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Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 75-79

Open and endoscopic medial maxillectomy for maxillary tumors – a review of surgical options

1 Departments of Otorhinolaryngology - Head and Neck Surgery, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
2 Department of Anatomy, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

Date of Submission16-Feb-2019
Date of Acceptance03-Sep-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Baharudin Abdullah
Department of Otorhinolaryngology – Head and Neck Surgery, School of Medical Sciences, University Sains Malaysia, 16150 Kubang Kerian, Kelantan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_6_19

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It has been the gold standard approach for maxillary tumors to do an open radical maxillectomy. The introduction of endoscopic surgery has provided an alternative method for tumor removal without creating a cosmetically disfiguring scar. We reviewed the literature to describe the open and endoscopic medial maxillectomy for the management of maxillary tumors. This review is based on a selective literature search of the PubMed database, searching for the terms “medial maxillectomy,” “endoscopic medial maxillectomy,” “partial maxillectomy,” “maxillary tumors,” “sinonasal neoplasms,” and “inverted papilloma.” Some older standard publications, textbooks, and our own clinical experience were also included. No language or year of publication restriction was applied. The indication for medial maxillectomy, either open or endoscopic medial maxillectomy is inverted papilloma, a benign locally invasive sinonasal tumor. The aim is to remove all diseased tumor tissue together with complete margin clearance. At the same time, the wide cavities provide easier monitoring of recurrent tumor on follow-up. Lack of complications of open surgery as well as improved access to medial and posterior sinonasal regions suggests that the endoscopic techniques for selected lesions may be a good alternative to open surgery. The endoscopic medial maxillectomy is the preferred option for the treatment of benign sinonasal neoplasm involving the medial wall of maxilla specifically inverted papilloma. Adjuvant external approach may be performed when needed to allow complete eradication of any residual disease.

Keywords: Benign, endoscopy, malignant, maxillary tumors, medial maxillectomy

How to cite this article:
Ishak MN, Lazim NM, Ismail ZI, Abdullah B. Open and endoscopic medial maxillectomy for maxillary tumors – a review of surgical options. Curr Med Issues 2019;17:75-9

How to cite this URL:
Ishak MN, Lazim NM, Ismail ZI, Abdullah B. Open and endoscopic medial maxillectomy for maxillary tumors – a review of surgical options. Curr Med Issues [serial online] 2019 [cited 2022 May 27];17:75-9. Available from: https://www.cmijournal.org/text.asp?2019/17/3/75/267913

  Introduction Top

Maxillectomy is a surgical procedure performed to remove all or part of the maxilla bone as a treatment for tumor of maxillary sinus, nose, hard palate, or other tumors that involve the maxilla. There are a lot of variations in maxillectomy technique and classification in view of the vast variety in histology, origin, and behavior of the tumors. Maxillectomy can be classified into three categories.[1] The first category is “limited maxillectomy,” which was any maxillectomy that removes one wall of the antrum. “Subtotal maxillectomy” was designed as any procedure which removes at least two walls of the maxilla including the palate, whereas “total maxillectomy” only for those who had a complete resection of the maxilla. Medial maxillectomy is surgical resection of the medial and superomedial walls of the maxillary antrum. This procedure is performed in managing the disease of the maxillary sinus and lateral nasal wall such as inverted papilloma. The aim of the management is to provide maximum disease control by the complete removal of involved tissue and decent access for the postoperative examination.

Before the period of endoscopic sinus surgery, neoplastic disease of the lateral nasal wall and maxillary sinus was accessed surgically with an open approach. Since then, the gold standard technique was an open radical procedure in the form of a lateral rhinotomy with medial maxillectomy.[2] Performing an open medial maxillectomy provides excellent exposure of the lateral nasal wall and maxillary sinus, ensuring good tumor clearance and cure rates. However, it contributes to morbidity and gives rise to secondary deformity.[3] This technique can result in disfigured facial scar and may lead to prolonged crusting due to persistent changes of normal sinonasal physiology.[4] With the advances in endoscopic sinus surgery, it provides improved access to specific nasal areas and better visualization of the tissue. It also had shown potential advantages of shorter hospital stay with less complications of open surgery. Endoscopic medial maxillectomy offers similar cure rates and is an alternative to more invasive open surgery. The objective of this review is to describe open and endoscopic medial maxillectomy techniques for the management of maxillary tumors.

  Methods Top

This article is based on a selective literature search of the PubMed database, searching for the terms “medial maxillectomy,” “endoscopic medial maxillectomy,” “partial maxillectomy,” “maxillary tumors,” “sinonasal neoplasms,” and “inverted papilloma” in the title of articles. Some older standard publications, textbooks, and our own clinical experience were also included.

  Anatomical Landmarks Top

A good understanding of anatomy is relevant in assisting the surgeon to plan the sequence of surgery and anticipate bleeding to minimize the blood loss. The maxillary sinus is a large pyramidal cavity located within the maxillary body. Its apex is directed laterally and formed by the zygomatic process. Its base is directed medially and is formed by the lateral wall of the nasal cavity. The superior wall of the maxillary sinus is related to the floor of the orbit, whereas the infratemporal fossa, pterygoid space, and pterygoid plates are located posterior to the sinus.[5] The floor is marked by several bony elevations formed by the roots of the upper molar and premolar teeth. The medial maxillary wall has an irregular aperture which communicates with the nasal cavity and is surrounded by the maxillary process of the inferior turbinate bone inferiorly, the perpendicular plate of the palatine bone posteriorly, a small portion of the lacrimal bone anterosuperior, and the uncinate process and bulla of the ethmoid superiorly. It opens into the middle meatus in the lower part of the hiatus semilunaris [Figure 1]. A second opening is often present at the posterior end of the hiatus. Both openings are closer to the roof than the floor of the sinus.[6] The maxillary sinus is lined by ciliated columnar epithelium, as most of the nasal cavity.[6]
Figure 1: Bony structures of the lateral nasal wall.

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The paranasal sinuses, including the maxillary sinus, obtain their blood supply from the carotid artery both internal and external branches. Arteries supplying the sinus include the alveolar branch of the maxillary artery, greater palatine artery, facial artery, and infraorbital artery. The facial vein and the pterygoid venous plexus provide venous drainage for the paranasal sinuses.[6] In open medial maxillectomy, important anatomical landmarks to observe include the facial artery which courses in the soft tissues of the face and passes the medial canthus as the angular artery [Figure 2]. The maxillary artery passes through the pterygomaxillary fissure to enter the pterygopalatine fossa.[7] The level of the floor of the anterior cranial fossa corresponds with the anterior and posterior ethmoidal foramina along the frontoethmoidal suture line, where the posterior ethmoidal artery is close to the optic nerve within the optic foramen.[8] To gain maximal access to the maxillary sinus during endoscopic sinus surgery, the lateral nasal wall resection has to be carried out inferiorly to the inferior meatal area and anteriorly to cover the nasolacrimal canal. A study by Tanna et al. showed that about 64% of the maxillary sinus rest below the level of the inferior turbinate, where complete access is available only with the resection of the lateral nasal wall to the nasal floor.[9]
Figure 2: Vasculature around the orbit.

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  Indication and Contraindication Top

The indication for medial maxillectomy, either open or endoscopic medial maxillectomy, is for the treatment of inverted papilloma, a benign locally invasive tumor. The other indications for endoscopic medial maxillectomy are for treating expansile maxillary mucoceles with erosion of the medial maxillary wall and inferior turbinate or in recurrent antrochoanal polyps which requires a greater medial wall removal.[10] When dealing with malignancies, complete resection and margin control for the endoscopic technique are the same oncological principles used as in open procedures.[3] Based on this principle, endoscopic medial maxillectomy is contraindicated in extensive malignant tumors given the difficulty of visualization and access, particularly the anterior maxillary sinus wall. Tumor extension or spread outside the sinonasal region is a contraindication for an endoscopic approach as it may give rise to incomplete tumor removal.[3] Thus, a comprehensive examination of the disease and the surrounding anatomy must be performed before suggesting an endoscopic approach. The involvement of the anterior, inferior, or lateral maxillary sinus may be a contraindication to the endoscopic approach.[11] Higher recurrence rates have been reported when endoscopic approach is used in these difficult areas, most probably due to poor visualization.[12] On the other hand, another study did not suggest maxillary sinus involvement as a limitation.[13]

  Technique Top

Assessment of patients with the maxillary sinus tumors requires the identification of the tumor origin, extent, and histological differentiation. Proper preoperative evaluation of the imaging is important to achieve complete tumor resection. For both open and endoscopic medial maxillectomy, the procedure is done under general anesthesia. In open medial maxillectomy, infiltration with 1% lidocaine with 1:100,000 epinephrine is applied at the marked incision site. There are few methods of skin incision in open medial maxillectomy. Earlier studies conclude that the gold standard technique was an open radical approach in the form of a lateral rhinotomy with medial maxillectomy.[14],[15] The incision continues from just inferior to the medial brow, medial to the medial canthus, inferiorly along the lateral nose, and around the ala in the alar crease to the lateral edge of the philtrum [Figure 3]. In case of neoplasm extending into the cranial vault, the approach can be combined with a frontal craniotomy, while orbital surgery can be included to address tumors with orbital involvement. A more extensive incision like a superior rhinotomy or an ipsilateral lower lid incision may also be performed to improve exposure. Sublabial incision is performed after splitting upper lip in midline which facilitates the elevation of the flap from the anterior wall of the maxilla. After the incision is created, a subperiosteal plane is elevated over the face of the maxilla. The medial part of the maxilla is removed with the preservation of eye and the hard palate. The nasolacrimal apparatus must be addressed to prevent epiphora. The antrum is approached through the anterior maxillary wall and the tumor or diseased mucosa can be removed from the sinus.[10] During closure, precise realignment is important to minimize deformity. Apart from that, few authors had described midfacial degloving as an option in view of some advantages over previously mentioned open procedures. The advantages of performing this procedure are good access and the ability to perform it bilaterally while avoiding facial scars and palatal injury.[3]
Figure 3: Skin incision for lateral rhinotomy.

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In endoscopic medial maxillectomy, the patient is put under general anesthesia and the nasal passage is packed with 1% oxymetazoline and 4% cocaine that will produce vasoconstriction and create decongestant and hemostatic effect. This will significantly refine visualization and access of the operation field. The mucosa of the inferior turbinate and lateral nasal wall is injected with 1% lidocaine with 1:100,000 epinephrine.[3] The telescope should be placed at the superior aspect of the nostril so that other instruments can move under freely in and out of the nasal cavity. The middle turbinate is then medialized using a freer elevator to further facilitate the surgery. The anterior head of the middle turbinate may be removed using a straight biter or turbinate scissors if access to the middle meatus is obstructed. Retrograde forceps is used to perform uncinectomy, and the natural ostium is identified lateral to the uncinate process. The ostium is then enlarged using a microdebrider or cutting instruments, posteriorly to the wall of the antrum, superiorly to the level of the lamina papyracea, and inferiorly to the level of the inferior turbinate. Resection to the level of the inferior meatus and anteriorly over the nasolacrimal canal is needed to gain necessary access to the maxillary sinus.

About 5% of the total maxillary sinus volume lies anterior to the nasolacrimal canal; hence, resection anterior to this structure will improve visualization.[9] The endoscopic medial maxillectomy has been described as a true medial maxillectomy, as it involves the resection of the entire lateral nasal wall and completed only with resection of the medial wall of the maxilla, including the inferior turbinate and its anterior wall.[16] Another study reported endoscopic medial maxillectomy could be done with the preservation of the inferior turbinate with a similar outcome, where the aim was to maintain the inferior turbinate critical function in the conditioning of the nasal airflow.[17]

  Complication Top

The complications from both open and endoscopic medial maxillectomy can be classified into mild to severe, or reversible to permanent, or acute versus chronic in nature. Acute complication includes intraoperative or immediate access postoperative hemorrhage, usually from the internal maxillary artery for both procedures. Following an endoscopic medial maxillectomy, visual disturbance could arise from direct injury to the optic nerve or vascular compromise to the nerve from overpacking of the maxillary defect. Other notable complications include nasal septal perforation, cerebrospinal fluid leaks, mucocele development, vestibular stenosis, and crusting and synechia formation.[16] The patient underwent open medial maxillectomy may have abnormal mucociliary clearance as a result of the extensive mucosal injury or connective tissue bands that divide the sinus into compartments.[18] The orbital complications of open medial maxillectomy include epiphora, diplopia, and corneal injury from the wrong placement of the corneal shield. However, if the periorbita is left uninjured and with meticulous subperiosteal elevation of the trochlea from its fossa, the orbital complications can be reduced and become less common.[19] Reported complications are infection, trismus, epiphora, facial scarring, prosthesis and flap failure, and palatal dysfunction.

  Discussion Top

Endoscopic medial maxillectomy is increasingly replacing open medial maxillectomy, which previously been considered the preferable treatment for neoplastic disease involving the lateral nasal wall and maxillary sinus. Kristensen et al.first established the superiority of the open medial maxillectomy over limited approaches as the standard for the surgical management of inverted papilloma.[20] Endoscopic medial maxillectomy has become the preferred approach for maxillary sinus tumor aided by the development of powered endoscopic instruments, image-guided navigation systems, and angled telescopes. Studies performed on the various disease of the lateral nasal wall and maxillary sinus have showed the efficacy of the endoscopic approach in addressing the diseases.[21],[22] Open medial maxillectomy alters the normal sinonasal physiology and may cause nasal crusting in addition to the facial scarring.[23] The endoscopic approach offers better magnification and visualization of the tumor bed, allowing more precise mapping and resection of the tumor. It also avoids additional damage to surrounding tissues and permits faster healing.

Sukenik and Casiano have showed that endoscopic assessment has better capability to differentiate normal and tumor disease.[24] They concluded that although preoperative computed tomography (CT) imaging is enough for evaluating the presence of disease, it is second to endoscopic technique in discriminating between normal and diseased mucosa. They found that CT imaging was 69% sensitive and only 20% specific, whereas intraoperative endoscopic examination had the same sensitivity but better specificity (68%). Apart from that, it has been shown that hospital stay was statistically shorter in patients treated by endoscopic approach while the cure rates are comparable with traditional open approaches.[4],[23] This technique has less morbidity with similar recurrence rates. The recurrence rate for open medial maxillectomy for inverted papilloma ranges from 0% to 36%, whereas the recurrence rate of endoscopic technique for inverted papilloma ranges from 0% to 25%.[2],[14],[15] In a study by Sautter et al., they found that patients with the advanced stage of inverted papilloma had higher risk of recurrence regardless of surgical technique.[23] They suggest that the risk of recurrence is possibly associated with extent and type of the tumor, not only dependent on the technique.

Another study by Schlosser et al. found that recurrences were noted in 19% (four out of 21 cases) in the treatment of inverted papilloma using the endoscopic technique.[25] Han et al. compared a study of 31 patients with inverted papilloma treated by open and endoscopic resection.[26] They found that regardless of surgical technique, the recurrence rate for primary inverted papilloma was 0% and for secondary inverted papilloma was 17%. However, despite the advantages of endoscopic medial maxillectomy, it should be performed only by surgeons with adequate experience and with the availability of requisite equipment. The complex sinus anatomy or tumor location and extent may also limit the applicability of this approach, for example, disease that involves the anterolateral maxillary sinus. Patients should always be advised of the possibility of performing a concomitant combined open approach such as the midfacial degloving procedure.[27] Midfacial degloving permits enough exposure and removal of tumor without the lateral rhinotomy incision scar; thus, it can achieve both tolerable cosmetic outcome with low recurrence rates.[28]

  Conclusions Top

The endoscopic medial maxillectomy is the preferred option for the treatment of benign sinonasal neoplasm involving the medial wall of the maxilla specifically inverted papilloma. This technique has less morbidity and similar cure rates when compared with open approaches. The adjuvant external approach may be performed when needed to allow complete eradication of any disease present.

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Conflicts of interest

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  References Top

Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification. Head Neck 1997;19:309-14.  Back to cited text no. 1
Lawson W, Ho BT, Shaari CM, Biller HF. Inverted papilloma: A report of 112 cases. Laryngoscope 1995;105:282-8.  Back to cited text no. 2
Cunningham K, Welch KC. Endoscopic medial maxillectomy. Oper Tech Otolaryngol Head Neck Surg 2010;21:111-6.  Back to cited text no. 3
Sauter A, Matharu R, Hörmann K, Naim R. Current advances in the basic research and clinical management of sinonasal inverted papilloma. Oncol Rep 2007;17:495-504.  Back to cited text no. 4
Balaji S, Laskin D. Textbook of Oral and Maxillofacial Surgery. New Delhi: Elsevier; 2007.  Back to cited text no. 5
Michael JG, Ray CC. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 7th ed. London: Hodder Arnold; 2008.  Back to cited text no. 6
Gray H. Anatomy of the Human Body. Philadelphia: Lea & Febiger; 2000. Available from: http://Bartleby.com. [Last accessed on 2019 Feb 01].  Back to cited text no. 7
Fagan J. Open Access Atlas of Otolaryngology, Head and Neck Operative Surgery. Available from http://www.entdev.uct.ac.za. [Last accessed on 2019 Feb 05].  Back to cited text no. 8
Tanna N, Edwards JD, Aghdam H, Sadeghi N. Transnasal endoscopic medial maxillectomy as the initial oncologic approach to sinonasal neoplasms: The anatomic basis. Arch Otolaryngol Head Neck Surg 2007;133:1139-42.  Back to cited text no. 9
Woodworth BA, Parker RO, Schlosser RJ. Modified endoscopic medial maxillectomy for chronic maxillary sinusitis. Am J Rhinol 2006;20:317-9.  Back to cited text no. 10
Sham CL, Woo JK, van Hasselt CA. Endoscopic resection of inverted papilloma of the nose and paranasal sinuses. J Laryngol Otol 1998;112:758-64.  Back to cited text no. 11
Phillips PP, Gustafson RO, Facer GW. The clinical behavior of inverting papilloma of the nose and paranasal sinuses: Report of 112 cases and review of the literature. Laryngoscope 1990;100:463-9.  Back to cited text no. 12
Tomenzoli D, Castelnuovo P, Pagella F, Berlucchi M, Pianta L, Delu G, et al. Different endoscopic surgical strategies in the management of inverted papilloma of the sinonasal tract: Experience with 47 patients. Laryngoscope 2004;114:193-200.  Back to cited text no. 13
Myers EN, Schramm Jr., VL, Barnes EL Jr. Management of inverted papilloma of the nose and paranasal sinuses. Laryngoscope 1981;91:2071-84.  Back to cited text no. 14
Lawson W, Kaufman MR, Biller HF. Treatment outcomes in the management of inverted papilloma: An analysis of 160 cases. Laryngoscope 2003;113:1548-56.  Back to cited text no. 15
Weisman R. Lateral rhinotomy and medial maxillectomy. Otolaryngol Clin North Am 1995;28:1145-56.  Back to cited text no. 16
Gras-Cabrerizo JR, Massegur-Solench H, Pujol-Olmo A, Montserrat-Gili JR, Ademá-Alcover JM, Zarraonandia-Andraca I. Endoscopic medial maxillectomy with preservation of inferior turbinate: How do we do it? Eur Arch Otorhinolaryngol 2011;268:389-92.  Back to cited text no. 17
Konstantinidis I, Constantinidis J. Medial maxillectomy in recalcitrant sinusitis: When, why and how? Curr Opin Otolaryngol Head Neck Surg 2014;22:68-74.  Back to cited text no. 18
Osguthorpe JD, Weisman RA. 'Medial Maxillectomy' for lateral nasal wall neoplasms. Arch Otolaryngol Head Neck Surg 1991;117:751-56.  Back to cited text no. 19
Kristensen S, Vorre P, Elbrond O, Søgaard H. Nasal Schneiderian papillomas: A study of 83 cases. Clin Otolaryngol Allied Sci 1985;10:125-34.  Back to cited text no. 20
Wormald PJ, Ooi E, van Hasselt CA, Nair S. Endoscopic removal of sinonasal inverted papilloma including endoscopic medial maxillectomy. Laryngoscope 2003;113:867-73.  Back to cited text no. 21
Busquets JM, Hwang PH. Endoscopic resection of sinonasal inverted papilloma: A meta-analysis. Otolaryngol Head Neck Surg 2006;134:476-82.  Back to cited text no. 22
Sautter NB, Cannady SB, Citardi MJ, Roh HJ, Batra PS. Comparison of open versus endoscopic resection of inverted papilloma. Am J Rhinol 2007;21:320-3.  Back to cited text no. 23
Sukenik MA, Casiano R. Endoscopic medial maxillectomy for inverted papillomas of the paranasal sinuses: Value of the intraoperative endoscopic examination. Laryngoscope 2000;110:39-42.  Back to cited text no. 24
Schlosser RJ, Mason JC, Gross CW. Aggressive endoscopic resection of inverted papilloma: An update. Otolaryngol Head Neck Surg 2001;125:49-53.  Back to cited text no. 25
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Karkos PD, Fyrmpas G, Carrie SC, Swift AC. Endoscopic versus open surgical interventions for inverted nasal papilloma: A systematic review. Clin Otolaryngol 2006;31:499-503.  Back to cited text no. 27
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  [Figure 1], [Figure 2], [Figure 3]


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