle specific actin & desmin: muscle specific actin & desmin

21. CXRCXR
1.1. to r/o secondaries in lungto r/o secondaries in lung
2.2. pulpulmonary statusmonary status
3.3. cardiac statuscardiac status
BIOPSYBIOPSY

interior of the mass.interior of the mass.

r/o vascular tumour/csf before biopsy.r/o vascular tumour/csf before biopsy.

biopsy is best done endoscopically – biopsy is best done endoscopically –
intranasally through the medial wall intranasally through the medial wall
of orbit.of orbit.

22. NODAL METASTASISNODAL METASTASIS

CT SCANCT SCAN finding –central nodal necrosis in absence of finding –central nodal necrosis in absence of
infectioninfection
--node size>1.5cm in jd & --node size>1.5cm in jd &
submandibular regionsubmandibular region
--node margin that enhances & ill --node margin that enhances & ill
defineddefined

MRIMRI : T1W : T1W central nonenhancement (necrosis) of central nonenhancement (necrosis) of
nodes with fat suppressionnodes with fat suppression
T2W T2W heterogenecity of nodesheterogenecity of nodes

PET SCANPET SCAN : F 18 : F 18

DUPLEX USS OF NECKDUPLEX USS OF NECK : differentiate benign nodal enlargement : differentiate benign nodal enlargement
from metastasis through differences in pulsatility & resistive indicesfrom metastasis through differences in pulsatility & resistive indices

23. MRI ANGIOGRAPHYMRI ANGIOGRAPHY
•Is done if tumor shows substantial enhancement Is done if tumor shows substantial enhancement
with gadoliniumwith gadolinium
•Is shown to abut ICA.Is shown to abut ICA.
•ArteriographyArteriography reserved for superselective pre reserved for superselective pre
op embolisation.,op embolisation.,
•Also to ascertain good collateral flow pre op, in Also to ascertain good collateral flow pre op, in
case ICA has to be temporarily ligated or case ICA has to be temporarily ligated or
resected per op.resected per op.

24. CONSULTATIONS BEFORE SURGERYCONSULTATIONS BEFORE SURGERY
•Opthalmic Opthalmic - document visual activity- document visual activity
- prosthetic rehabilitation- prosthetic rehabilitation
- harvest corneal graft- harvest corneal graft
- radiation cataract- radiation cataract
•DentalDental
-take dental impression to prepare prosthesis-take dental impression to prepare prosthesis
-attention to periodontal structures before radiotherapy-attention to periodontal structures before radiotherapy
•RadiotherapistRadiotherapist
-when post op radiotherapy is planned ,formulate treatment plans-when post op radiotherapy is planned ,formulate treatment plans
•CounsellingCounselling
-eye removal-eye removal
- facial disfigurement- facial disfigurement
-altered speech,mastication-altered speech,mastication
- regular follow up for- regular follow up for change of obturator change of obturator
r/o recurrencer/o recurrence

25. SURGICAL OPTIONSSURGICAL OPTIONS
•First First assess the bony & soft tissue structures to assess the bony & soft tissue structures to
be included in en bloc resectionbe included in en bloc resection
•SecondSecond approach must be designed to provide approach must be designed to provide
adequate exposure while preserving functional adequate exposure while preserving functional
tissue & cosmesistissue & cosmesis
•ThirdThird repair should be planned to use prosthesis repair should be planned to use prosthesis
or soft tissue techniques for best advantagesor soft tissue techniques for best advantages

26. MEDIAL MAXILLECTOMY/LATERALMEDIAL MAXILLECTOMY/LATERAL
RHINOTOMYRHINOTOMY
•IndicationsIndications: : larger benign or intermediate tumours larger benign or intermediate tumours
involving the entire lateral nasal wall without extension involving the entire lateral nasal wall without extension
to orbit,ACF,lateral maxilla or alveolusto orbit,ACF,lateral maxilla or alveolus
•AnaesthesiaAnaesthesia: GA,15: GA,15° ° head up positionhead up position
temporary tarsorrhaphytemporary tarsorrhaphy
1% lignocaine with 1:2,00,000 local 1% lignocaine with 1:2,00,000 local
infiltrationinfiltration
•Incision:Incision: Moure’s incision(1902),Michaux in 1848Moure’s incision(1902),Michaux in 1848

27. Medial maxillectomyMedial maxillectomy
•Bony excisionBony excision: lateral : lateral
nasal wall including all nasal wall including all
turbinates & contents of turbinates & contents of
ethmoids and maxillary ethmoids and maxillary
sinus.sinus.

28. •Incision,soft tissue elevation and retractionIncision,soft tissue elevation and retraction
•Periosteum elevated & LS displaced laterallyPeriosteum elevated & LS displaced laterally
•Medial canthal lig is partially detached , ant ethmoidal Medial canthal lig is partially detached , ant ethmoidal
vessels clipped.vessels clipped.
•Alternatively Alternatively mid facial degloving approachmid facial degloving approach
•Gingivobuccal incision, soft tissue elevated over nasal Gingivobuccal incision, soft tissue elevated over nasal
spinespine

29. •Then b/l Then b/l
intercartilaginous & full intercartilaginous & full
transfixion incision transfixion incision
appliedapplied
•Circumvestibular release Circumvestibular release
& across floor of nose to & across floor of nose to
base of transfixion base of transfixion
incisionincision
•Deepening across the Deepening across the
floor will link to floor will link to
buccogingival incisionbuccogingival incision

30. •Soft tissues retracted upto FE suture lineSoft tissues retracted upto FE suture line
•LLC elevated, ULC are left attached to pyriform LLC elevated, ULC are left attached to pyriform
apertureaperture
•Perform medial maxillectomy-lateral nasal wall Perform medial maxillectomy-lateral nasal wall
including lateral & superolat aspect of PF,medial 30% including lateral & superolat aspect of PF,medial 30%
of orbital floor and orbital rim,pars papyracea & of orbital floor and orbital rim,pars papyracea &
lacrimal fossa.lacrimal fossa.

31. •First NLD is identified and transected at the level of First NLD is identified and transected at the level of
orbital floororbital floor
•LS is dissected from lac fossa and transectedLS is dissected from lac fossa and transected
•A low lateral osteotomy followed by a superior one, A low lateral osteotomy followed by a superior one,
2mm above the superior canthal ligament is made to 2mm above the superior canthal ligament is made to
reflect nasal bones without detachment.reflect nasal bones without detachment.

32. •Create an access anterior Create an access anterior
antrostomyantrostomy
•Superior and inferior Superior and inferior
resection osteotomyresection osteotomy
•Finally mobilisation of the Finally mobilisation of the
specimen and hemostasis specimen and hemostasis
securedsecured
•Sphenoid and post ethmoid Sphenoid and post ethmoid
are checked by frozen are checked by frozen
sectionsection

33. •Cannulate inferior Cannulate inferior
lacrimal puncta for lacrimal puncta for
identification of L.sac.identification of L.sac.
•Pack cavity with BIPP, Pack cavity with BIPP,
•Incision closed 3/0 Incision closed 3/0
chromic & 5/0 prolene .chromic & 5/0 prolene .

34. RADICAL MAXILLECTOMYRADICAL MAXILLECTOMY
•Indication:Indication: advanced ca advanced ca
of maxillaof maxilla
•PreparationPreparation: patient laid : patient laid
supine with head supine with head
extendedextended
• temporary tarsorrhaphy temporary tarsorrhaphy
& &
tracheostomytracheostomy
•Incision:Incision: weber-ferguson weber-ferguson
incisionincision

35. RADICAL MAXILLECTOMY RADICAL MAXILLECTOMY
INCISIONINCISION
•Gingivo buccal incision.Gingivo buccal incision.
•Curves medially at Curves medially at
junction of hard & soft junction of hard & soft
palate.palate.
•Palatal incision.Palatal incision.

36. Radical maxillectomy incisionRadical maxillectomy incision
•Soft tissue elevated over Soft tissue elevated over
the cheekthe cheek

37. BONE CUTSBONE CUTS
•11
stst
bone cut through the body of bone cut through the body of
zygomazygoma
•22
ndnd
:palate is transected with the gigli :palate is transected with the gigli
saw through the nose into the mouth saw through the nose into the mouth
at the junction of hard & soft palate.at the junction of hard & soft palate.
alveolar cut should pass through the alveolar cut should pass through the
socket of the extracted tooth.socket of the extracted tooth.
•33
rdrd
cut cut: chisel used to separate the : chisel used to separate the
nasomaxilary suture,the separation nasomaxilary suture,the separation
being 2-3mm inferior to anterior & being 2-3mm inferior to anterior &
posterior ethmoid vesselposterior ethmoid vessel
•44
thth
cut: cut: chisel turned posteriorly into chisel turned posteriorly into
the ethmoidal labyrinth to the depth the ethmoidal labyrinth to the depth
of post.ethm.art & then is turned of post.ethm.art & then is turned
inferiorly into the inferior orbital inferiorly into the inferior orbital
fissure.fissure.

38. •
55
thth
cut: cut:it ts last to be made owing to theit ts last to be made owing to the brisk bleeding from IMA & pterygoid brisk bleeding from IMA & pterygoid
plexuses.the mandible is depressed & the pterygoid plates are separated with a plexuses.the mandible is depressed & the pterygoid plates are separated with a
curved osteotome.the entire maxilla can then be rocked anteriorly & inferiorly curved osteotome.the entire maxilla can then be rocked anteriorly & inferiorly
& final soft tissue mucosal & muscular atttachments are released with large & final soft tissue mucosal & muscular atttachments are released with large
scissor.scissor.
•The cavity is packed with BIPP & stay sutures are inserted from the palate The cavity is packed with BIPP & stay sutures are inserted from the palate
remnant to the buccal mucosa to keep pack in place.remnant to the buccal mucosa to keep pack in place.
•If patient has an upper denture or if a partial upper denture has been made If patient has an upper denture or if a partial upper denture has been made
prior to the operation,the pack can be kept in place with this..prior to the operation,the pack can be kept in place with this..

39. •If orbital contents are to be exenterated:If orbital contents are to be exenterated:
 upper lid skin raised from the tarsal plate upwards to upper lid skin raised from the tarsal plate upwards to
the bony orbital rim.( circumferential incision in the bony orbital rim.( circumferential incision in
conjunctiva to preserve lids )conjunctiva to preserve lids )
incise the periosteum along the orbital rim,elevate the incise the periosteum along the orbital rim,elevate the
priosteum medially & superiorly to the apex of SOF & priosteum medially & superiorly to the apex of SOF &
laterally & inferiorly to the IOF.laterally & inferiorly to the IOF.
orbital apex is clamped & scissors used to transect the orbital apex is clamped & scissors used to transect the
optic nerve,vessels,posterior muscle attachments.optic nerve,vessels,posterior muscle attachments.
the fibrous attachments at the IOF are also detached.the fibrous attachments at the IOF are also detached.

40. IMMEDIATE RECONSTRUCTIONIMMEDIATE RECONSTRUCTION
•
Reconstruction of maxillary defect with spitReconstruction of maxillary defect with spit thicknessthickness skin graft skin graft
to the back side of cheek flap & orbital cavity,pterygoid space to the back side of cheek flap & orbital cavity,pterygoid space
folllowed by dental prosthetic appliance.folllowed by dental prosthetic appliance.
•Before incision is closed,upper & lower lacrimal puncta are Before incision is closed,upper & lower lacrimal puncta are
cannulated into the nose,removed after 2-3 months after cannulated into the nose,removed after 2-3 months after
radiotherapy.radiotherapy.

41. COMPLICATIONSCOMPLICATIONS
•Peroperative - bleedingPeroperative - bleeding
•Postoperative – crusting of nosePostoperative – crusting of nose
trismustrismus
impaired motor functionimpaired motor function
•Radiation induced – trismusRadiation induced – trismus
radiation cataractradiation cataract
xerostomiaxerostomia
mucositismucositis

42. MANAGEMENT OF EYEMANAGEMENT OF EYE
•As long as the integrity of the lateral canthus & periorbita is As long as the integrity of the lateral canthus & periorbita is
maintained, no reconstruction is required.maintained, no reconstruction is required.
•When orbital floor is excised with canthal reattachment or excision is When orbital floor is excised with canthal reattachment or excision is
made lateral to whitnall’s tubercle,then the globe looses support for made lateral to whitnall’s tubercle,then the globe looses support for
which the following modalities can be done for reconstruction of which the following modalities can be done for reconstruction of
floor of orbit.floor of orbit.
simple split thickness skin graftsimple split thickness skin graft
transposition of temporalis fascia mediallytransposition of temporalis fascia medially
dermal graftsdermal grafts
tantalum or polyethylene meshtantalum or polyethylene mesh
•If medial canthal ligament has been released, then reattached slightly If medial canthal ligament has been released, then reattached slightly
higher to avoid dystopia & cosmetic deformity.higher to avoid dystopia & cosmetic deformity.

43. •When orbital exenteration is done the lid margins & tarsal plates When orbital exenteration is done the lid margins & tarsal plates
are excised leaving a smooth skin lined cavity.are excised leaving a smooth skin lined cavity.
•removal of lateral wall of the orbit allows the onlay prosthesis to removal of lateral wall of the orbit allows the onlay prosthesis to
be fitted more posteriorly with the medial canthus in its correct be fitted more posteriorly with the medial canthus in its correct
positionposition

44. •If a shallow cavity is created by split thickness skin graft on the If a shallow cavity is created by split thickness skin graft on the
undersurface then patient can wear a black patch or alternatively undersurface then patient can wear a black patch or alternatively
an artificial eye mounted on to a spectacle framean artificial eye mounted on to a spectacle frame

45. CRANIOFACIAL RESECTIONCRANIOFACIAL RESECTION
Operation done in conjunction with a neurosurgeonOperation done in conjunction with a neurosurgeon
Anesthesia :GAAnesthesia :GA
shrinkage of brain is achieved by 200ml of 20%shrinkage of brain is achieved by 200ml of 20%
mannitol in 20min &150mg hydrocort.mannitol in 20min &150mg hydrocort.
deliberate hyperventilationdeliberate hyperventilation
IAP is kept at normal.IAP is kept at normal.

46. INCISIONINCISION
•Lateral rhinotomy approach Lateral rhinotomy approach
continued up through the medial continued up through the medial
canthus on to the forehead upto canthus on to the forehead upto
the hairline.the hairline.
•Allow retraction of frontal boneAllow retraction of frontal bone
•Easier & quickerEasier & quicker
•Other incisions areOther incisions are
1.1.Craniotomy from a bicoronal Craniotomy from a bicoronal
incisionincision
2.2.Midfacial degloving with bicoronal Midfacial degloving with bicoronal
flapflap
3.3.Weber-ferguson incision is required Weber-ferguson incision is required
when complete maxillectomy is when complete maxillectomy is
requiredrequired

47. CRANIOTOMYCRANIOTOMY
•Sheild shaped segment of bone is Sheild shaped segment of bone is
removed from frontal bone.removed from frontal bone.
•This segment comes right down to This segment comes right down to
the floor of anterior fossathe floor of anterior fossa
•Not to cut/tear dura,sagittal sinusNot to cut/tear dura,sagittal sinus
•The dura is lifted off cribriform The dura is lifted off cribriform
plate & fovea ethmoidalis back to plate & fovea ethmoidalis back to
optic foramen,& the optic nerve optic foramen,& the optic nerve
visualised.visualised.
•Frontal lobe retracted & operability Frontal lobe retracted & operability
assessedassessed

48. •Further surgery isFurther surgery is contraindicated contraindicated
if tumour extensionif tumour extension
frontal lobesfrontal lobes
beyond post margin of beyond post margin of
cribriform platecribriform plate
into optic nervesinto optic nerves
laterally outside the boundaries laterally outside the boundaries
of foveaof fovea
•If no contraindicationsIf no contraindications then,then,
maxillectomy is done firstmaxillectomy is done first
cuts are made through fovea on cuts are made through fovea on
each side & through post part of each side & through post part of
CPCP
cutting through the ant ethm cells cutting through the ant ethm cells
allow the whole segment to be allow the whole segment to be
removed in a blockremoved in a block
posterior extension makes en bloc posterior extension makes en bloc
resection difficultresection difficult

49. CLOSURECLOSURE
•Dural defect closed with fascia lata graftDural defect closed with fascia lata graft
•Strengthened by cutting a flap of frontalis & galeal Strengthened by cutting a flap of frontalis & galeal
aponeurosis,& slipping it under the dura in the anterior aponeurosis,& slipping it under the dura in the anterior
fossafossa
A BIPP pack is put in place & oral defect closed with A BIPP pack is put in place & oral defect closed with
either the patient’s own denture or a specially made either the patient’s own denture or a specially made
partial one.partial one.
AFTERCAREAFTERCARE
• antibiotics:because of danger of meningitisantibiotics:because of danger of meningitis
metronidazole (10days) & co-amoxiclav(3wks)metronidazole (10days) & co-amoxiclav(3wks)
neurological observations made for 24 hrsneurological observations made for 24 hrs
anticonvulsant for upto 1 yranticonvulsant for upto 1 yr
CSF leak is expected & treated accordinglyCSF leak is expected & treated accordingly

50. COMPLICATIONSCOMPLICATIONS
•Persistent CSF leakPersistent CSF leak
•MeningitisMeningitis
•Venous bleedingVenous bleeding
•convulsionsconvulsions

51. EXTENDED CRANIOFACIALEXTENDED CRANIOFACIAL
RESECTIONRESECTION
•Indications :each operation tailored individually.Indications :each operation tailored individually.
extensive tumours involving the ant.skull base, pterygoid plates.extensive tumours involving the ant.skull base, pterygoid plates.
•Bony margins:posterior line of resection is defined by the oval Bony margins:posterior line of resection is defined by the oval
foramen,foramen rotundum & ICA.foramen,foramen rotundum & ICA.
excision may extend through the sphenoid sinus & upto excision may extend through the sphenoid sinus & upto
contralateral optic nervecontralateral optic nerve

52. Surgical approach:Surgical approach:
Neurosurgeon & ENTNeurosurgeon & ENT
Combination of bicoronal & anterior or lateral facial incision is Combination of bicoronal & anterior or lateral facial incision is
used.used.

53. LIMITATIONS:LIMITATIONS:
•Does not provide adequate en bloc removal of tumour at orbital Does not provide adequate en bloc removal of tumour at orbital
apex,nasopharynx or deeply infiltrating the pterygoid spaceapex,nasopharynx or deeply infiltrating the pterygoid space
•Supplemented with intraoperative radiotherapy of the skull base Supplemented with intraoperative radiotherapy of the skull base
has been documented to improve local recurrencehas been documented to improve local recurrence
•Other supplements:intraoperative iodine seed implantationOther supplements:intraoperative iodine seed implantation
eg: in adenoidcystic carcinomaeg: in adenoidcystic carcinoma

54. RADIOTHERAPY TECHNIQUES FORRADIOTHERAPY TECHNIQUES FOR
TUMOURS OF NASAL CAVITY & SINUSESTUMOURS OF NASAL CAVITY & SINUSES
•It is essentially same whether pre-op/post-op rxIt is essentially same whether pre-op/post-op rx
•Patient lies supine with head fixed in neutral position by Patient lies supine with head fixed in neutral position by
an individually pepared beam directing perspex.shellan individually pepared beam directing perspex.shell
•Bite block---to depress tongue & lower lip & for mouth Bite block---to depress tongue & lower lip & for mouth
breathing.breathing.
•Volume to be treated is determined on basis of Volume to be treated is determined on basis of
CT/MRI/clinical/surgical assessmentCT/MRI/clinical/surgical assessment
•It includes primary site,tumour extension ,also other It includes primary site,tumour extension ,also other
routes of local spreadroutes of local spread
•If demonstrable nodal spread,then ipsilateral neck should If demonstrable nodal spread,then ipsilateral neck should
also be irradiatedalso be irradiated
•Critical structures to be spared are contralateral Critical structures to be spared are contralateral
eye/brainstem/upper cervical cordeye/brainstem/upper cervical cord

55. •Two fields are used for Two fields are used for
treatment of antral treatment of antral
tumourstumours
1.1.Anterior fieldAnterior field
2.2.Lateral fieldLateral field
•Lateral field should be Lateral field should be
angled 5-10angled 5-10°posteriorly °posteriorly
to avoid irradiation of to avoid irradiation of
contralateral eye.contralateral eye.

56. •For radiotherapyFor radiotherapy of maxillary carcinoma megavoltage x-rays(4- of maxillary carcinoma megavoltage x-rays(4-
6 MV) is used.6 MV) is used.
50-55GY in 20 fractions over 4 wks50-55GY in 20 fractions over 4 wks
60-65GY in 30-33 fractions over 6-6.5wks60-65GY in 30-33 fractions over 6-6.5wks
For lymphoma 40 GY in 20 fractions over 4 wksFor lymphoma 40 GY in 20 fractions over 4 wks
•Intracavitary techniquesIntracavitary techniques for post-op irradiation or treatment of for post-op irradiation or treatment of
small local recurrences. suitable radionuclide is loaded into the small local recurrences. suitable radionuclide is loaded into the
cast of surgical defect, which is worn by the patient for cast of surgical defect, which is worn by the patient for
calculated period.calculated period.
•LIMITATION:LIMITATION:
rapid fall-off of dose away from the surface of mould, so only rapid fall-off of dose away from the surface of mould, so only
relatively superficial tissues are effectively treated.relatively superficial tissues are effectively treated.

57. ADVANTAGES OF PREOP RADIOTHERAPYADVANTAGES OF PREOP RADIOTHERAPY
1.1.Shrinking of tumour Shrinking of tumour inoperable to operableinoperable to operable
2.2.Magnitude of operation necessary may be Magnitude of operation necessary may be
reducedreduced
3.3.Reduces chances that surgical manipulation Reduces chances that surgical manipulation
may cause distant metastasis/local seedingmay cause distant metastasis/local seeding
4.4.Avoids any treatment delay in therapy if wound Avoids any treatment delay in therapy if wound
healing is slowhealing is slow

58. DISADVANTAGES OF PREOP RADIOTHERAPYDISADVANTAGES OF PREOP RADIOTHERAPY
1.1.Surgical complications may beSurgical complications may be increased either increased either
directly or through malnutritiondirectly or through malnutrition
2.2.Patient with good initial response may refuse Patient with good initial response may refuse
surgerysurgery
3.3.Tumour extent less well definedTumour extent less well defined
4.4.Wound healing may be impaired.Wound healing may be impaired.

59. Advantages of post op radiotherapyAdvantages of post op radiotherapy

More effective as bulk of tumor is More effective as bulk of tumor is
reducedreduced

Precise irradiation can be given to Precise irradiation can be given to
residual or suspected marginsresidual or suspected margins

Post op healing is betterPost op healing is better

Few complications of flap Few complications of flap
necrosis,fistula formation,infection.necrosis,fistula formation,infection.

60. 
Post irradiation is also indicated when Post irradiation is also indicated when
bone/cartilage involvedbone/cartilage involved

LN shows extracapsular spreadLN shows extracapsular spread

Neck nodes are multiple / LN >3cmsNeck nodes are multiple / LN >3cms

DISADVANTAGES: DISADVANTAGES:

Post operatively blood supply to Post operatively blood supply to
tissues is interfered, so hypoxic cells tissues is interfered, so hypoxic cells
will not respond.will not respond.

61. CHEMORADIATIONCHEMORADIATION
•Sakai & othersSakai & others over 50 yrs from 1957,in 780 patients at over 50 yrs from 1957,in 780 patients at
kobe & osaka university japan,used 5000 cGy, 5FU, kobe & osaka university japan,used 5000 cGy, 5FU,
tumour reduction & immunotherapy; reported 5yr tumour reduction & immunotherapy; reported 5yr
survival from 20 to 54%,sustantial decrease in functional survival from 20 to 54%,sustantial decrease in functional
disability.disability.
•Rotterdam,Holland Rotterdam,Holland in a series of 60 patient used similar in a series of 60 patient used similar
regimen & showed 2 yr survival 76% & 5 yr survival 65%regimen & showed 2 yr survival 76% & 5 yr survival 65%
•Fitzek & othersFitzek & others used 6920cGy & adjuvent chemotherapy used 6920cGy & adjuvent chemotherapy
with cisplatin-demonstrated local control rates of 88% with cisplatin-demonstrated local control rates of 88%
•Nibu & othersNibu & others : preop 3000-4000 cGy with concomitant : preop 3000-4000 cGy with concomitant
5FU & cisplatin, follwed by 3000-4000cGy post op 5FU & cisplatin, follwed by 3000-4000cGy post op
therapytherapy5yr survival rate of 86% in T3 & 67% in T4 5yr survival rate of 86% in T3 & 67% in T4
lesions.lesions.

62. Maxillary prosthesisMaxillary prosthesis
•Temporary dentureTemporary denture
Advantages Advantages
speech disability is decreasedspeech disability is decreased
eating difficulty is decreasedeating difficulty is decreased
secondary contracture is preventedsecondary contracture is prevented
adhesions of soft tissues minimizedadhesions of soft tissues minimized
METHODS OF RETENTIONMETHODS OF RETENTION
•
teethteeth
• spaces leading to the nasal cavity are made use ofspaces leading to the nasal cavity are made use of
• spiral springsspiral springs
• osseointegrated implantsosseointegrated implants

63. PROPERTIES OF IDEAL IMPLANTSPROPERTIES OF IDEAL IMPLANTS
•Tissue compatibilityTissue compatibility
•Reproduction of skin tones Reproduction of skin tones
•Translucency to x-raysTranslucency to x-rays
•FlexibilityFlexibility
•DurabilityDurability
•Low thermal conductivityLow thermal conductivity
•Lightness in weightLightness in weight
•Ease of processingEase of processing
•Ease of duplicationEase of duplication
•Easy cleaningEasy cleaning
•Chemical & physical Chemical & physical
inertnessinertness

64. SYNTHETIC BIOMATERIALSSYNTHETIC BIOMATERIALS
Since Fallopius implanted aSince Fallopius implanted a gold plate to repair a calvarial gold plate to repair a calvarial
defect in 1600, many bio materials have been tried.defect in 1600, many bio materials have been tried.
Patients undergoing surgery for placement of a synthetic Patients undergoing surgery for placement of a synthetic
alloplast should receive clindamycin or cephalosporin alloplast should receive clindamycin or cephalosporin
pre operatively.pre operatively.
Soak the implant in solution containing bacitracin, gentaSoak the implant in solution containing bacitracin, genta
-mycin,and clindamycin.-mycin,and clindamycin.

65. SILICONESILICONE
•Used for past 40 yearsUsed for past 40 years
•First alloplast usedFirst alloplast used
•One of the fastestOne of the fastest
•Silicone is a polymer of Si & oxygenSilicone is a polymer of Si & oxygen
SOLID SILICONE IMPLANTSSOLID SILICONE IMPLANTS
•Can be fabricated into many shapesCan be fabricated into many shapes
•AutoclavedAutoclaved
•Can be carved intraoperativelyCan be carved intraoperatively
•Inert spacer within a fibrous capsuleInert spacer within a fibrous capsule
•Dacron webbing embedded in some silicone implants for stabilityDacron webbing embedded in some silicone implants for stability
SILICONE GEL IMPLANTSSILICONE GEL IMPLANTS
•Can be broken up into smaller particles and phagocytosed by macrophagesCan be broken up into smaller particles and phagocytosed by macrophages
•Leads to chronic inflammatory reactionLeads to chronic inflammatory reaction
•Can lead to type IV reactionCan lead to type IV reaction

66. BIOPLASTIQUEBIOPLASTIQUE : : Not approved byNot approved by FDAFDA
Specific applicationsSpecific applications
•Malar &submalar augmentationMalar &submalar augmentation
•Genial augmentationGenial augmentation
•Augmentation of the nasal dorsumAugmentation of the nasal dorsum
•ThyroplastyThyroplasty
•Contouring of the frontal bone following frontal sinus Contouring of the frontal bone following frontal sinus
ablation or frontal traumaablation or frontal trauma
•Contouring of the temple due to fascial asymmetrysContouring of the temple due to fascial asymmetrys

67. OthersOthers
•PolytetrafluroethylenePolytetrafluroethylene
•TeflonTeflon –initiates chronic inflammatory reaction if injected –initiates chronic inflammatory reaction if injected
in facein face
•Proplast Proplast
teflon + grafite leads to spongy material of black colourteflon + grafite leads to spongy material of black colour
proplast I –black colourproplast I –black colour
proplast II – white colourproplast II – white colour
pores present. fibrovascular ingrowth gives it strength. proplast hydroxy pores present. fibrovascular ingrowth gives it strength. proplast hydroxy
apatite replaced proplast II ,which was later withdrawn from market.apatite replaced proplast II ,which was later withdrawn from market.
•GoretexGoretex
sheeting composed of a very fine expanded PTTE in a grid fashionsheeting composed of a very fine expanded PTTE in a grid fashion
significant tissue growth is seensignificant tissue growth is seen
best synthetic material currently available for dorsal nasal augmentationbest synthetic material currently available for dorsal nasal augmentation

68. METAL IMPLANTSMETAL IMPLANTS
Osseointegrative implants provide attachment points to which a Osseointegrative implants provide attachment points to which a
restorative facial prosthesis can be fixed. permanently embedded in restorative facial prosthesis can be fixed. permanently embedded in
patient’s bone.patient’s bone.
All metal implants classified as All metal implants classified as
1.1.Cobalt chromium alloys & titaniumCobalt chromium alloys & titanium
2.2.Stainless steelStainless steel
Bone grows upto the osseointegrating implants & binds to their surface Bone grows upto the osseointegrating implants & binds to their surface
without an intervening layer of fibrous tissue.without an intervening layer of fibrous tissue.
The bone does this as the bone recognises it as a biological materialThe bone does this as the bone recognises it as a biological material
EPITEC SYSTEMEPITEC SYSTEM
Three dimensional titanium reconstruction plates with percutaneous Three dimensional titanium reconstruction plates with percutaneous
implant posts to create unique system that is very strong and requires implant posts to create unique system that is very strong and requires
very little bone for fixation.very little bone for fixation.

69. Metal implantMetal implant

70. referencesreferences
•Tumors of nose and sinuses,stell and maran’s Tumors of nose and sinuses,stell and maran’s
head and neck surgery 4head and neck surgery 4
thth
edn p377-396. edn p377-396.
•Cysts , granulomas and tumors of jaws ,nose Cysts , granulomas and tumors of jaws ,nose
and sinuses, A.D Cheesman and P. jani scott-and sinuses, A.D Cheesman and P. jani scott-
brown’s otolarngology 6brown’s otolarngology 6
thth
edn p5/23/1-40. edn p5/23/1-40.
•Neoplasms ,ernest A weymuller,jr. thomas j.gal , Neoplasms ,ernest A weymuller,jr. thomas j.gal ,
cummings otolaryngology 4cummings otolaryngology 4
thth
edn p1197-1215 edn p1197-1215

71. THANK YOUTHANK YOU
THANK YOUTHANK YOU
THANK YOUTHANK YOU