Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

Chapter 6
Juvenile Angiofi broma
41
and are the rule in tumors with intracranial extension.
Therefore the angiographer should evaluate the circula-
tion of the external and internal carotid arteries bilater-
ally. Angiography, however, is invasive and is associated
with a defi ned, albeit low, number of complications. Its
use is reserved for preoperative embolization.
Embolization should be considered as part of the
preoperative preparation and should be performed
shortly before the surgical procedure (<24 hours),
because JA is known to achieve rapid revascularization.
This diagnostic angiography and the therapeutic angi-
ography (e.g., embolization) are scheduled as a single-
stage procedure. Other factors, such as limitations on
the maximal volume of contrast, patient anxiety, and
length of the procedure, may necessitate a modifi cation
of this plan (Figs. 6-3 and 6-4).
Biopsy
Histologic confi rmation is not usually necessary for the
diagnosis of JA. A defi nitive diagnosis is usually made
with clinical and imaging fi ndings. Malignant tumors
such as rhabdomyosarcoma and olfactory neuroblas-
toma can mimic JA; therefore, a biopsy is prudent in
those patients who are to be treated with primary radia-
tion (poor surgical candidates) or in patients in whom
the diagnosis remains uncertain even after thorough
evaluation. The biopsy should be performed in the
operating room with the patient under general anesthe-
sia (e.g., controlled airway). The characteristic histo-
logic appearance is that of a thin-walled vascular network
surrounded by fi brous stroma (Fig. 6-5).1
Staging
Different staging systems have been proposed for JA
(Tables 6-1 and 6-2).3,4 They facilitate communication
among different institutions and allow comparisons of
outcomes after different therapeutic modalities and
surgical approaches. Nevertheless, these systems are
rarely used prospectively and their usefulness is limited
because most institutions have not adopted any single
staging system.
PREOPERATIVE PLANNING
Preoperative preparation aims to diminish the risk of
complications associated with massive bleeding and
blood transfusions. Hormonal therapy, using andro-
gens or estrogens, has been advocated in the past as a
B
A
Figure 6-3. B, Angiography with
injection in the right common
carotid artery demonstrating the
tumor blush. Branches of the
external and the internal carotid
arteries supply blood to the tumor.
B, Postembolization view.
B
A
Figure 6-4. A,
Superselective
angiography with injection of con-
trast in the internal maxillary
artery producing an intense tumor
blush. B, Postembolization view.
To obtain this degree of blood
fl ow
reduction,
the
patient
required bilateral superselective
embolization of the distal internal
maxillary arteries (to preserve the
blood supply to the masseter and
temporalis muscles) and ascend-
ing pharyngeal arteries.

42
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
way to decrease the bulk and vascularity of JA. However,
these drugs have signifi cant side effects that are very
undesirable for any adolescent male (e.g., testicular
atrophy, feminization, gynecomastia). These side
effects, as well as new developments in the instrumenta-
tion and techniques for angiographic embolization,
make hormonal therapy undesirable and unnecessary.
Angiography and embolization should be com-
pleted in a single procedure. JAs may develop rapid
revascularization after embolization; therefore, defi ni-
tive surgery should ideally be scheduled within 24 hours
after the angiography. Close communication with the
interventional radiologist is essential. Details, such as
preservation of the blood supply to the temporalis
muscle if needed for reconstruction, should be dis-
cussed in advance.
Despite adequate embolization, blood in the form
of packed red blood cells should be available for the
surgery. We encourage the use of autologous blood
banking to avoid the risks of mismatched blood transfu-
sion and the transmission of infectious agents. Fre-
quently, the surgery may be delayed for several weeks
to allow for autologous donation of 2 to 3 units of
blood. A cell saver device, which allows the safe recy-
cling of the patient’s blood despite contamination by
the fl ora of the upper aerodigestive tract, can also be
used during the surgery.
The extirpative surgery is considered to be clean-
contaminated, for which perioperative prophylactic
antibiotics with broad-spectrum coverage of the fl ora of
the upper aerodigestive tract are recommended. The
antibiotics are initiated at the time of surgery and con-
tinued for 24 hours postoperatively. In those cases in
which there is communication of the cranial cavity with
the upper aerodigestive tract, antibiotics are continued
for 48 hours postoperatively.5
SURGICAL TECHNIQUE
Therapeutic Modalities
Historically, surgery and radiation therapy yield a similar
control rate (80% cure) of JA.6-10 However, surgery is
favored for most cases owing to the long-term sequelae
of radiation therapy (e.g., secondary malignancies, cata-
racts, pituitary insuffi ciency, mucous gland metaplasia)
and the improved surgical outcome and morbidity
brought about by advancements in embolization and
surgical approaches.6-14
Radiation may be considered a primary therapeutic
modality for the rare patient who is a poor surgical
candidate or for those who refuse surgery. The recom-
mended dose ranges from 35 to 45 Gy.6,7 Adjunctive
radiation is also recommended for those cases in which
the intracranial component (or intracranial recur-
rence) is deemed unresectable. Many of these patients,
A
B
Figure 6-5. Histologic section of juvenile angiofi broma at ×10 (A)
and ×40 (B) magnifi cation, demonstrating the characteristic thin-
walled vascular network (arrows) surrounded by fi brous stroma.
Table 6-1
STAGING OF JUVENILE
NASOPHARYNGEAL ANGIOFIBROMA
Stage I
Tumor limited to posterior nares and
nasopharyngeal vault
Stage IIA
Minimal lateral extension into the
pterygomaxillary fossa
Stage IIB
Tumor fi lls pterygomaxillary fossa,
displacing posterior wall of antrum, and
extends superiorly, eroding bone of orbit
Stage IIC
Extension into cheek and temporal fossa
through pterygomaxillary fossa
Stage III
Intracranial extension
Table 6-2
STAGING OF JUVENILE
NASOPHARYNGEAL ANGIOFIBROMA
Stage
Tumor Location
I
Nasopharynx
II
Nasal cavity and sphenoid
III
Ethmoid and maxillary sinuses,
pterygomaxillary space, infratemporal fossa,
orbit, and cheek
IV
Intracranial

Chapter 6
Juvenile Angiofi broma
43
however, do not need any treatment and may be fol-
lowed with imaging (remnants of tumors may show
involution).
Other therapeutic modalities, such as cryosurgery
and sclerotherapy, are of historical importance only.
Chemotherapy has been advocated by some authors for
the treatment of recurrent or progressive nonresectable
tumors that have failed to respond to radiation therapy.15
Future advances in tumor biology may lead to new non-
surgical therapies using inhibitors of specifi c growth
factors or angiogenesis.
SURGICAL APPROACHES
The surgical approaches to JA are tailored to the extent
of the tumor but are also based on the surgeon’s experi-
ence and familiarity with the different approaches
(experienced surgeons may use the more limited
approaches to remove even massive tumors). In many
instances, the extirpative surgery requires the use of a
combination of approaches to provide for complete
visualization of the tumor and control of bleeding.
The surgical approaches can be divided into infe-
rior, anterior, and lateral. Inferior approaches include
transpalatal (i.e., through the hard palate) and trans-
oral-transpharyngeal routes, with or without a soft
palate split. These techniques provide access to the
nasopharynx and the nasal cavity. Anterior approaches
expose the nasal cavity (e.g., lateral rhinotomy and mid-
facial degloving) and can be extended through the
medial maxilla to expose the antrum and ethmoid
sinuses and the pterygopalatine fossa (e.g., LeFort I,
Denker’s, and medial maxillectomy) or even the sphe-
noid sinus and nasopharynx (e.g., swing maxillotomy
and facial translocation). In addition, these latter
approaches may be extended to expose the infratempo-
ral fossa, infratemporal skull base, middle cranial fossa,
or paramedian skull base (anterolateral exposure).
Alternatively, the infratemporal fossa may be approached
laterally through a preauricular subtemporal route
(i.e., lateral approach).
Endoscopic techniques are our preferred approach
for the extirpation of JAs.11 Rod lens endoscopes are
useful during the preoperative evaluation to visualize
the anterior extension of the tumor and to complement
the most limited approaches (e.g., transpharyngeal and
transpalatal) by providing improved visualization of the
ethmoid and sphenoid sinuses. Selected tumors extend-
ing to the nasal cavity, nasopharynx orbit, infratempo-
ral fossa, or cranial cavity may be amenable to an
endoscopic transnasal approach. The middle turbinate
is removed and a wide nasoantral window (NAW) is
opened to facilitate the removal of the posterior wall of
the antrum (Fig. 6-6A and B). Septal and sphenoidal
A
MT
PWA
B
A
PWA
C
A
IMA
Figure 6-6. Intraoperative picture demonstrating the initial approach
to the right middle meatus and opening of a large nasoantral window to
expose the posterior wall of the antrum (PWA). B, Intraoperative picture
demonstrating the augmented exposure of the tumor after removal of
the middle turbinate. C, Intraoperative picture demonstrating the medial
retraction of the tumor toward the nasal cavity after removing the PWA.
A, angiofi broma, E, ethmoid sinuses; IMA, internal maxillary artery; LP,
lamina papyracea; MT, middle turbinate.

44
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Figure 6-7. Incision for the soft palate split. The horizontal release
incision should be performed anterior to the posterior edge of the
hard palate to prevent the formation of an oral-nasal fi stula at the
trifurcation. Alternatively, this horizontal incision may be performed
as a V-shaped incision and closed in a V-to-Y fashion to elongate the
soft palate.
Figure 6-8. Retraction of the soft palate after the split, providing
exposure of the tumor.
Figure 6-9. U-shaped mucoperiosteal incision. The dashed line cor-
responds to a release incision to provide further exposure to the
pterygoid plates (the pterygopalatine fossa) and more mobility to the
mucoperiosteal fl ap on the side ipsilateral to the tumor.
extensions are freed so that the tumor can be pushed
into the nasopharynx. This gains space within the nasal
cavity and allows an easier manipulation of the tumor.
Extensions into the PtPF (pterygopalatine fossa) and
ITF (infratemporal fossa) are reached by mobilizing the
tumor from its bony attachments at these areas and
then retracting the tumor into the nasoantral area (see
Fig. 6-6C). The mucosa around the tumor is incised
using an electrocautery, and the tumor is dissected off
the pharyngobasilar and basioccipital fascia in toward
the nasopharynx.
Transpharyngeal or transpalatal approaches are
viable alternatives. The soft palate may be retracted with
the help of two red rubber catheters introduced through
the nose and taken out through the mouth. If the tumor
is adequately visualized, the surgeon proceeds with the
resection; if not, a midpalate split is recommended. The
midpalate split is performed using electrocautery fol-
lowing a lazy S pattern (Fig. 6-7). This type of incision
prevents velopharyngeal insuffi ciency brought by con-
traction of a linear scar. Each half of the velum is
retracted laterally to allow full visualization of the naso-
pharynx and posterior choanae (Fig. 6-8).
The exposure of the pterygopalatine fossa may be
enhanced by resecting the bone of the hard palate. The
mucoperiosteum of the hard palate is incised, creating
a U-shaped, posteriorly based fl ap (Fig. 6-9). The muco-

Chapter 6
Juvenile Angiofi broma
45
ynx. The bone is then removed with a Kerrison rongeur,
exposing the mucosa of the fl oor of the nose, which is
then incised (Fig. 6-11). The posterior septum may be
removed to better expose the nasopharynx and rostrum
of the sphenoid. The hamulus process and the inferior
portion of the medial pterygoid plate can be removed
for better exposure of the pterygopalatine fossa
(Fig. 6-12).
The fi nal stage of the tumor resection may be
described as a controlled avulsion. The mucosa around
the tumor is incised using an electrocautery, and the
tumor is dissected off the pharyngobasilar and basioc-
cipital fascia in toward the nasopharynx. At this point,
the tumor is avulsed, using blunt dissection. Bleeding
is controlled with Yankauer suctions, bipolar cautery,
and packing.
The fl oor of the nasal mucosa and the hard palate
mucoperiosteum are repaired with interrupted absorb-
able sutures (e.g., chromic 3-0). The soft palate is
repaired with a three-layer closure using chromic 3-0
interrupted sutures for the nasal surface and Vicryl 3-0
for the muscle, oral mucosa, and mucoperiosteum. The
hard palate mucoperiosteum is pressed against the
remaining bone using an acrylic splint (Fig. 6-13).
The LeFort I osteotomy also provides exposure of
the anterior nasal cavity, pterygopalatine fossa, and
nasopharynx. In addition, the hard palate and premax-
illa can be split sagittally to swing the ipsilateral maxilla
as a medially based fl ap. The basic approach consists of
a degloving incision that follows the horizontal plane
from maxillary tuberosity to maxillary tuberosity approx-
imately 5 cm above the gingival margins (Fig. 6-14A)
and intranasal incisions (see Fig. 6-14B). The soft tissues
of the midface are elevated in a subperiosteal plane,
exposing the infraorbital neurovascular bundles, the
body of the zygomatic bone, and the piriform aperture
(Fig. 6-15). The mucosa over the fl oor of the nose and
the mucoperichondrium and mucoperiosteum of the
septum are elevated, exposing the septal cartilage,
Figure 6-10. The mucoperiosteal fl ap has been elevated to expose
the bone of the hard palate. The greater palatine neurovascular
bundle, ipsilateral to the tumor, has been ligated and transected to
enhance the mobility of the mucoperiosteal fl ap.
A
B
Figure 6-11. A, The palatine
bone corresponding to the fl oor of
the nose has been removed with a
Kerrison rongeur (or drill), and
the mucosa has been incised to
provide exposure of the tumor.
B, Three-dimensional illustration
of the approach to a tumor occu-
pying the posterior nasal cavity
and with minimal invasion of the
pterygopalatine fossa.
periosteum is elevated, exposing the palatine bone back
to the junction with the soft palate. Alternatively, the
mucoperiosteum can be based on the contralateral
greater palatine neurovascular bundle (sacrifi cing the
ipsilateral nerve, artery, and vein) (Fig. 6-10). This
upgrades the mobility of the fl ap and provides uninter-
rupted exposure from the nasal cavity to the nasophar-

46
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
C
A
B
Figure 6-12. A, Exposure of the
inferior aspect of the tumor exten-
sion into the pterygopalatine fossa
after removal of the inferior aspect
of the pterygoid plates. B, Three-
dimensional illustration of the com-
pleted approach.
A
B
Figure 6-13. A, An acrylic splint. B, A well-healed palate incision.
Figure 6-11, cont’d C, Intraoperative view demonstrating the
removal of the right palatine bone (arrows) to expose the mucoperi-
osteum of the nasal fl oor (n).
vomer, and maxillary crest, bilaterally. The nasal septum
and vomer are separated from the maxilla using a 6-mm
chisel or osteotome. The position for the LeFort I oste-
otomy is marked, and rigid osteosynthesis plates are
bent to conform to the surface of the maxilla and are
screwed in place, as will be required to repair the oste-
otomies (Fig. 6-16). The plates and screws are then
removed and the LeFort I osteotomy is performed with
a reciprocating saw, preserving the apices of the dental
roots. The pterygoid plates are separated from the
maxilla using a curved osteotome. Care is taken to avoid
injury to the internal maxillary artery. (It is preferable
to identify and clip the ipsilateral internal maxillary
artery in order to secure hemostasis.) The junction with
the lateral wall of the nose is separated with Mayo or
double-action scissors, and the posterior wall of the
antrum is fractured on mobilization of the maxilla in a
caudal direction (Fig. 6-17).

Chapter 6
Juvenile Angiofi broma
47
A
B
I
II
III
Figure 6-14. A, Gingivobuccal
incision. B, Intercartilaginous inci-
sions (I) are joined to a transfi xion
incision at the anterior edge of the
nasal septum (II). The soft tissue is
elevated from the nasal bones (III).
Hemostasis should be complete at the end of
surgery. The routine use of postoperative anterior or
posterior nasal packings or nasogastric tubes is discour-
aged. A nasal airway (e.g., nasal trumpet) may be
used to secure the airway, especially in patients who
develop signifi cant soft palate swelling. A tracheotomy
is indicated if the swelling involves the rest of the oro-
pharynx or extends to the hypopharynx or larynx, as
may be the case after extensive infratemporal fossa
dissection.
POSTOPERATIVE CARE
Postoperatively, the patient is transferred to an inten-
sive care unit for close monitoring of vital signs, oxim-
etry, and neurologic status. As soon as the gastrointestinal
tract is deemed ready, a clear liquid diet is started and
advanced as the patient tolerates. A soft diet is contin-
ued for 10 to 14 days for those patients who undergo a
soft palate split. Patients treated with anterior or lateral
approaches may be advanced to a regular diet as toler-

48
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
A
B
Figure 6-15. The soft tissues of the midface are elevated, providing
access to the maxilla and nasal cavity bilaterally. The superior expo-
sure is limited by the infraorbital neurovascular bundles.
Figure 6-16. A, Level of LeFort I maxillary osteotomies. The attach-
ments of the cartilaginous septum to the maxillary crest and the
vomer bone are severed. It is greatly advantageous to pre-plate the
maxilla before the osteotomies are performed. Pre-plating obviates
the need for maxillomandibular wiring to restore occlusion before
plating, saving considerable time. The attachment of the pterygoid
plate to the maxilla is fractured with a curved osteotome. B, Intraop-
erative photograph demonstrating pre-plating of a Le Fort I osteot-
omy. The anterior osteotomy is performed and the maxilla is
pre-plated before completing the posterior osteotomy.
ated. Patients with wounds over the hard palate benefi t
from a palatal splint to protect the suture line and
to press the mucoperiosteum against the remaining
bone.
Skin incisions are cleaned three times daily with
normal saline solution and are then covered with an
antibiotic ointment. Intraoral wounds mandate the use
of antiseptic mouthwashes (e.g., chlorhexidine gluco-
nate [Peridex]). An oral hygiene appliance (Water Pik)
is recommended for dental care, because patients are
advised not to brush their teeth for 10 to 14 days or
until the wounds are healed.
Prophylactic antibiotics are continued as discussed
under “Preoperative Planning” earlier in this chapter.
COMPLICATIONS
Postoperative bleeding after surgery for JA varies from
simple oozing to massive hemorrhage that needs rapid
volume replacement and control of the airway. This
discussion concerns the latter situation.
Management of signifi cant hemorrhage should
follow the ABCs of resuscitation. When at risk, the
airway should be controlled through endotracheal intu-
bation or tracheotomy, and the intravascular volume
should be initially replaced with isotonic solutions
(e.g., Ringer’s lactate).
At the same time, measures are taken to control the
bleeding. The method for controlling the hemorrhage
is infl uenced by the extension of the surgery and the
surgical approach. In most cases, the surgeon has a
clear idea what vessels could have been injured during
the operation. An emergency posterior packing will
control most bleeding problems after JA surgery, pro-
viding time for a more thorough evaluation. After the
initial stabilization, the patient is transferred to the
operating room for identifi cation and ligation of the
bleeding vessel. Alternatively, in some cases an angiog-
raphy with embolization can provide hemostasis without
disrupting the surgical fi eld. This may be the procedure
of choice in patients in whom multiple approaches
were used or in those who required a complex
reconstruction.
Infection after surgery for JA is rare. Its treatment
should follow the same sensible principles for treat-

Chapter 6
Juvenile Angiofi broma
49
A
B
Figure 6-17. A, The LeFort I osteotomies have been completed,
and the internal maxillary artery has been clipped and transected,
exposing the tumor occupying the nasal cavity and pterygopalatine
fossa. B, Intraoperative photograph demonstrating plating of the Le
Fort I osteotomy (arrows).
ment of postoperative infection anywhere else. Celluli-
tis is treated with intravenous antibiotics, abscesses
should be drained, and necrotic tissue should be
débrided. Bone grafts or fl aps usually remain viable as
long as the rigid fi xation is stable.
Other complications such as cranial nerve
defi cit or intracranial problems are discussed in
Chapter 101.
PEARLS
• Any adolescent male with signifi cant and/or
repeated nosebleeds should be evaluated for a
juvenile angiofi broma.
• Preoperative embolization reduces operative
bleeding.
• During an endoscopic transnasal resection, do not
divide the juvenile angiofi broma within the
infratemporal fossa because it will be more diffi cult
to retract and dissect.
• Attention should be paid to the site of origin
(medial pterygoid plate) and the vidian foramen
because these are common places for recurrences.
• Follow-up should include a CT scan with contrast.
PITFALLS
• Biopsy of a juvenile angiofi broma will produce
signifi cant hemorrhage.
• Embolization may be associated with signifi cant
morbidity.
• Incomplete resection of the site of origin often
results in a progressively growing recurrence.
• All surgical approaches have the potential to
interfere with facial growth.
• Destruction of the nasal epithelium invariably leads
to nasal crusting and subsequent scarring.
References
1. Batsakis JG: Tumors of the Head and Neck, 2nd ed. Baltimore,
Williams & Wilkins, 1979, pp 291-312.
2. Economou TS, Abemayor E, Ward PH: Juvenile nasopharyngeal
angiofi broma: An update of the UCLA experience, 1960-1985.
Laryngoscope 98:170-175, 1988.
3. Sessions RB, Bryan RN, Naclerio RM, et al: Radiographic staging
of juvenile angiofi broma. Head Neck Surg 3:279-283, 1981.
4. Chandler JR, Goulding R, Moskowitz L, et al: Nasopharyngeal
angiofi bromas: Staging and management. Ann Otol Rhinol Lar-
yngol 93:322-329, 1984.
5. Carrau RL, Snyderman CH, Janecka IP, et al: Antibiotic prophy-
laxis in cranial base surgery. Head Neck 13:311-317, 1991.
6. Wiatrak BJ, Koopmann CF, Turrisi AT: Radiation therapy as an
alternative to surgery in the management of intracranial juvenile
nasopharyngeal angiofi broma. Int J Pediatr Otorhinolaryngol
18:51-61, 1993.
7. Kasper ME, Parsons JT, Mancuso AA, et al: Radiation therapy for
juvenile angiofi broma: Evaluation by CT and MRI, analysis of
tumor regression, and selection of patients. Int J Radiat Oncol
Biol Phys 25:689-694, 1993.
8. Spector JG: Management of juvenile angiofi bromata. Laryngo-
scope 98:1016-1026, 1988.
9. Gullane PJ, Davidson J, O’Dwyer T, Forte V: Juvenile angiofi -
broma: A review of the literature and a case series report. Laryn-
goscope 102:928-933, 1992.
10. Bremer JW, Neel HB, DeSanto LW, Jones GC: Angiofi broma:
Treatment trends in 150 patients during 40 years. Laryngoscope
96:1321-1329, 1986.
11. Carrau RL, Snyderman CH, Kassam AB, Jungreis CA: Endoscopic
and endoscopic-assisted surgery for juvenile angiofi broma. Laryn-
goscope 111:483-487, 2001.

50
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
12. Pryor SG, Moore EJ, Kasperbauer JL: Endoscopic versus tradi-
tional approaches for excision of juvenile nasopharyngeal angio-
fi broma. Laryngoscope 115:1201-1207, 2005.
13. Pasquini E, Sciarretta V, Frank G, et al: Endoscopic treatment of
benign tumors of the nose and paranasal sinuses. Otolaryngol
Head Neck Surg 131:180-186, 2004.
14. Nicolai P, Berlucchi M, Tomenzoli D, et al: Endoscopic surgery
for juvenile angiofi broma: When and how. Laryngoscope 113:775-
782, 2003.
15. Goepfert H, Cangir A, Lee YY: Chemotherapy for aggressive juve-
nile nasopharyngeal angiofi broma. Arch Otolaryngol 111:285-
289, 1985.

Maxillary Sinus
Chapter 7
The Endoscopic Approach
Barry M. Schaitkin
The goals of treatment of maxillary sinus disease are
aeration and resumption of normal mucociliary fl ow.
Normal mucociliary function from birth results in con-
tinuous removal of mucus against gravity through the
natural ostium of the maxillary sinus. This ostium is
bounded by the uncinate process and the ethmoid
bulla. In some cases (Fig. 7-1), additional cells on the
fl oor of the orbit known as Haller cells can also contrib-
ute to obstruction.
A patient with chronic maxillary sinusitis must be
evaluated completely. After a thorough history is elic-
ited, the nose should be maximally decongested and
endoscopic examination of the nose, including the infe-
rior, middle, and superior meatus, should be performed.
Abnormal secretions can be sampled endoscopically for
culture, and abnormalities should be noted. Traditional
examination with a headlight and nasal speculum is of
historic interest only in evaluating patients with chronic
sinusitis. Detailed notes of the nasal endoscopy and, if
possible, clinical photographs allow better preoperative
surgical planning. Correlation of endoscopic fi ndings
with those on computed tomography (CT) allows
further evaluation of the anatomy and function of these
highly variable and very interesting structures. Diagnos-
tic information about nasal tumors, as well as diseases
of the mucous membranes such as Kartagener’s syn-
drome, cystic fi brosis, and Wegner’s granulomatosis,
can be gleaned from nasal endoscopy.
Inferior meatal antrostomy is no longer considered
a worthwhile procedure for the treatment of patients
with chronic sinusitis. The natural ostium is the only
functional ostium within the sinus, and the inferior
meatus will be ignored by mucociliary activity. Patients
who have undergone inferior meatal antrostomy can
easily be examined in the offi ce through that opening
with 0- and 30-degree endoscopes, and not infrequently,
an obstructed natural ostium can be seen despite a
surgically patent inferior meatal antrostomy.
Patients evaluated by the otolaryngologist because
of symptoms of recurrent or persistent maxillary sinus-
itis and who are noted to have endoscopic fi ndings
consistent with this condition are treated for 4 to 6
weeks with antibiotics and adjunctive medications as
deemed appropriate. Medical treatment of chronic
sinusitis is beyond the scope of this surgical text. Those
whose symptoms persist should undergo imaging studies
at the end of treatment. Coronal CT without contrast
enhancement is the “gold standard.” High-quality
coronal scans effectively delineate the area of the maxil-
lary sinus ostium or ostiomeatal complex and provide
verifi cation of anatomic abnormalities that may be con-
tributing to the sinus obstruction. When using the stan-
dard window approach popularized by Zinreich and
colleagues,1 no mucosa should be apparent, so any
amount of mucosal thickening seen within the bound-
aries of the maxillary sinuses is considered abnormal.
Coronal CT scans are mandatory for preoperative plan-
ning in patients who are expected to undergo endo-
scopic surgery. The surgeon should review the CT scans
several times with particular emphasis placed on the
important structures that lie adjacent to the sinus cavi-
ties. For the maxillary sinus, this primarily entails a
thorough evaluation of the lamina papyracea and the
fl oor of the orbit to look for any areas of dehiscence.
PATIENT SELECTION
Controversy continues regarding the optimal extent of
surgery that should be performed in patients with
chronic sinusitis, and surgical treatment of the maxil-
lary sinus is no exception. Some surgeons recommend
wide antrostomy to improve sinus drainage. Others
maintain that the goal of maxillary sinus surgery should
be removal of the minimal amount of tissue necessary
to restore patency of the outfl ow tract.2-4 Practi -
tioners of both schools continue to espouse their own
51

52
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
philosophies, and both schools seem to be getting rea-
sonable results. The following is our philosophy in
terms of treatment of the maxillary sinus.
The hallmark of all endoscopic techniques is pres-
ervation of the mucosa. The idea of stripping mucosa
is certainly no longer believed to be recommended by
experts in the fi eld. The excellent studies of Moriyama
and coworkers5 have demonstrated that once this lining
is removed, the subsequent reparative lining is never
organized in a ciliated pattern that would be able to
return to normal. Thus, all current endoscopic sinus
procedures are predicated on an improved ability to
preserve the mucous membrane.
A patient who has additional openings in the maxil-
lary sinus presents a different problem. These openings
will lie in the sagittal plane and appear as though the
fontanelle had a punched-out area in its membrane
(Fig. 7-2). They will be round and lack the anterior
elliptical extension that only the natural ostium pro-
vides. Patients are frequently symptomatic when there
is circular movement of secretions between the natural
ostium and one of these additional openings. Such
patients will complain of thick postnasal discharge, as
well as symptoms of recurrent infection. Examination
in the offi ce with a 30-degree nasal endoscope pointed
laterally will often demonstrate these secretions, which
frequently contain bubbles moving between the two
ostia. CT will demonstrate these bubbles (Fig. 7-3) on
the fl oor of the maxillary sinus. When faced with an
additional opening, obvious recirculation seen endo-
scopically, and bubbles on CT scan, the decision is
usually made preoperatively to enlarge the natural
ostium into these accessory ostia.
PREOPERATIVE PLANNING
The procedure begins in the holding area with the
application of topical decongestants 30 minutes before
the procedure, and repeat topical therapy is given at 15
minutes and on call in the operating room. The patient
arrives in the operating room and undergoes either
general or local anesthesia with intravenous sedation,
depending on patient preference and the planned
extent of surgery.
Surgical preference will dictate the manner in
which the operating room and Mayo stand are orga-
nized. We use a two-handed technique,6 which is par-
ticularly helpful in patients with acute infl ammation
and bleeding. Many different systems of powered instru-
ments are available, and optimal settings will vary. In
general, if one is having diffi culty, the device should be
slowed down to allow a greater period when the window
is open to entrap the tissue, particularly in the case of
polyps.
There are many ways to clean the lens of the scope
and prevent fogging, and some scopes are self-irrigat-
ing. In the two-surgeon technique, the assistant instills
Figure 7-1. Haller cell (star) on a coronal computed tomography
scan and natural ostium of the right maxillary sinus (arrow).
Figure 7-2. Endoscopic view of accessory ostia (arrows) in the left
posterior fontanelle.
Figure 7-3. Bubbles (arrow) suggesting recirculation in the fl oor of
the right maxillary sinus.

Chapter 7
The Endoscopic Approach
53
water into the nose via a 60-mL syringe with a blunt 18-
gauge needle, and some soft tissue shavers irrigate the
lens by squirting water from the tip of the dissecting
instrument. Antifog agents are available from multiple
manufacturers as well. Such agents are helpful but
should not be used if an irrigating sleeve is on the
endoscope because the fi lm prevents irrigation of the
tip of the scope. A clean endoscope and a dry fi eld will
enable surgical precision and decrease frustration and
complications.
To maintain a dry fi eld, oxymetazoline and 1:1000
topical adrenaline are applied on 1/2- by 3-inch radi-
opaque neuropatties. Both are poured by the circulator
into labeled basins. The adrenalin is dyed with a single
drop of methylene blue to further decrease the risk of
confusing it with local anesthetic and injecting it in the
nose.
Local anesthesia is provided by injecting 1% lido-
caine (Xylocaine) with 1:100,000 epinephrine as a vaso-
constrictor before all procedures. The injections sites
are the superior attachment of the middle turbinate
and the inferior aspect of the uncinate process, as well
as the tail of the middle turbinate (Fig. 7-4). After 5
minutes has elapsed, the procedure is begun.
TECHNIQUE
A right-handed surgeon stands on the right side of the
patient. However, risk is increased when operating this
side. Right-handed surgeons have more right-sided
orbital complications because of the ergonomics of
holding the scopes and instruments. This may not be
true now that endoscopic sinus surgery has matured as
a discipline, and no recent study on this subject could
be found. The scope is positioned in the superior aspect
of the nasal vault so that placement of surgical instru-
ments is unencumbered. Surgery may proceed with
visualization either via the monitor or directly through
the telescope, although only the use of a monitor allows
the superb teaching afforded by this technique.
The middle turbinate is gently medialized with
attention paid to transmission of force to the lateral
lamella of the cribriform plate. With a bulky, paradoxi-
cally curved turbinate and certainly for the concha
bullosa, access is achieved by lateral reduction of the
middle turbinate with a soft tissue shaver. Most patients
do not require more than just gentle retraction of the
middle turbinate. The narrowest part of the ethmoid
labyrinth is located between the anterior portion of the
middle turbinate and the uncinate and lacrimal proc-
esses. Care should be taken in this area to avoid mucosal
damage and subsequent synechia formation.
After studying the orbital complications associated
with endoscopic sinus surgery, we found that the orbit
is entered most commonly during uncinectomy, pri-
marily as a result of the tip of the sickle knife going
through the lamina papyracea. We now routinely
perform retrograde dissection of the uncinate with
pediatric back-biting forceps.7
After confi rming the location of the free edge of
the uncinate process, retrograde dissection is performed
approximately a third of the way from the attachment
of the uncinate process to the ethmoidal process of the
inferior turbinate. A powered instrument is then used
to remove the uncinate superior to the retrograde cut
up to the level of the agger nasi or as dictated by the
remainder of the procedure. The portion inferior to
the uncinate window then consists of the nasal mucosa,
the residual bone of the uncinate process, which inserts
into the inferior turbinate, and the mucosa on the sinus
side (Fig. 7-5). The mucosa on the nasal side is gently
removed with the microdébrider to expose the unci-
nate bone, which is dissected and elevated submuco-
sally with a double-ball probe seeker (Fig. 7-6). This
instrument is used to deliver the uncinate out of the
mucosal pocket while leaving the maxillary ostium
intact (Fig. 7-7). This allows the microdébrider to bring
Figure 7-4. Injection sites for maxillary sinus surgery (marked with
an X).
Figure 7-5. Uncinate window created by retrograde dissection on
the left side with pediatric back-biting forceps. The inferior portion
consists of the remaining uncinate attached to the ethmoidal process
of the inferior turbinate and the mucosa medially and laterally.

54
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
the mucosal fl ap to meet the nasal side. Removing the
uncinate process in this submucosal fashion permits the
natural ostium of the maxillary sinus to be enlarged
without damage to the entire mucosal circumference of
the ostium. The parasagittal orientation of the sinus
opening is also maintained. Care is taken to not damage
any of this mucosa, which could result in at least obstruc-
tion and edema with resultant infection and, at worst,
maxillary ostial stenosis. If irrigation of the sinuses is
required, it is performed externally or by passing a
small pediatric suction device through the natural
ostium in atraumatic fashion for use as irrigation. Irriga-
tion can also be performed through the accessory
ostium or via the inferior meatus. This technique is
used for standard cases of recurrent acute sinusitis and
chronic maxillary sinusitis (see Video 7-1).
Patients who have severe primary mucosal defects
are not always candidates for the standard marsupializa-
tion as performed in the maxillary ostium approach just
described. Instead, these patients often require creation
of a formal maxillary antrostomy. Such patients include
those with cystic fi brosis, allergic fungal sinusitis, eosin-
ophilic mucin, rhinosinusitis, and Kartagener’s syn-
drome, as well as many patients with Samter’s triad,
multiply recurrent polyposis, and some revision sinus
cases.
The natural ostium is found by retrograde dissec-
tion of the uncinate process as described earlier. Once
the location of the natural ostium has been verifi ed, the
posterior fontanelle is entered while preserving the
maxillary sinus mucosa 270 degrees anteriorly. A ball
probe seeker with a knife blade on its rounded end can
be used to enlarge the area posteriorly to the perpen-
dicular plate of the palatine bone. A side biter or micro-
débrider is then used to remove the residual fontanelle
membrane while taking care to not abrade any of the
mucosa of the maxillary sinus. Diffi cult pathology can
then be addressed by suctioning and irrigation tech-
niques. It may at times be necessary to access the sinus
simultaneously from both the inferior and middle
meatus, as well as through a canine fossa endoscopic
approach.8
POSTOPERATIVE CARE
The majority of patients require minimal to no postop-
erative management. Routine examination and removal
of dried blood and crust are rarely necessary with the
technique described here. Sinus irrigation is usually
suffi cient to keep this area clean. The major complica-
tion is the development of synechia. However, a large
number of studies are now investigating the use of dif-
ferent spacers to avoid this complication, as well as
other techniques such as middle turbinate transseptal
suturing.9 The best results are obtained by meticulous
surgical technique, as well as by minimizing infl amma-
tion and infection at the time of surgery and during
the healing process with the use of steroids and
antibiotics.
COMPLICATIONS
In many patients, the lack of a clear diagnosis and indi-
cation for surgery can result in unwarranted surgery. It
is diffi cult to know what to do with patients who have a
great deal of symptoms and no objective endoscopic or
CT evidence of sinus disease. This group creates a great
deal of confusion diagnostically, and ideally they should
undergo multiple nasal endoscopic examinations in an
attempt to ascertain what is occurring in the nose when
they are sick. One should endeavor to reevaluate them
during acute infections so that a correct diagnosis can
be made. Patients with facial pain in the absence of
Figure 7-6. Submucosal dissection of the uncinate process on the
left side with a double-ball probe seeker.
Figure 7-7. Mucosal preservation of 360 degrees of the left natural
ostium.

Chapter 7
The Endoscopic Approach
55
other symptoms are rarely offered surgery unless every
other avenue has been undertaken and the patient
understands that no guarantee can be made.
Bleeding is not usually a major problem with maxil-
lary sinus surgery unless one violates the posterior limit
of dissection, which is the ascending process of the
palatine bone, or causes the inferior turbinate to bleed
by overly aggressive resection of the uncinate attach-
ment site.
The main pitfall remains synechia formation, and
the use of powered instrumentation has minimized
mucosal trauma and thus has avoided the vast majority
of these problems. Powered instruments allow preserva-
tion of most or all of the mucosal ring of the natural
ostium. If the mucosal preservation technique is used
without a formal antrostomy, the middle turbinate will
not obstruct the sinus even if it does lateralize. Figure
7-8 demonstrates such a case. The sinus does not
become obstructed because the natural ostium is still in
the parasagittal plane and its outfl ow tract is inaccessi-
ble to the lateralized middle turbinate. This is not the
case if a formal antrostomy is performed and lateraliza-
tion of the turbinate occurs as seen in Figure 7-9. Com-
plications are minimal when an antrostomy is not
performed.
In general, the complications associated with maxil-
lary sinus surgery consist of persistent disease, ostial
stenosis, lacrimal injury, orbital entry, bleeding,
and recirculation of mucus from failure to incorporate
the
natural
ostium
into
a
surgically
created
antrostomy.
Figure 7-8. The lateralized middle turbinate (arrow) on the left side
cannot obstruct the maxillary sinus because the undisturbed maxil-
lary ostium is left in the parasagittal plane.
Figure 7-9. Computed tomography appearance of a scarred lateral-
ized middle turbinate causing right maxillary obstruction after
antrostomy.
PEARLS
• Removal of the uncinate process is the key opening
step in maxillary sinus surgery.
• A retrograde approach to the uncinate process
decreases the risk of orbital injury.
• Not every case requires a formal maxillary
antrostomy.
• The best results occur when operating with good
vasoconstriction, minimal bleeding, good
visualization, and minimal mucosal trauma.
PITFALLS
• Patient selection is important for successful maxillary
sinus surgery.
• Do not rely solely on the patient’s history.
• Abnormal pneumatization of the maxillary sinus
increases the risk of orbital injury.
• Creating an antrostomy does not solve all maxillary
sinus problems.
References
1. Zinreich SJ, Kennedy DW, Rosenbaum AE, et al: Paranasal sinuses:
CT imaging requirements for endoscopic surgery. Radiology
163:769-775, 1987.
2. Setliff RC III: The small-hole technique in endoscopic sinus
surgery. Otolaryngol Clin North Am 30:341-354, 1997.
3. Albu S, Tomescu E: Small and large middle meatus antrostomies
in the treatment of chronic maxillary sinusitis. Otolaryngol Head
Neck Surg 131:542-545, 2004.

56
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
4. Wadwongtham W, Aeumjaturapat S: Large middle meatal antros-
tomy vs undisturbed maxillary ostium in the endoscopic sinus
surgery of nasal polyposis. J Med Assoc Thai 2:S373-S378, 2003.
5. Moriyama J, Yanagi K, Ohtori N, Fukami M: Evaluation of endo-
scopic sinus surgery. Am J Rhinol 10:61-66, 1996.
6. May M, Hoffman DF, Sobol SM: Video endoscopic sinus surgery:
A two-handed technique. Laryngoscope 100:430-432, 1990.
7. Schaitkin BM, Mester SJ, May M: Orbital penetration and endo-
scopic sinus surgery. Am J Rhinol 7:49-52, 1993.
8. Sathananthar S, Nagaonkar S, Paleri V, et al: Canine fossa punc-
ture and clearance of the maxillary sinus for the severely diseased
maxillary sinus. Laryngoscope 115:1026-1029, 2005.
9. Catalano PJ, Roffman EJ: Evaluation of middle meatal stenting
after minimally invasive sinus techniques. Otolaryngol Head Neck
Surg 128:875-881, 2003.

Chapter 8
Anterior Antrostomy:
The Caldwell-Luc Operation
David E. Eibling and Eugene N. Myers
Open surgical access to the maxillary sinus was once
a common procedure frequently undertaken for a
variety of indications. Open approaches for the man-
agement of chronic infection, for excision or biopsy of
masses, or for access to the spaces medial, superior, and
posterior to the sinus were part of every otolaryngolo-
gist’s repertoire. Open transantral approaches to the
pterygopalatine space for internal maxillary artery liga-
tion or vidian neurectomy, to the orbital fl oor for repair
of fractures and for orbital decompression, and even to
the posterior ethmoid and sphenoid sinuses and pitu-
itary were routine and commonly encountered in most
training programs.1
Over the past 2 decades, endoscopic approaches
have replaced traditional open procedures, so residents
who trained in the 1990s and thereafter may never have
been afforded the opportunity to perform an open
maxillary sinus procedure other than as part of a maxil-
lectomy or for the treatment of midfacial fractures. An
understanding of the procedure is, however, valuable
because there are occasional situations in which an
open approach may be preferable to an endoscopic
one.
Anterior antrostomy is known as the Caldwell-Luc
procedure after the two surgeons, one American and
the other French, who independently described the
approach to the antrum through the canine fossa more
than a century ago. The history of these two physicians
is interesting and is recounted by McBeth, who dis-
cusses not only their contributions but also how they
came to be connected with the fl edgling specialty of
otorhinolaryngology.2 Caldwell was born in Vermont
and practiced in New York City; he published his report
on anterior antrostomy in 1893 in the New York Medical
Journal. Luc, unaware of Caldwell’s report (these events
obviously predate MEDLINE), reported his procedure
in 1897. Luc was French and studied otolaryngology in
Vienna under the tutelage of Politzer. He practiced in
57
Paris and was a cofounder and editor of the International
Archives of Otorhinolaryngology, established in 1889. Luc
has been called the “father of French rhinology,” and
both these physicians did much to help establish the
specialty of otorhinolaryngology.2,3
Both physicians emphasized the need for “coun-
terdrainage” into the nose; Caldwell described the infe-
rior meatal route and Luc, enlargement of the natural
ostium in the middle meatus. It is interesting to note
that controversy regarding techniques to ensure ade-
quate sinus drainage and aeration continues to this
day.
ANATOMY
The anatomy of the maxillary sinus is easily visualized
on a coronal computed tomography (CT) scan of the
normal sinuses (Fig. 8-1A). Congenital hypoplasia is not
uncommon and is also easily identifi ed on CT (Fig.
8-1B). The roof of the maxillary sinus is the fl oor of the
orbit anterior to the infraorbital fi ssure. Medially and
posteriorly, the orbital fl oor is composed of the ethmoid
sinuses. The fl oor of the maxillary sinus is the maxillary
alveolus and it is inferior to the level of the fl oor of the
nose in adults. The alveolar bone atrophies in edentu-
lous patients such that the fl oor of the sinus may lie
signifi cantly below the level of the nasal fl oor. Anteri-
orly, the anterior wall of the maxilla extends laterally to
the zygomatic buttress. The medial wall of the sinus is
the lateral wall of the nose, and the natural-draining
ostium is located in the midportion of the superior
aspect of the medial wall. The sinus drains into the
middle meatus through the infundibulum posterior to
the uncinate process and anterior to the ethmoid bulla,
a narrow crevice easily seen on fi ne-cut coronal CT
scans.
The inferior turbinate is attached in an oblique line
along the wall below the level of the ostium, and the

58
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
nasolacrimal duct traverses the thicker bone at the junc-
tion of the medial and anterior walls before it opens
below the inferior turbinate.
The maxillary sinus is lined with ciliated columnar
epithelium, and beating of the cilia is organized in such
a fashion to move secretions toward the natural ostium
(Fig. 8-2). Appreciation of this normal centripetal
mucociliary fl ow is key to an understanding of sinus
physiology.
The internal maxillary artery is the blood supply to
the sinus mucosa through its branches the postero-
superior alveolar, infraorbital, and descending palatine
arteries, as well as through the mucosal lining of the
natural ostium on the medial wall. The nerve supply is
derived from the second division of the trigeminal
nerve. The infraorbital neurovascular bundle travels
through a groove in the orbital fl oor and then a bony
canal in the roof of the sinus. This canal can be dehis-
cent and result in referred pain from pathology in the
sinus affecting the nerve. It exits into the soft tissue of
the cheek through a foramen located approximately
5 mm below the anterior midportion of the inferior
orbital rim. Care must be taken when elevating the
periosteum from the anterior wall of the sinus to avoid
injury to the infraorbital nerve as it exits this canal. The
bony walls of the maxillary sinus are thin medially, pos-
teriorly, superiorly, and anteriorly. Thicker bone is
located in the zygomatic buttress, within the maxillary
alveolus, adjacent to the fl oor of the nose, posteriorly
along the descending palatine canal, and along the
inferior orbital rim. These regions of thicker bone are
critical fi xation points for the treatment of midfacial
fractures. A shallow depression on the anterior wall of
the maxilla superolateral to the root of the canine
tooth, inferior to the infraorbital nerve foramen, and
medial to the zygomatic buttress is termed the canine
fossa (Fig. 8-3). This bone is relatively thin and can
generally be easily punctured to provide access for diag-
nostic and therapeutic sinus puncture, as well as trocar
puncture for insertion of sinus endoscopes.
PATIENT SELECTION
Table 8-1 includes the historical indications for anterior
antrostomy. It should be noted, however, that in the
past 20 years, anterior antrostomy has essentially been
A
B
Figure 8-1. A, Computed tomography (CT) scan demonstrating
normal anatomy. B, Hypoplastic sinus (left maxillary) demonstrated
by a coronal CT scan.
Figure 8-2. Flow of mucus is directed by the cilia toward the natural
ostium; hence drainage is not facilitated by an inferior meatal
antrostomy.

Chapter 8
Anterior Antrostomy: The Caldwell-Luc Operation
59
replaced by endoscopic approaches for the initial surgi-
cal management of chronic sinusitis, biopsy of masses,
management of oral-antral fi stulas, and removal of
antral-choanal polyps, as well as for approaches to the
orbital fl oor and the pterygopalatine fossa. The most
likely indications encountered by an otolaryngologist
today will be for management of complex midfacial
trauma, for removal of foreign bodies (Fig. 8-4), for
lesions that are not amenable to endoscopic excision,
or as an approach to lesions of the pterygoid region.4
Imaging is standard in all diagnostic evaluations of
the maxillary sinuses. Plain radiographs of the sinuses
are no longer used for the evaluation of sinus disease
because far superior modalities are available at only an
incremental increase in cost. CT scans are now standard
because they provide much more detailed images of the
nose and sinuses. Axial scans are commonly available at
the time of referral; however, CT scans should be
obtained in the coronal plane in essentially all cases in
which surgical management is being contemplated.
Coronal cuts provide improved visualization of the
orbital fl oor, maxillary alveolus, and sinus outfl ow tract
anatomy not visible on axial views and can be obtained
either by reconstruction or by direct coronal acquisi-
tion (Fig. 8-5). Other imaging modalities such as mag-
Figure 8-3. The bone in this region is quite thin and easily perfo-
rated. The arrow indicates the canine fossa.
Table 8-1
HISTORICAL INDICATIONS FOR
ANTERIOR ANTROSTOMY*
Infl ammatory disease
Chronic maxillary sinusitis
Antral-choanal polyp
Fungal sinusitis
Neoplastic disease
Biopsy of maxillary sinus tumors
Excision of benign dental tumors
Staging of palate carcinoma
Access to the pterygopalatine space
Initial step in medial maxillectomy
Access to the orbital fl oor for orbital decompression
Access to the orbital fl oor for repair of
zygomaticomaxillary complex fractures
Closure of oral-antral fi stulas
*Anterior antrostomy has been replaced by endoscopic tech-
niques for most of these indications.
Figure 8-4. Coronal computed tomography scan of a patient with
chronic sinusitis of many years’ duration that resulted in the forma-
tion of a calcifi ed foreign body (“sinolith”). Treatment required ante-
rior antrostomy for visualization and removal of the sinolith.
Figure 8-5. Coronal computed tomography scan through the max-
illary sinus in a patient with an antral-choanal polyp. Note expansion
of the natural ostium (arrows) by the polyp.

60
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
netic resonance imaging (MRI) may be required
occasionally to further evaluate the consistency of the
sinus contents. It must be noted that the critical bone
detail required for sinus evaluation is not provided by
MRI; hence, the availability of MRI does not obviate the
requirement for coronal CT scanning. MRI is useful in
distinguishing between soft tissue and mucus in the
sinuses.
Controversy regarding the management of diseased
mucosa was prevalent a decade ago. The success of
minimally invasive sinus surgery has now conclusively
demonstrated that with adequate aeration and drain-
age, diseased mucosa will normalize so that removal is
not required. The primary indication for anterior
antrostomy was chronic sinusitis with total mucosal
extirpation, but removal is no longer considered
necessary.
PREOPERATIVE PLANNING
Patient selection is the most diffi cult portion of the
preoperative preparation and, in most cases, will consist
of patients with diseases or conditions deemed not suit-
able for endoscopic management. Perioperative pro-
phylactic antibiotics are not routinely administered, nor
are steroids, except in the unusual case in which an
anterior antrostomy is planned for the management of
chronic hyperplastic sinusitis with polyposis and steroid-
dependent asthma.
Bleeding can be a signifi cant problem in patients
with coagulopathies. Patients with bleeding disorders
must be identifi ed and appropriate steps taken to correct
the abnormality before surgery. Patients who have been
taking aspirin, warfarin (Coumadin), or similar medica-
tions should discontinue taking them and similar drugs
several days or even weeks before surgery.
Occasionally, surgery will be necessary in immuno-
compromised and coagulopathic patients. In these cir-
cumstances, adequate quantities of platelets, fresh
frozen plasma, and other blood products must be avail-
able if their use is anticipated. Decisions regarding
surgery in these patients are often complex, but it must
be remembered that uncontrolled infection in immu-
nocompromised patients can be rapidly fatal. One such
entity is invasive fungal sinusitis. The surgeon must have
a low threshold for operative intervention in these
patients because angioinvasion will rapidly progress to
necrosis of signifi cant amounts of tissue. These patients
often exhibit only minor bleeding at the time of the
procedure because of the angio-occlusive nature of the
fungal hyphae.
Not only must preoperative counseling include the
usual risks of bleeding, infection, and other problems,
but mention should also be made of the high potential
for numbness of the midface and upper lip, which is a
consequence of injury or traction on the infraorbital
nerve during retraction of the soft tissue of the face to
provide exposure. Discussion regarding postoperative
ecchymosis, facial edema, the value of elevation of the
head, and dietary recommendations is also helpful to
the patient.
TECHNIQUE
The procedure may be performed with the patient
under either local or general anesthesia. It is more com-
monly performed under general anesthesia, although
adequate blockade of the sinus mucosa can be obtained
by injecting the posterosuperior alveolar nerve, as well
as the descending palatine foramen. Lidocaine (Xylo-
caine) with epinephrine 1:1,000,000 is injected directly
into the buccogingival sulcus approximately 5 minutes
before the beginning of the procedure to assist with
hemostasis. Decongestion of the nasal mucosa with
oxymetazoline (Afrin) or 0.25% phenylephrine (Neo-
Synephrine) is used in patients in whom associated
intranasal surgery is planned in conjunction with the
antrostomy.
The upper lip is retracted and the incision is made
such that approximately 0.5 cm of free buccogingival
mucosa is preserved for later closure (Fig. 8-6). In eden-
tulous patients the incision should be made over the
attached gingiva rather than the buccogingival sulcus
to permit early wearing of dentures. Early wearing of
dentures by patients who have undergone a standard
buccogingival incision, particularly in cases in which
there is infraorbital nerve anesthesia, can result in
suture line disruption because of pressure of the buccal
fl ange of the denture, as well as the subsequent devel-
opment of a chronic oral-antral fi stula. Dissection is
carried down to the anterior wall of the maxilla via
electrocautery. With a wide periosteal elevator, the peri-
osteum is elevated from the anterior wall of the maxilla
as far as the infraorbital nerve (Fig. 8-7). Elevation is
diffi cult over the attached gingiva in edentulous patients
but easier once the dissection progresses superiorly to
Figure 8-6. The incision is made in the buccogingival sulcus. In
edentulous patients, the incision is made over the gingiva to permit
earlier wearing of dentures.

Chapter 8
Anterior Antrostomy: The Caldwell-Luc Operation
61
the alveolus. Care is taken to avoid injury to the infra-
orbital nerve as it exits the infraorbital foramen (Fig.
8-8). The canine fossa is easily identifi ed at this stage,
and a mallet and osteotome are used to enter the maxil-
lary sinus. The opening is enlarged with Kerrison ron-
geurs to gain as much exposure as necessary for the
planned procedure (Fig. 8-9). Care is taken to avoid
injury to the neurovascular supply to the tooth roots,
the infraorbital nerve, and the soft tissue anterior to the
maxilla. The mucosa is then opened and the planned
procedure is performed. Brisk bleeding from the edges
of the mucosa or bone can be controlled with electro-
cautery, bone wax, or temporary packing with 0.25%
phenylephrine- or oxymetazoline-soaked material.
If the antrostomy is being carried out for removal
of an antrochoanal polyp, all the mucosa is undermined
and left attached at the widened natural ostium. The
antrochoanal polyp is then approached through the
oral cavity and nasopharynx. It may be necessary to
retract the soft palate to visualize the polyp. Traction is
placed on the polyp. A sharp elevator should be used
to undermine any residual mucosa that might be tether-
ing the polyp to the natural ostium. Once the mucosa
has been freed, continuous traction will remove the
antrochoanal polyp and all the mucosa of the maxillary
antrum in one specimen to prevent recurrence.1
A nasoantral window is formed to provide drainage,
aeration, and a natural way to remove packing from the
antrum should it be necessary. The bone of the inferior
meatus is visualized through the antrostomy. This bone
is quite thin and, with pressure from a periosteal eleva-
tor, can be fractured and then removed piecemeal until
a large window is formed (Fig. 8-10). It is helpful to
insert a curved hemostat into the inferior meatus to
push the mucosa toward the maxillary antrum. Electro-
Figure 8-7. Exposure of the canine fossa. Care is taken to avoid
undue trauma or stretching of the infraorbital nerve.
Infraorbital nerve
Figure 8-8. The infraorbital nerve is identifi ed at the point where
it exits the infraorbital foramen and is preserved.
Figure 8-9. Opening the sinus with a Kerrison rongeur.
cautery is used to make an inferiorly based fl ap of this
mucosa, which is then draped into the medial wall of
the sinus. This fl ap is subsequently placed into the max-
illary antrum to facilitate the healing process.
Hemostasis can usually be achieved by cautery
alone, unless extensive removal of mucosa is performed,
in which case packing may be required. The wall of the
antrum is lined with pledgets of compressed Gelfoam

62
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
or a similar hemostatic substance. Petrolatum (Vase-
line) gauze impregnated with bacitracin is used to
loosely pack the antrum, and the end of the pack is
brought out into the nose via the nasoantral window.
Care must be taken to ensure that the packing is layered
in such a way that it can be easily removed through the
antrostomy. A suture on the end of the packing identi-
fi es it for later removal, a particularly valuable step if
the nose is packed as well. The incision is closed with
absorbable sutures and care taken to ensure that the
mucosal edges are accurately approximated to prevent
the occurrence of an oral-antral fi stula. If packing is
used, care must be taken to ensure that it is not caught
by the suture or on a bone spicule.
POSTOPERATIVE CARE
The packing can be removed on the second or third
day, depending on the hematologic status of the patient,
as well as the disease process. It is critical that all packing
be removed because “lost packing” is a foreign body
that may result in chronic infection and additional
surgery will be required. Routine cleansing through the
nasal antral window can be performed in patients who
require it. Some patients may benefi t from irrigation
through a catheter placed in the sinus and secured with
a suture for several days. Patients should be advised to
not wear an upper denture for 7 to 10 days to allow time
for healing of the buccogingival incision because the
trauma of wearing dentures too soon can lead to an
oral-antral fi stula.
Most patients will experience some temporary
hypoesthesia in the distribution of the infraorbital nerve
as a result of retraction on the nerve during the proce-
dure. This usually resolves within 4 to 6 weeks. Some
patients will also experience numbness of their canine
and premolar teeth as a consequence of bone removal
because branches of the superior alveolar nerve pass
Figure 8-10. Creation of a window in the inferior meatus.
through the inferior anterior maxillary wall. Avoiding
excessive removal of inferior bone in dentate patients
can help minimize this sequela.
PEARLS
• Anterior antrostomy (Caldwell-Luc operation)
remains a very useful procedure for treating patients
with facial fractures and foreign bodies in the
maxillary antrum.
• Maxillary antrostomy is the fi rst step in performing
medial maxillectomy for benign tumors of the
paranasal sinuses.
• Anterior antrostomy is very important in the closure
of an oroantral fi stula.
• After the gingivobuccal sulcus incision is made,
caution must be exercised when elevating the soft
tissues off the anterior wall of the antrum to avoid
injury to the infraorbital nerve.
• An antrostomy must always be made in the inferior
meatus if an anterior antrostomy is performed to
provide drainage of secretions during the healing
process.
PITFALLS
• Failure to create adequate nasal drainage may result
in the accumulation of blood and secretions within
the sinus.
• Intraoperative injury to the fl oor of the orbit may
lead to orbital emphysema.
• Injury to the infraorbital nerve will produce
permanent hypoesthesia of the cheek, lip, and nasal
ala.
• Injury to the neurovascular supply to the tooth roots
because of aggressive removal of bone from the
anterior wall of the antrum can result in loss of
tooth vitality.
• Failure to obtain adequate hemostasis at the time of
surgery may lead to postoperative bleeding,
particularly in coagulopathic patients.
References
1. Eibling DE: Anterior antrostomy: The Caldwell-Luc operation. In
Myers EN (ed): Operative Otolaryngology—Head and Neck
Surgery. Philadelphia, WB Saunders, 1997, pp 92-99.
2. McBeth R: Caldwell, Luc, and their operation. Laryngoscope
81:1652-1657, 1971.
3. Myers EN: Caldwell-Luc operations and extensions. In Goldman
JL (ed): The Principles and Practice of Rhinology. New York,
Wiley, 1987, pp 455-474.
4. Har-El
G:
Combined
endoscopic
transmaxillary-transnasal
approach to the pterygoid region, lateral sphenoid sinus, and ret-
robulbar orbit. Ann Otol Rhinol Laryngol 114:439-442, 2005.

Chapter 9
Oral-Antral Fistulas
Jonas T. Johnson
Oral-antral fi stulas are usually encountered as sequelae
of tooth extraction or anterior antrostomy. All of the
maxillary teeth are potentially in close proximity to the
antrum. This is especially true of the molar teeth (Fig.
9-1A). In patients with extensive development of the
maxillary sinus, all the molar teeth may be immediately
adjacent to the maxillary sinus. In one study, oral-antral
fi stula was investigated in 87 patients. The tooth most
frequently involved was the fi rst molar, followed by the
second and third molars.1,2 Tooth extraction may be
associated with the development of an iatrogenic oral-
antral fi stula. If recognized at the time of tooth extrac-
tion, local tissues can sometimes be used to close the
defect. Unfortunately, wound breakdown, chronic max-
illary sinusitis, and the development of an epithelium-
lined tract between the oral cavity and the sinus mucosa
result in a true oral-antral fi stula. Oral-antral fi stulas
may also complicate maxillary implant surgery.3 They
are an uncommon complication of the Caldwell-Luc
operation. In one series of 670 patients, oral-antral fi s-
tulas developed in 5 patients (<1%).4
PATIENT SELECTION
Patients with an oral-antral fi stula should be evaluated
to determine the cause of the fi stula. An oral-antral
fi stula that develops in the setting of chronic sinus
disease may refl ect underlying obstruction of the natural
ostium of the maxillary sinus (Fig. 9-1B). Accordingly,
these patients should be studied with intranasal endos-
copy to ascertain the patency of the natural ostium or
surgically created nasal-antral window. Evidence of
osteomyelitis in the margins of the fi stula should prompt
the administration of antibiotics and a plan for
débridement.
In patients in whom an oral-antral fi stula develops
after tooth extraction, evaluation of the extraction site
frequently reveals necrotic debris and osteomyelitis.
Oral-antral fi stulas that are due to tooth extraction
usually lead to secondary sinusitis (Fig. 9-2). In one
study of odontogenic sinusitis with a persistent oral-
antral fi stula, opacifi cation of the maxillary sinus was
observed in all patients. Surgical treatment consisted of
antrostomy and closure of the oral-antral fi stula.5
PREOPERATIVE EVALUATION
The status of the maxillary sinus and ostiomeatal
complex should be determined endoscopically. Coronal
computed tomography helps assess the status of the
maxillary sinus and can identify retained dental roots
and unerupted teeth. When evidence of obstruction of
the sinus ostium is present, the planned procedure
should include reestablishment of maxillary sinus drain-
age (Fig. 9-3).
If a palatal fl ap is planned, patients can be aided
through fabrication of an acrylic splint that is fi xed with
clasps to the residual dentition for protection of the
wound while it heals.
SURGICAL APPROACHES
Closure of an oral-antral fi stula consists of two proce-
dures completed at the same setting. First, chronic
sinusitis must be dealt with either by drainage through
a nasoantral window and complete removal of the
infected mucosa or by opening of the natural
ostium.
Closure of an oral-antral fi stula may be undertaken
with the patient under either local anesthesia with intra-
venous sedation or general anesthesia. Local anesthesia
may be achieved with a local fi eld block, occasionally
supplemented with lidocaine injected into the greater
palatine foramen.
63

64
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
B
A
Figure 9-1. A, Computed tomog-
raphy scan clearly demonstrating
the relationship between a molar
tooth (arrow) and a well-aerated
maxillary sinus. B, Oral-antral
fi stula that developed after tooth
extraction. The most common
explanation for this is failure to
provide adequate nasal drainage.
Figure 9-2. Oral-antral fi stula (arrow) that developed after extrac-
tion of the maxillary second molar. Soft tissue in the tract between
the maxillary sinus and the oral cavity must be removed before
closure.
Figure 9-3. Computed tomography scan demonstrating an oral-
antral fi stula with obstruction of the maxillary sinus. Adequate intra-
nasal drainage to either the middle meatus or the inferior meatus
must be achieved to ensure success when the fi stula is closed.
Necrotic bone and soft tissue must be removed.
The status of the mucosa in the sinus is ascertained, and
diseased or polypoid mucosa is removed if it is obstruct-
ing sinus drainage. The preferred technique is enlarge-
ment of the natural ostium. Epithelium bridging the
defect from the oral cavity to the maxillary sinus must
be removed, as well as infected or necrotic bone. At this
point, either a sliding bipedicle fl ap or an advancement
rotation fl ap should be developed from the adjacent
buccal or palatal mucosa (Fig. 9-4). The surgeon must
plan the fl ap so that the gingivobuccal sulcus is not
obliterated in patients who use dentures. Adequate
length of the fl ap must be achieved to allow closure
without tension. The fl ap is developed in a plane just
superfi cial to the periosteum and rotated or advanced
to close the oral-antral fi stula (Fig. 9-5). Either perma-
nent sutures (e.g., silk) or long-lasting absorbable
sutures (e.g., Vicryl) are used.
We use an alternative technique for the manage-
ment of oral-antral fi stulas that develop after dental
extractions (Fig. 9-6). These fi stula frequently arise
directly on the alveolar ridge. Once again, it is necessary
to débride necrotic bone and remove any diseased epi-
thelium bridging the mucosa of the maxillary sinus with
the alveolar ridge. This is facilitated by making an inci-
sion through the mucosa of the alveolar ridge parallel
to the alveolar ridge (Fig. 9-7). The necrotic bone is
débrided superiorly until normal bone is identifi ed
(Fig. 9-8) to permit mobilization of the mucosal fl aps
for primary closure. With adequate débridement of

Chapter 9
Oral-Antral Fistulas
65
Figure 9-4. Design of a posteriorly based palatal fl ap.
Figure 9-5. Mobilization and rotation of the palatal fl ap to cover
the fi stula. The resulting mucosal defect in the palate is allowed to
granulate and heal by secondary intention. Most patients will be more
comfortable if an acrylic splint is fabricated for use during eating.
Figure 9-6. Oral-antral fi stula on the maxillary alveolus after
removal of a molar tooth.
Figure 9-7. The mucosa is mobilized in either direction through a
longitudinal incision made along the alveolus. The soft tissue lining
the fi stula is removed.
bone, the mucosa of the alveolus can be closed directly
over the fi stula site (Fig. 9-9).
POSTOPERATIVE MANAGEMENT
Two to 3 weeks of healing is required to achieve ade-
quate wound strength to withstand the trauma of mas-
tication. The use of a dental prosthesis (bridgework or
dentures) and chewing are avoided during convales-
cence. If an acrylic splint is available to cover the palatal
defect, most patients can begin to drink fl uids the after-
noon of surgery. Administration of an antibiotic effec-
tive against oral fl ora may be of some benefi t. Patients
are instructed to eat a soft diet and chew on the con-
tralateral side. The patient must clean the mouth and
suture line with half-strength peroxide or Peridex after
each meal for 6 weeks.
Failure to ensure adequate drainage of the maxil-
lary sinus into the nasal cavity may result in a persistent
oral-antral fi stula. Effort must be made to ensure either
that the natural ostium is patent or that a new nasal
antrostomy has been created.

66
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Figure 9-8. The bone is recessed superiorly to ensure removal of
all osteomyelitic bone. This, in turn, enhances primary closure of the
mucosa.
Figure 9-9. The mucosa is closed primarily over the fi stula site.
Failure to remove necrotic tissue, osteomyelitic
bone, chronically infected antral mucosa, and epithelial
bridges from the oral mucosa to the maxillary sinus may
prevent healing and result in persistent infection and
recurring fi stula. These issues should be carefully
addressed during surgery.
Development of a buccal or palatal fl ap of insuffi -
cient length or breadth may compromise healing
because of a tight suture line and lead to a resultant
recurrent fi stula. Similarly, repair with absorbable
sutures such as catgut or chromic catgut may be inade-
quate to ensure healing before dissolution of the suture
material.
A recurrent oral-antral fi stula after attempted surgi-
cal repair is usually a result of inadequate management
of the sinusitis, which is frustrating to both the surgeon
and patient. The literature abounds with techniques
advocated for repair of chronic oral-antral fi stulas,
including the use of vascularized tissue such as buccal
fat pad,6 a submental island fl ap,7 and palatal rotation.8
Some patients benefi t from nonsurgical management
with a prosthesis.9
PEARLS
• Extraction of maxillary molar teeth is the most
common cause of an oral-antral fi stula.
• An acrylic splint facilitates protection of the palate
repair.
• Successful repair requires débridement of necrotic
tissue, bone, and intervening epithelium.
• Avoid crossing the buccogingival sulcus with the
fl ap because this will obliterate the sulcus and
interfere with wearing dentures.
PITFALLS
• Maxillary sinus obstruction may contribute to a
failed fi stula repair.
• Rotation fl aps of insuffi cient length may fail.
• Do not obliterate the gingival sulcus with soft tissue.
• Failure to remove infected bone may result in failure.
References
1. Punwutikorn J, Waikakul A, Pairuchveg V: Clinically signifi cant
oroantral communications: A study of incidence and site. Int J Oral
Maxillofac Surg 23:19-21, 1994.
2. Vanclooster R, Schautteet H, Bourgois F, et al: Oroantral commu-
nication and its treatment. Rev Belge Med Dent 46(3):20-26,
1991.
3. Mioduski TE Jr, Guinn NJ: Dental implants: Permanent replace-
ment for lost teeth. AORN J 51:729-734, 1990.
4. DeFreitas J, Lucente FE: The Caldwell-Luc procedure: Institutional
review of 670 cases: 1975-1985. Laryngoscope 98:1297-1300,
1988.
5. Lin PT, Bukachevsky R, Blake M: Management of odontogenic
sinusitis with persistent oroantral fi stula. Ear Nose Throat J 70:488-
490, 1991.
6. Dolanmaz D, Tuz H, Dayraktar S, et al: Use of pedicled buccal fat
pad in the closure of oroantral communication: Analysis of 75
cases. Quintessence Int 35:241-246, 2004.
7. Genden EM, Buchbinder D, Urken ML: The submental island fl ap
for palatal reconstruction: A novel technique. J Oral Maxillofac
Surg 62:387-390, 2004.
8. Anavi Y, Gal G, Silfen R, Calderon S: Palatal rotation-advancement
fl ap for delayed repair of oroantral fi stula: A retrospective evalua-
tion of 63 cases. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 96:527-534, 2003.
9. Logan RM, Coates EA: Non-surgical management of an oro-antral
fi stula in a patient with HIV infection. Aust Dent J 48:255-258,
2003.

Chapter 10
Medial Maxillectomy
Eugene N. Myers
Medial maxillectomy is a procedure commonly used
for the removal of benign and low-grade malignant
tumors involving the medial aspect of the maxilla, the
lateral nasal wall, the ethmoid sinuses, and the lacrimal
sac. Medial maxillectomy may be carried out through
a lateral rhinotomy incision or through a midfacial
degloving procedure. It has been supplanted by endo-
scopic sinus surgery techniques for certain indications
in recent years; however, the lateral rhinotomy approach
continues to be useful because of the outstanding ex -
posure provided. This technique has also proved to be
quite valuable when used in conjunction with a cranio-
facial approach to aggressive neoplasms in the skull
base. Lateral rhinotomy is useful as an approach to the
management of neoplasms in the nasal septum. It may
also be performed in conjunction with inferior maxil-
lectomy for removal of tumors in the inferior aspect of
the maxillary antrum or for tumors arising on the hard
palate and alveolus. Performance of lateral rhinotomy
for removal of oral cavity neoplasms is discussed in
Chapter 27. Lateral rhinotomy and medial maxillec-
tomy may also be used in selected patients with juvenile
angiofi broma of the nasopharynx.
The midfacial degloving procedure has been used
for modifi cations of the medial maxillectomy involving
tumors isolated to the inferior turbinate or to the area
of the premaxilla or nasal septum. The midfacial deglov-
ing procedure does not allow suffi cient access for satis-
factory exposure superiorly (e.g., removal of the anterior
ethmoid air cell system or the area of the frontoeth-
moid recess).
LATERAL RHINOTOMY
Lateral rhinotomy was fi rst described by Moure of Bor-
deaux and was primarily used for the removal of tumors
in the ethmoid air cell system. Harrison later correctly
pointed out that “lateral rhinotomy” is the name of an
incision, not an operation, and that medial maxillec-
tomy is the operation most commonly carried out
through this incision.1
The lateral rhinotomy approach to lesions in the
nose and paranasal sinuses has been part of the natural
evolution of the otolaryngologist into a head and neck
surgeon. The previous approaches for benign and low-
grade malignant tumors in this area were far more
limited and were generally carried out either transna-
sally or through external ethmoidectomy or Caldwell-
Luc operations. The limited exposure provided by these
approaches resulted in a high rate of recurrence of
benign tumors and an inability to cure malignant
tumors.
The most common use of lateral rhinotomy has
been for the management of benign tumors, particu-
larly inverted papillomas of the sinonasal tract. An
awareness that inverted papillomas have a tendency to
destroy bone, to recur after incomplete removal, and
occasionally to undergo malignant transformation
or coexist with malignancy has led to the belief
that wide exposure is required for complete removal.
The historically high recurrence rates reported
after limited resection were due to inadequate tumor
removal as a result of the limited access provided
through the classic techniques of sinus surgery. The
ideal surgical approach for the management of inverted
papillomas must fulfi ll certain requirements: (1) ade-
quate exposure for complete removal of tumor, (2)
adequate view of the sinonasal cavity for postoperative
examination, and (3) acceptable cosmetic and func-
tional results.
For several decades, reports in the literature from
Vrabec,2 Lawson,3 Thorp,4 and Myers5 and their col-
leagues described excellent results in the management
of inverted papilloma with the technique of lateral rhi-
notomy and medial maxillectomy. However, in 1992,
Waitz and Wigand reported excellent results with endo-
scopic sinus surgery in the treatment of inverted papil-
loma, even in advanced cases.6
67

68
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
With these promising results, together with the
advent of powered instrumentation, endoscopes with
magnifi cation, and angled views, visualization has
improved and allowed more accurate tumor localiza-
tion, and an evolution in our management of these
tumors has taken place. The presence of many nasal
endoscopists in our residency training programs has
resulted in a growing body of evidence to support the
use of endoscopic surgery in the resection of these
tumors because of results comparable to those achieved
with the external approach.7-12
The technique of lateral rhinotomy and medial
maxillectomy with removal of the lateral nasal wall, fol-
lowed by meticulous removal of all mucosa in the ipsi-
lateral maxillary antrum, ethmoid sinuses, and sphenoid
sinuses, is a requirement for complete excision of
large inverted papillomas. When satisfactorily executed
and meticulously closed, the lateral rhinotomy incision
heals well, is inconspicuous, and is accepted by most
patients. The lateral rhinotomy incision is also used for
total maxillectomy. It provides adequate exposure so
that it is not necessary to use the Weber-Ferguson exten-
sion, which results in an unsightly scar and often a poor
cosmetic outcome. Midfacial degloving is reserved for
use in patients who have a tendency for the develop-
ment of pigmented scars or keloids.
PATIENT SELECTION
Patients who have benign and malignant tumors of the
nasal cavity and paranasal sinuses, such as inverted pap-
illomas, tumors of minor salivary gland origin, tumors
of the lacrimal sac, and tumors of the nasal septum, may
all be adequately treated with the technique of medial
maxillectomy. An occasional patient may have a foreign
body in the nose that may become quite large and
produce concretions known as “rhinoliths” that may
have to be removed through a lateral rhinotomy.
Tumors of the nasal septum may also be approached in
this manner. Lateral rhinotomy alone does not provide
adequate exposure if the tumor is located in the poste-
rior two thirds of the septum, so other approaches will
be required as well. Patients who have malignant tumors
in these anatomic sites, as well as the cribriform plate
area, such as esthesioneuroblastoma, may benefi t from
a lateral rhinotomy carried out as part of the craniofa-
cial resection.
PREOPERATIVE PLANNING
Computed tomography (CT) and magnetic resonance
imaging (MRI) provide very precise information about
the exact location and the dimensions of the tumor to
be removed. These imaging studies also provide an
exact view of the anatomy, including any anatomic vari-
ations, thereby facilitating preoperative planning (Fig.
10-1). CT scanning offers precise evaluation of bone
detail, particularly the presence of bone erosion or
tumor invasion into adjacent structures such as the
cranial base or the orbit. However, CT scanning may
overestimate the mass of the tumor, especially if the
tumor obstructs the sinus, because CT cannot differen-
tiate tumor from adjacent infl amed mucosa or retained
secretions. In contrast, MRI may be used to distinguish
tumor from secretions secondary to obstruction of the
sinus (Fig. 10-2). In particular, T2-weighted images and
contrast-enhanced T1-weighted images can differenti-
ate between tumor and adjacent infl ammatory changes.
In general, inverted papilloma exhibits intermediate
signal intensity on T2-weighted images, whereas in -
fl ammatory changes adjacent to an inverted papilloma
exhibit extremely high signal intensity. In addition,
inverted papilloma shows a solid enhancement pattern
resembling that exhibited by malignant tumors, whereas
infl ammatory mucosa shows intense peripheral rim
enhancement. Oikawa and associates13 demonstrated in
their series of patients with inverted papilloma that MRI
assessment of inverted papilloma can accurately predict
the extent of tumor involvement. Preoperative staging
of inverted papilloma by MRI may be useful for plan-
ning an appropriate surgical approach. Positron emis-
sion tomography (PET) yields qualitative information
about the malignant potential of the tumor based on
its fl uorodeoxyglucose (FDG) avidity and may be even
more useful when combined with simultaneous CT
scanning (PET/CT scan).
Biopsy is important to establish a histologic diagno-
sis before surgery, particularly in this anatomic area
because of the wide variety of tumors that may be
encountered. If the tumor is extensive and high grade
on biopsy, a more extensive procedure may be required.
Concern about hemorrhage after biopsy has led many
surgeons to routinely perform the biopsy in the operat-
ing room. The use of sinonasal endoscopy has also
helped determine the extent of the disease more pre-
cisely, thus aiding in planning of the procedure.
Figure 10-1. Computed tomography scan demonstrating a tumor
involving the lateral nasal wall, the nasal cavity, and the paranasal
sinuses.

Chapter 10
Medial Maxillectomy
69
SURGICAL TECHNIQUE
Lateral rhinotomy is performed with the patient under
general oral endotracheal anesthesia. The endotracheal
tube should be fi xed by tape or suture to the side of the
oral cavity contralateral to the surgical procedure. Peri-
operative antibiotics are administered. This skin is
marked for the incision before skin preparation. The
incision for lateral rhinotomy extends from just above
the medial canthus along the lateral aspect of the nose
into the alar crease (Fig. 10-3). If necessary, wider expo-
sure may be gained by splitting the lip. When the lip is
to be split, as with a radical maxillectomy, a mark should
be made in the vermilion border with the tip of the
knife blade to reapproximate the two sides of the lip
properly. Accurate approximation of the vermilion
border is critical for satisfactory cosmesis when the lip
is reapproximated at the end of the procedure. The
vertical line for the lip-split should be placed in the
vertical line of the philtrum on the ipsilateral side
because such placement helps camoufl age the scar. The
line of the incision is marked with a marking pen.
After the face is prepared and draped, a temporary
tarsorrhaphy is performed on the ipsilateral eye with 6-0
silk on a cutting needle to prevent injury to the cornea
during the procedure. The incision is made with a
scalpel, and the underlying soft tissues are dissected
with electrocautery. The periosteum, together with the
soft tissue, is elevated off the anterior wall of the maxilla
as far lateral as the lateral aspect of the maxillary antrum
and as far superior as the orbital rim to expose and
preserve the infraorbital nerve (Fig. 10-4). The perior-
bita is then undermined off the lamina papyracea. This
complete undermining will also dislocate the lacrimal
sac out of the lacrimal fossa. The lacrimal duct should
be transected as far distally as possible (Fig. 10-5). Such
transection will allow further undermining of the peri-
orbita to expose the medial third of the fl oor of the
orbit. Bleeding from the lacrimal bone may be managed
by electrocoagulation. The periorbita is then elevated
posteriorly to the anterior and posterior ethmoid arter-
ies, which should be identifi ed but not ligated or divided
because these vessels provide the most constant land-
marks for the frontoethmoid suture. Staying below this
suture line is a safety feature of unparalleled impor-
tance in avoiding entrance into the anterior cranial
fossa.
A
B
Figure 10-2. A, Coronal computed tomography (CT) demonstrat-
ing opacifi cation of the left-sided maxillary sinus. With CT images it
is diffi cult to determine which portion of the opacifi cation represents
the tumor and which represents obstructed secretions. B, Coronal
T2-weighted magnetic resonance image demonstrating an inverted
papilloma as an intermediate–signal intensity mass (arrow) involving
the medial portion of the left maxillary sinus. High-signal intensity
(star) indicates the obstructed secretions in the left maxillary sinus.
(Reprinted with permission from Oikawa K, Furuta Y, Oridate N, et al: Pre-
operative staging of sinonasal inverted papilloma by magnetic resonance
imaging. Laryngoscope 113:1985, 2003.)
Figure 10-3. The lateral rhinotomy incision is outlined. It is not
usually necessary to split the lip. The nasal vestibule should not be
violated.

70
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
the nerve is endangered when electrocautery is used to
control the bleeding. Subperiosteal dissection is carried
out along the nasal bone and ascending process of the
maxilla. At this point, elevation of the periorbita may
be completed more easily. Osteotomies are made (Fig.
10-6A to C) (1) along the nasal bone, (2) along the
fl oor of the nose connecting the nasal cavity with the
antrum, (3) below the frontoethmoid suture, and (4)
at the junction of the lamina papyracea with the fl oor
of the orbit. An oscillating saw or a rongeur may be used
for osteotomies 1 and 2; however, osteotomies along
the frontoethmoid suture and junction of the lamina
papyracea with the fl oor of the orbit should be carried
out under direct vision with a thin osteotome. After the
osteotomies have been completed, heavy scissors are
used to separate the posterior soft tissue attachments
from the bone (Fig. 10-7). One blade of the scissors is
placed in the orbit just below the frontoethmoid suture
in the osteotomy, and the other blade is placed in the
nasal cavity at approximately the level of the midpor-
tion of the middle turbinate. By applying gentle trac-
tion inferiorly while cutting, the surgeon separates the
block consisting of the lateral nasal wall (medial maxil-
lectomy) from the surrounding tissues. Bleeding may
be encountered from branches of the internal maxillary
artery.
After removal of the specimen, all of the mucosa is
removed from the maxillary antrum and sent to the
pathology department as a separate specimen. Individ-
ual bleeding points may be controlled by electrocoagu-
lation at that time, with the exception of the area
around the infraorbital nerve. The mucosa from any
remaining ethmoid cells is removed and sent to the
pathology department as a separate specimen. Frag-
ments of the lamina papyracea are removed to ensure
good healing and an easy-to-clean nasal cavity. Failure
to remove residual mucosa may result in infection
or edema. The sphenoid sinus is then opened, and
the front wall of the sinus is removed with a small
Kerrison rongeur. The mucosa of the sphenoid sinus
is removed to prevent subsequent infection and
edema. Removing the mucosa prevents the possibility
of mistaking edematous mucosa for tumor in follow-up.
It is appropriate at this time to perform a dacryocysto-
rhinostomy. The lacrimal sac is opened (Fig. 10-8A)
and sutured to the surrounding soft tissues with absorb-
able catgut suture to prevent postoperative epiphora
(Fig. 10-8B). The bone around the nasofrontal recess
must be removed widely to ensure adequate ventilation
and prevent subsequent stenosis with mucocele
formation.
Although lacerations of the periorbita occur infre-
quently, when present, they should be repaired with
absorbable suture. The wound is irrigated. Once the
mucosa has been removed in its entirety, there should
be no bleeding. The sphenoid sinus is packed with
Gelfoam. The bone along the roof of the ethmoid and
the entire maxillary antrum should be lined with pled-
gets of Gelfoam. A gauze plug impregnated with antibi-
otics is placed in the posterior choana. One string is
brought out through the oral cavity and taped to the
Figure 10-4. Elevation of the periosteum off the maxilla with expo-
sure of the infraorbital nerve.
Figure 10-5. The lacrimal sac is elevated from the lacrimal fossa
and transected as far distally as possible.
The nasal cavity is then entered by incising the
mucosa along the piriform aperture. Transection of the
nasal mucosa anterior to the inferior turbinate with an
electrocoagulating current decreases the bleeding. The
nasal ala is kept intact as a unit to avoid subsequent
distortion with narrowing of the nasal vestibule.
An opening is made through the anterior wall of
the maxillary antrum with a mallet and osteotome or a
cutting burr. The entire front wall of the maxillary
antrum is removed up to the orbital rim and the medial
wall to provide access for subsequent osteotomies. The
infraorbital nerve must be preserved whenever possible.
Caution should be exercised to not remove bone too
close to the infraorbital nerve because vessels accom-
pany the nerve. These vessels are too small to ligate, and

Chapter 10
Medial Maxillectomy
71
A
C
B
Figure 10-6. Osteotomies are made along the fl oor of the nose through the bone
between the antrum and the nasal cavity (A), through the frontal-ethmoid suture below
the level of the anterior ethmoid artery (B), and along the medial fl oor of the orbit to
the posterior wall of the antrum (C).
Figure 10-7. Heavy scissors are used to cut through the middle and
inferior turbinate attachments.
cheek. The other strings are brought out through the
anterior nasal cavity and tied over a dental roll (not
around the columella). The sinonasal cavity is then
packed loosely with 1–2 -inch gauze impregnated with
antibiotic ointment. Lining the cavities with Gelfoam
before packing promotes hemostasis and facilitates
removal of the nasal packing because it is removed from
the Gelfoam rather than from the bony walls of the
sinus and thus reduces the chance of bleeding.
Repositioning of the medial canthal ligament must
be precise. It is important to compare the repair with
the contralateral normal side to make certain that the
repositioning is accurate. If the periorbita is respected
and minimal nasal bone has been removed, meticulous
closure of the skin and subcutaneous tissue will result
in adequate realignment of the medial canthal
ligament.
The wound is meticulously closed to provide a good
cosmetic outcome. If the lip has been split, the area of

72
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
POSTOPERATIVE MANAGEMENT
The head of the bed is elevated in the recovery room.
The posterior plug and eye patch are removed on the
fi rst postoperative day. The nasal airway is also removed
at this time. If a gingivobuccal incision was made, half-
strength peroxide should be used to rinse the mouth
four times a day over the next 5 days. The nasal packing
is removed on the third postoperative day, and the
patient is discharged on the following day. The patient
is seen in the offi ce 7 to 10 days postoperatively, and
the Steri-Strips are removed at that time. The absorb-
able skin sutures come out when the Steri-Strips are
removed. The patient is requested to use bacitracin
ointment on the incision line over the next week to
enhance healing. The patient is seen in the offi ce 3 to
4 weeks later, at which time crusts of dried mucus are
removed from the sinonasal cavity and the patient is
given instructions for once- or twice-daily sinonasal irri-
gation with saline solution through a small rubber bulb
syringe.
COMPLICATIONS
The major potential intraoperative complications asso-
ciated with this operation have to do with the central
nervous system and the orbit. If an osteotomy is per-
formed superior to the level of the anterior ethmoid
artery and frontoethmoid suture, it is possible to enter
the cranial cavity with resultant leakage of cerebrospi-
nal fl uid (CSF). Extending the dissection medial to the
attachment of the middle turbinate will also precipitate
CSF leakage. This complication should be recognized
and repaired immediately. The bone edge is débrided
to widen the defect to afford the surgeon ample expo-
sure to fully evaluate the injury. The laceration is closed
with a small circle needle. Using fi brin glue, a piece of
fascia is placed over the laceration with the edges tucked
under the edges of bone. If an actual defect in the dura
is noted, a septal mucosal fl ap or a fl ap from the middle
turbinate may be used. Most CSF leaks can be con-
trolled when they are encountered. Those that are iden-
tifi ed in the postoperative period can often be managed
endoscopically (see Chapter 18).
The proximity of the orbit puts the eye at risk in all
operations involving the lateral nasal wall. Injury to the
orbit and the optic nerve is a potentially serious com-
plication. It is important to not lacerate the periorbita
to avoid herniation of fat with the subsequent possibility
of enophthalmos. If such lacerations occur, effort
should be made to replace the herniated fat within the
periorbita to close the laceration. If the periorbita has
been removed, it may be replaced with temporalis
fascia.
Carrying the osteotomies too far posteriorly or not
being precise with the soft tissue cuts may result in
direct injury to the optic nerve. Preserving the posterior
third of the lamina papyracea and being cautious with
the osteotomies can prevent inadvertent optic nerve
injury. Blindness after medial maxillectomy is an
extremely rare complication. Other orbital complica-
A
B
Figure 10-8. A, The lacrimal sac is incised along its long axis. B,
The sac is sutured open to prevent stenosis.
the vermilion border must be reapproximated fi rst
as the keystone to closure of the incision. The skin
along the lateral rhinotomy should be closed, with the
subcutaneous layer of 4-0 chromic catgut sutures placed
close together. Care must be taken to not catch the
gauze pack in the suture because this will make it diffi -
cult to remove the pack later and runs the risk of leaving
part of the pack in the nasal cavity as a foreign body.
The gingivobuccal sulcus incision, when present, is
closed with interrupted 3-0 chromic catgut suture.
If the lip has been split, this incision should be
closed in four layers (mucosa, muscle, subcutaneous
tissue, and skin). A 6-0 plain catgut suture, either
running or interrupted, is used for the skin closure.
Mastisol is then spread along the suture line and allowed
to dry. Once the Mastisol is dry, Steri-Strips are applied
along the suture line as a sterile dressing and to reduce
tension on the skin. A nasopharyngeal airway is placed
in the nasal cavity contralateral to the lateral rhinotomy.
The tarsorrhaphy suture is now removed. Ophthalmic
ointment is placed in the eye, and an eye patch dressing
is used. A gentle pressure dressing may be used to
prevent edema of the face and upper lip. The pharynx
is suctioned clear of blood, and the patient is
extubated.

Chapter 10
Medial Maxillectomy
73
tions of medial maxillectomy include epiphora, dacryo-
cystitis, ectropion, diplopia, and orbital hemorrhage.
Kalavagunta and coauthors reported a case of blindness
after medial maxillectomy that they attributed to indi-
rect injury to the optic nerve.14
Accurate repositioning of the medial canthal liga-
ment will help prevent malalignment of the structures.
An unsightly scar is virtually always avoidable by accu-
rate placement of the incision before distortion with
infi ltration anesthesia and by adequate marking of the
skin along the incision to ensure precise realignment
during skin closure.
Epiphora is usually avoided by opening the lacrimal
sac and suturing it to the soft tissues to prevent stenosis.
Occasionally, even after taking these precautions it is
necessary to dilate the punctum, use a stent, or revise
the dacryocystorhinostomy.
Rarely, a mucocele may form in the operated maxil-
lary antrum. It may be asymptomatic or may produce
diplopia as a result of superior displacement of the
globe (Fig. 10-9).
MIDFACIAL DEGLOVING
PROCEDURE
Although this procedure was fi rst described in 1974,15
not until 1979 did Conley and Price report its use for
removal of tumor in 26 patients.16 In 1984, Sacks and
coworkers reported a composite experience of 46
patients in whom inverted papilloma was removed with
the degloving approach.17 Other authors have elabo-
rated on the usefulness of this technique either alone
or as part of a craniofacial approach to tumors. The
degloving approach has been used in the management
of benign and low-grade malignant tumors of the sino-
nasal tract. Several modifi cations of the midfacial
degloving procedure for the prevention of vestibular
stenosis have been reported.18-20 Jeon and colleagues20
described another modifi cation of midfacial degloving
that is intended to avoid unnecessary exposure of the
healthy (contralateral) side of the midface, as well as
vestibular stenosis. The authors describe a procedure
involving a gingivobuccal incision across the midline, a
septal transfi xion incision, a piriform operative inci-
sion, and a lateral osteotomy along the frontal process
of the maxilla to the nasion.
PATIENT SELECTION
We do not routinely use the midfacial degloving proce-
dure because the exposure seems somewhat limited,
particularly in the superior ethmoid and frontoethmoid
recess. Meticulous reapproximation of tissues has pro-
vided a minimal and quite acceptable facial scar with
the lateral rhinotomy procedure. We have therefore
restricted use of the degloving procedure to patients
with limited tumors in the inferior aspect of the nasal
cavity or nasal septum. Other patients who would be
selected for this operation are those who may have a
propensity for the development of hyperplastic or pig-
mented scars.
PREOPERATIVE PLANNING
Preoperative planning is similar to that described earlier
for lateral rhinotomy.
SURGICAL TECHNIQUE
The operation is performed with the patient under
general oral endotracheal anesthesia with a skin prepa-
ration of povidone-iodine solution. Tarsorrhaphy
sutures are used bilaterally. Cotton pledgets with vaso-
constrictive decongestants are placed on the mucosa of
the nasal cavity and the area of the columella. Bilateral
septocolumellar and intercartilaginous incisions are
made, as well as a transfi xion incision (Fig. 10-10A to
C). Connecting the transfi xion and the intercartilagi-
nous incisions helps separate the nasal tip from the
nasal dorsum. A gingivobuccal incision is made from
one maxillary tubercle to the other (Fig. 10-11). Com-
plete release of the soft tissues in this area is accom-
plished by incising the tissues around the piriform
aperture and nasal fl oor. To release the nasal tip, the
remaining soft tissue attachments to the bone are
sharply divided. Retractors are then used to retract the
upper lip and gain exposure to the gingivobuccal sulcus.
The soft tissues are undermined as high as the orbital
rims (Fig. 10-12). Care must be taken to not injure the
infraorbital nerve.
Medial maxillectomy is carried out as described
earlier and the tumor removed. The cavity is packed
as described previously. Meticulous suturing of the
intercartilaginous and transfi xion incisions should be
carried out to prevent vestibular stenosis. The tarsor-
rhaphy sutures are removed at the end of the
procedure.
Figure 10-9. A scan reveals a mucocele of the operated maxillary
antrum with destruction of the fl oor of the orbit. Superior displace-
ment of the globe is causing diplopia.

74
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Figure 10-11. A gingivobuccal sulcus incision is made and the soft
tissues are retracted to expose the bony skeleton.
Figure 10-12. The soft tissues are undermined as far superior as
the orbital rims.
A
B
C
Figure 10-10. A, Bilateral septo-
columellar and intercartilaginous
incisions. B, Transfi xion incision.
C, The nasal dorsal skin is under -
mined.

Chapter 10
Medial Maxillectomy
75
References
1. Harrison DFN: Lateral rhinotomy: A neglected operation. Ann
Otol 86:756-759, 1977.
2. Vrabec DP: The inverted Schneiderian papilloma: A clinical and
pathological study. Laryngoscope 85:186-220, 1975.
3. Lawson W, Ho BT, Shaari CM, Biller HF: Inverted papilloma: A
report of 112 cases. Laryngoscope 105:282-288, 1995.
4. Thorp MA, Oyarzabal-Amigo MF, du Plessis JH, Sellars SL:
Inverted papilloma: A review of 53 cases. Laryngoscope 111:1401-
1405, 2001.
5. Myers EN, Fernau JL, Johnson JT, et al: Management of inverted
papilloma. Laryngoscope 100:481-490, 1990.
6. Waitz G, Wigand ME: Results of endoscopic sinus surgery for the
treatment of inverted papilloma. Laryngoscope 102:917-922,
1992.
7. Wormald PJ, Ooi E, van Hasselt A, Nair S: Endoscopic removal
of sinonasal inverted papilloma including endoscopic medial
maxillectomy. Laryngoscope 113:867-873, 2003.
8. Sukenik MA, Casiano R: Endoscopic medial maxillectomy for
inverted papillomas of the paranasal sinuses: Value of the intra-
operative endoscopic examination. Laryngoscope 110:39-42,
2000.
9. Yoon JH, Kim CH, Choi EC: Treatment outcomes of primary and
recurrent inverted papilloma: An analysis of 96 cases. J Laryngol
Otol 116:699-702, 2002.
10. Chee LWJ, Sethi DS: The endoscopic management of sinonasal
inverted papillomas. Clin Otolaryngol 24:61-66, 1999.
11. Kraft M, Simmen D, Kaufmann T, Holzmann D: Long-term
results of endonasal sinus surgery in sinonasal papillomas. Laryn-
goscope 113:1541-1547, 2003.
12. Sadeghi N, Al-Dhahri S, Manoukian JJ: Transnasal endoscopic
medial maxillectomy for inverting papilloma. Laryngoscope
113:749-753, 2003.
13. Oikawa K, Furuta Y, Oridate N, et al: Preoperative staging of
sinonasal inverted papilloma by magnetic resonance imaging.
Laryngoscope 113:1983-1987, 2003.
14. Kalavagunta S, Roy D, Fish B, Jackson S: Blindness following
medial maxillectomy. Rhinology 40:223-225, 2002.
15. Casson PR, Bonanno PC, Converse KM: The mid-facial degloving
procedure. Plast Reconstr Surg 53:102-103, 1974.
16. Conley J, Price JC: Sublabial approach to the nasal and nasopha-
ryngeal cavities. Am J Surg 138:615-618, 1979.
17. Sacks MA, Conley J, Rabuzzi DD, et al: The degloving approach
for total excision of inverting papilloma. Laryngoscope 94:1595-
1598, 1984.
18. Buchwald C, Bonding P, Kirkby B, Fallentin E: Modifi ed midfacial
degloving: A practical approach to extensive bilateral benign
tumors of the nasal cavity and paranasal sinuses. Rhinology 33:39-
42, 1995.
19. Krause GE, Jafek BW: A modifi cation of the midface degloving
technique. Laryngoscope 109:1781-1784, 1999.
20. Jeon SY, Jeong JH, Kim HS, et al: Hemifacial degloving approach
for medial maxillectomy: A modifi cation of midfacial degloving
approach. Laryngoscope 113:754-756, 2003.
PEARLS
• The use of preoperative CT scanning with contrast
enhancement provides very precise information with
respect to the volume of tumor, bone destruction,
and vascularity.
• MRI may be important to differentiate mucus in the
sinonasal tract from tumor.
• The lateral rhinotomy technique provides maximum
exposure of the sinonasal tract and nasopharynx.
• Incisions for both lateral rhinotomy and midfacial
degloving heal well and are cosmetically acceptable.
• Epiphora may be avoided by opening the lacrimal
sac and suturing it to the surrounding soft tissue.
PITFALLS
• Inaccurate planning, execution, or closure of the skin
incisions in the lateral rhinotomy technique will lead
to an unsightly and unacceptable cosmetic result.
• Injury to the orbit or cranial nerves is possible but
can be minimized by precise information from
preoperative imaging and meticulous surgical
technique.
• CSF rhinorrhea should be treated aggressively to
prevent meningitis. Effort should be made to close
dural lacerations or to use fascial grafts or a
mucosal fl ap from the septum or middle turbinate
secured with fi brin glue and packing at the time of
surgery.
• Care should be taken to not lacerate the periorbita
to avoid enophthalmos.
• The midfacial degloving procedure may produce
narrowing and even stenosis of the vestibule. Proper
attention to adequate repositioning and suturing of
the nasal structures is fundamental in preventing this
complication.

Chapter 11
Complete Maxillectomy
Jonas T. Johnson
Tumors affecting the hard palate and maxillary sinus
may originate from any of the tissues forming these
structures. Squamous cell cancer is the most common
pathologic diagnosis. Tumors both benign and malig-
nant that originate in bone or minor salivary glands, as
well as tumors that develop from the odontogenic appa-
ratus, are encountered occasionally. Standard therapy
for all these tumors, with the exception of lymphoma,
rhabdomyosarcoma, and other cancers that are highly
responsive to chemotherapy or radiotherapy, is surgical
removal, frequently followed by adjuvant radiation
therapy.
Tumors involving the infrastructure of the maxil-
lary sinus are tumors of the oral cavity. These tumors,
both benign and malignant, may be effectively treated
by partial maxillectomy in which only the inferior aspect
of the sinus is removed and the trimalar complex, infe-
rior orbital rim, and orbital fl oor are preserved. The
precise limits of the resection must, of necessity, be
determined by the extent of the tumor. For most
patients the defects are rehabilitated with the aid of a
maxillofacial prosthodontist.1 However, special circum-
stances may arise that call for tissue reconstruction;
when resection requires transection of the nasolacrimal
duct, immediate dacryocystorhinostomy is mandatory.
PATIENT SELECTION
Staging of tumors of the maxillary sinus is best accom-
plished with either computed tomography (CT) or
magnetic resonance imaging (MRI). Ohngren’s line,
an imaginary line drawn from the medial canthus to the
angle of the mandible (Fig. 11-1), separates the maxil-
lary sinus into anteroinferior and posterosuperior
aspects.2 Not surprisingly, tumors anterior to Ohngren’s
line are associated with a better prognosis. Tumors
posterior to Ohngren’s line are more likely to have
involvement of the orbit and infratemporal fossa and,
because of the proximity of these structures, are less
curable.
Therapeutic intervention depends on the extent of
the tumor and the patient’s general condition, comor-
bid conditions, and life expectancy, as well as the
patient’s preference and the bias of the treatment team.
Complete surgical excision with or without adjuvant
radiation therapy results in the best chance for local
control. However, involvement of vital or important
neurosensory structures and the propensity for peri-
neural spread of tumor may make complete surgical
removal diffi cult, impossible, or unacceptable. Manage-
ment with radiation therapy as the sole modality is often
associated with signifi cant injury to the skin, adnexa,
and orbit and may result in osteomyelitis with progres-
sion of the tumor. Cancer involving bone is generally
thought to be incurable by radiation therapy. Com-
bined-modality protocols consisting of radiation therapy
and chemotherapy are commonly used but have not yet
proved superior in dealing with these diffi cult-to-treat
tumors.
Most patients undergoing maxillectomy suffer loss
of oral-nasal separation, which results in reduction of
speech intelligibility and nasal refl ux of fl uids. Such
patients are best rehabilitated with the help of a maxil-
lofacial prosthodontist who can fabricate an obturator.3
The integrity of the nasolacrimal system should be
restored intraoperatively through the performance of
dacryocystorhinostomy. Involvement of the orbital fl oor
by cancer is not an absolute indication for orbital exen-
teration; however, when the cancer invades through the
periorbita to involve the orbital muscles and fat, useful
vision can rarely be preserved and orbital exenteration
should be considered. Extended total maxillectomy is
required for patients with involvement of the soft tissue
of the cheek or with posterior involvement of the soft
77

78
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
tissue of the pterygopalatine or infratemporal fossa.
This procedure may be adapted to include a transcra-
nial skull base approach, thereby permitting resection
of the bone of the middle fossa to ensure completion
of resection. Perineural spread of tumor is most likely
responsible for the high incidence of local recurrence
despite complete tumor resection. Decisions regarding
the administration of radiation therapy must consider
the potential for damage to vital structures, most impor-
tantly the central nervous system and eye.
PREOPERATIVE EVALUATION
Preoperative evaluation should include physical exami-
nation with special emphasis directed to the nasal fossa
and nasopharynx. Use of a nasal endoscope allows
detailed inspection of intranasal anatomy. Assessment
of the integrity of the inferior orbital nerve and the
bony walls of the sinus is necessary to determine spread
of the tumor outside the maxillary sinus either anteri-
orly into the soft tissues of the cheek or posterolaterally
into the infratemporal fossa.
All patients are evaluated preoperatively with CT,
MRI, or both. CT shows bony anatomy in more detail
and is generally our group’s fi rst choice to image tumors
of the maxillary sinus. Both axial and coronal planes
should be studied. CT clearly demonstrates bone abnor-
mality; however, it may overestimate the extent of tumor
(Fig. 11-2). MRI distinguishes tumor from surrounding
soft tissue and is especially valuable in differentiating
tumor from secretions resulting from sinus obstruction
(Fig. 11-3). MRI also demonstrates perineural spread
better than CT does.
A biopsy specimen should be obtained for histo-
logic confi rmation as a preliminary to surgical resec-
tion. The timing and technique of obtaining the
specimen depend on the site of the tumor. Tumors
visible in the nasal fossa may be biopsied directly
through the nose. Tumors involving the alveolus or
hard palate may be biopsied directly through the oral
cavity. Tumors confi ned within the maxillary sinus may
be accessible to biopsy through the nose, on occasion
with the use of endoscopic sinus instrumentation. In
some instances, an anterior antrostomy through an inci-
sion in the buccogingival sulcus may be needed to
obtain histologic confi rmation of malignancy confi ned
to the maxillary sinus. In highly unusual circumstances,
when radiographic fi ndings conclusively disclose a
destructive process, excisional biopsy may be justi -
fi ed without benefi t of a histologically confi rmed
diagnosis.
An inferior maxillectomy is adequate for tumors
confi ned to the alveolus, palate, or the inferior portion
of the sinus cavity. Extension of tumor to the fl oor of
the orbit and inferior orbital rim is a contraindication
to inferior maxillectomy, and total maxillectomy is con-
sidered the procedure of choice. Similarly, extension
through the posterior maxillary wall to involve the infra-
temporal or pterygopalatine fossa is an indication for
extended maxillectomy.
Consultation with an ophthalmologist may help
determine the potential for orbital involvement, as well
as document the status of the visual system preopera-
tively. All patients should be seen before surgery by a
maxillofacial prosthodontist so that impressions can be
obtained and a surgical obturator constructed. Most
patients require postoperative adjuvant radiation
therapy when being treated for squamous cell carci-
noma or other high-grade neoplasms based on the bio-
logic behavior of bone involvement and perineural
spread. Accordingly, consideration of the status of the
remaining dentition should be made at the time of
surgery and extractions and restorations performed
when indicated. Provision for treatment of the remain-
ing teeth should be provided. Cervical metastases are
unusual and occur in less than 10% of patients. Metas-
tasis should be considered a sign of advanced disease.
Routine treatment of the uninvolved part of the neck
is not indicated.
Preoperative evaluation by a maxillofacial pros-
thodontist affords the opportunity to take the necessary
impressions so that a surgical obturator can be fabri-
cated. This obturator should be available for insertion
in the operating room after completion of the proce-
dure. The design of the prosthesis may vary according
to the specifi cs of the anticipated resection and the
surgeon’s intended method of stabilizing it. If the resec-
Figure 11-1. Ohngren’s line is an imaginary line drawn from the
lateral projection of the medial canthus to the angle of the mandible.
It divides the maxillary sinus into an anteroinferior quadrant and a
posterosuperior quadrant.

Chapter 11
Complete Maxillectomy
79
A
B
Figure 11-2. A, A coronal com-
puted tomography (CT) scan clearly
identifi es a massive tumor within the
maxillary sinus. The orbital fl oor
appears intact. B, This coronal CT
scan demonstrates orbital involve-
ment by the tumor, thus suggesting
that
complete
surgical
removal
of the lesion will require orbital
exenteration.
A
B
Figure 11-3. A, Axial computed
tomography scan demonstrating a
tumor fi lling the posterior ethmoid
and sphenoid sinuses (arrows).
B, Axial T2-weighted magnetic
resonance imaging allows differen-
tiation of the tumor (black arrows)
from the mucus-fi lled sinus (white
arrow) in the ethmoid and part of
the sphenoid.
tion is more extensive than planned, the prosthodon-
tists can add to it with acrylic to be certain of a
comfortable and effective fi t.
Soft tissue reconstruction of defects that involve
half of the hard palate may be undertaken with a
regional fl ap such as a forehead or temporalis fl ap. The
fl ap obscures possible areas of recurrence in the maxil-
lary cavity that might have been seen if a full view of the
cavity were possible. Additionally, soft tissue fl ap recon-
structions tend to herniate into the oral cavity by gravity,
thus making prosthetic rehabilitation diffi cult.
The advent of microvascular techniques has allowed
the application of free tissue transfer to palatal recon-
struction.4-8 Purely soft tissue reconstruction does not
address maxillary rehabilitation; therefore, rehabilita-
tion of masticatory function remains a major defi ciency
because dentures cannot generally be used in such
cases. The best function is achieved with a compound
free fl ap involving bone and soft tissue. Techniques of
reconstruction with an osseocutaneous free fl ap may
provide the possibility of dental implants. The bone
must be covered with soft tissue internally (within the
sinus). This bulk may result in obstruction of the nasal
fossae.
The choice of incision depends on the surgeon’s
preference, the wishes of the patient, and the type and
extent of the cancer.
SURGICAL APPROACH
Total Maxillectomy
Total maxillectomy should be performed with the
patient under general anesthesia and anesthetic moni-
toring appropriate to the patient’s condition. Extreme
blood loss is unusual; however, precautions should be

80
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
taken for the rapid replacement of fl uid volume should
excessive hemorrhage be encountered. Such hemor-
rhage most commonly occurs with transection of the
internal maxillary artery in the infratemporal fossa at
the time of tumor removal. The eye is protected by
temporary tarsorrhaphy of the eyelid on the side of the
maxillectomy. The suture is removed at the conclusion
of the procedure. Total maxillectomy with orbital exen-
teration can be performed through a lateral rhinotomy
incision (Figs. 11-4 and 11-5). The upper lip is divided
on the ipsilateral side of the philtrum. The cheek fl ap
is elevated with the periosteum of the anterior maxilla
unless tumor has penetrated the anterior wall of the
maxillary sinus. The infraorbital nerve is divided. A
Weber-Ferguson extension along the inferior orbital
lid is not ordinarily required unless exposure is needed
to perform orbital exenteration or tumor involves
the infratemporal fossa. In this case, better exposure
posteriorly may be appropriate. When tumor extends
posteriorly to involve the cranial base, additional
techniques may be appropriate and are discussed in
Chapter 100.
After the skin incision, dissection is carried to the
bone of the ascending process of the maxilla. The peri-
orbita is elevated inferiorly and medially to expose the
fl oor of the orbit, lacrimal fossa, and lamina papyracea.
The lacrimal sac is identifi ed, resected, and retracted,
and the nasolacrimal duct is transected. At this juncture
in the operation, the surgeon has the opportunity to
assess the extent of orbital involvement to determine
whether orbital exenteration is required. Direct exten-
sion of tumor through the periorbita is an indication
for orbital exenteration. In some cases, frozen section
evaluation may be of assistance in making this
decision.
The inferior orbital rim is transected laterally
through the trimalar buttress and medially into the
ethmoid sinus at approximately the level of the fronto-
ethmoid suture line (Figs. 11-6 and 11-7). When cancer
involves the ethmoid sinus and extends through the
fovea ethmoidalis, a cranial skull base approach should
be considered. When the ethmoid is free of tumor, it
can be taken down with biting forceps along the fron-
toethmoid suture line to afford the surgeon good visu-
alization of this incision. An alternative is to make this
osteotome cut with a fi ne chisel, although orientation
of the chisel in the correct plane is critical to avoid
inadvertent entry into the anterior cranial fossa. In situ-
ations in which the margin is not close, we prefer to use
a rongeur because it affords a wider osteotomy and
improved visibility. The palate is divided with an osteo-
tome or saw. When possible, this incision should ideally
be made 2 to 3 mm ipsilateral to the nasal septum to
facilitate maxillofacial reconstruction (Fig. 11-8). In
dentulous patients, the ipsilateral central and, when
possible, the lateral incisor teeth should be preserved
and the osteotomy made through the socket of the
lateral incisor. Preservation of the central incisor helps
the prosthodontist provide a much better cosmetic
result. The soft tissue of the palate should be separated
between the hard and soft palates intraorally. This inci-
sion is carried laterally to join the buccogingival sulcus
incision at the posterior maxillary buttress. The lateral
orbital wall is then divided with either a saw or heavy
scissors, after which the maxilla can be fractured and
removed from the pterygoid plates with a curved osteo-
tome placed just anterior to the pterygoid process.
Bleeding will be brisk at this point and cannot be easily
managed until the specimen is removed. Hence, the
fi nal heavy scissors cuts are made blindly by digital iden-
tifi cation of the location of the soft tissue attachments
posterior to the maxilla.
Once the specimen is removed, bleeding from the
internal maxillary artery is initially controlled with
packing, after which the artery must be identifi ed and
either clipped or suture-ligated. Venous bleeding of the
pterygoid veins can be managed by packing bipolar
cautery, or suture ligature. A dacryocystorhinostomy is
performed by fi rst passing a lacrimal probe through the
inferior punctum, which facilitates identifi cation of the
lacrimal sac. The sac is incised and marsupialized by
suturing the cut edges to the adjacent soft tissue
(Fig. 11-9).
The facial skin fl ap should be lined with a split-
thickness skin graft to promote rapid re-epithelializa-
tion in the maxillary cavity. The skin graft will prevent
contracture of the facial skin, and the interface between
the skin graft and the residual buccal mucosa forms a
shelf that helps retain the prosthesis (Fig. 11-10).
Figure 11-4. A lateral rhinotomy is a skin incision that begins
approximately midway between the medial canthus and the dorsum
of the nose and extends in a vertical direction around the alae. Lip
splitting is used adjunctively as indicated.

Chapter 11
Complete Maxillectomy
81
The surgical prosthesis is then inserted and fi xed
with a lag screw (Fig. 11-11). The posterior edge of the
splint should have drill holes to permit suturing of the
soft palate to the prosthesis, which reduces the poten-
tial for nasopharyngeal refl ux of food and facilitates
early return to an oral diet. Use of the prosthesis also
eliminates the need for a nasogastric feeding tube. The
cavity is packed with antibiotic-impregnated gauze. The
skin incision is closed in layers, with care taken to reap-
proximate the medial canthal tendon to the periosteum
of the nasal bone. The eyelid suture is removed. An
external dressing is applied to reduce eyelid edema and
to coapt the cheek fl ap to the split-thickness skin graft.
Trache-otomy is rarely required in patients undergoing
maxillectomy.9 A fi nal prosthesis is completed when the
wound is healed (Fig. 11-12).
Orbital Exenteration
Orbital exenteration should be performed when tumor
invades through the fl oor of the orbit and involves the
orbital muscles or fat. Bone erosion without involve-
ment of the periosteum of the orbit may be treated with
a maxillectomy without orbital exenteration. MRI best
demonstrates the relationship between tumor and
normal tissue. The relationship between tumor and
periorbita is subtle, and in many cases the decision to
exenterate cannot be made preoperatively but is made
Figure 11-5. A, An incision in the buccal sulcus allows elevation of a cheek fl ap.
B, This approach affords adequate exposure for most patients who require removal of
the infrastructure of the maxilla. C, A lateral rhinotomy incision affords good exposure
of the maxillary infrastructure.
A
B
C

82
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Figure 11-6. The bone cuts ordinarily used for a hemimaxillectomy
are outlined. Modifi cations are made depending on the size and
location of the tumor.
Figure 11-7. The bone cuts made for maxillectomy are further
demonstrated.
Figure 11-8. When a radical maxillectomy is per-
formed, a shelf of bone on the nasal fl oor adjacent to
the nasal septum (arrow) should be preserved if possible.
This shelf provides a ledge to help retain a prosthesis.
in the operating room at the time of exploration. After
elevation of the periorbita, the fl oor of the orbit is
evaluated. If the orbital periosteum is free of tumor, the
orbital contents can be preserved; however, the surgeon
should recognize that ultimate function of that eye will
be compromised. The compromised vision is due in
part to the fact that it is diffi cult to reconstruct the fl oor
of the orbit except by means of an osseocutaneous free
fl ap. A number of factors, such as reabsorption of
orbital fat and wound contracture during healing, may
result in enophthalmos with diplopia. Similarly, range
of motion is often compromised. Secondarily, patients

Chapter 11
Complete Maxillectomy
83
Figure 11-9. A, The lacrimal sac is opened
with fi ne scissors. B, Dacryocystorhinostomy is
accomplished by suturing the walls of the lacri-
mal sac open.
with high-grade cancer almost always require postoper-
ative radiation therapy. Radiation results in atrophy of
fat, tissue contraction, and eventual cataract formation.
Accordingly, a practical approach in patients with
erosion of the bone of the fl oor of the orbit is to discuss
the situation with the patient in an honest and open
fashion and undertake elective orbital exenteration
when the patient will permit it.
Tumors that involve the roof of the orbit or the
orbital apex may be better treated via a cranial base
approach (see Chapter 100).
The eyelids can be preserved unless involved by the
cancer. When the eyelids are tumor free, they may be
closed at the completion of surgery. Alternatively, when
tumor involvement requires more extensive surgery
with removal of facial skin, the facial defect may be
improved with the use of an orbital-facial moulage or a
free fl ap. The decision to leave the orbit exposed will
facilitate postoperative evaluation but is a defi nite cos-
metic compromise. When all else is equal, closure of
the eyelids is preferable because the maxillary cavity can
be inspected through the mouth. After orbital exenter-
ation, all the soft tissue of the orbit has been resected,
so an orbital prosthesis cannot be used. Camoufl age
with the use of an eye patch or facial moulage or surgi-
cal closure with lid approximation and soft tissue closure
has been satisfactorily undertaken.
Technique
Exposure for orbital exenteration when undertaken via
maxillectomy can ordinarily be accomplished through
the same lateral rhinotomy incision used for the maxil-
lectomy. The incision can be carried superiorly so that
it passes approximately midway between the medial
canthus and the dorsum of the nose up to the medial
aspect of the brow as needed. Resection of the lower lid
may be necessary if the cancer extends through the
orbital septum. When the orbital septum is free of
A
B

84
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Figure 11-10. A split-thickness skin graft is used to line the facial
fl ap and cover the exposed soft tissue in the infratemporal fossa.
Figure 11-11. Placement of an acrylic splint after inferior maxil-
lectomy. Packing is used to hold the skin graft in place. A lateral rhi-
notomy, used in this circumstance, affords good exposure. A single
lag screw fi xes the splint.
cancer, the incision may be made through the conjunc-
tiva of the lower lid to allow refl ection of the cheek fl ap
laterally. Similarly, an incision may be made through
the conjunctiva of the upper lid, which would permit
complete resection of the entire contents of the orbit.
When the cancer is limited to the infrastructure of the
orbit, it may be prudent to preserve the periosteum of
the roof of the orbit, thereby facilitating subsequent
skin grafting. As the dissection is carried posteriorly
along the roof of the orbit, the anterior and then pos-
terior ethmoid arteries may be ligated.
When undertaking orbital exenteration for control
of tumor, the entire contents of the orbit are removed,
including the rectus muscles in continuity with the
globe. Accordingly, these muscles are retracted inferi-
orly to allow them to be divided at the orbital apex. The
optic nerve should be identifi ed and clamped before
ligation, after which it is securely tied with permanent
suture. This allows the resection to be carried through
the inferior rectus muscles at the orbital apex. The
osteotomy cuts are then made to separate the ethmoid
from the frontal bone, with the frontoethmoid suture
used as a landmark. A lateral osteotomy must be made
to separate the superior orbital rim from the specimen.
Some judgment can be used relative to the location and
extent of the cancer. Preservation of the lateral orbital
rim and maxillary buttress permits better cosmesis;
however, such preservation must not be done at the
expense of control of the cancer. The orbital specimen
is removed in continuity with the maxilla as the ptery-
goid plates are detached from the skull base. This may
be accomplished with a mallet and osteotomy or, alter-
natively, with Mayo scissors.
The cheek fl ap is lined with a split-thickness skin
graft. Suffi cient skin graft should be obtained to resur-
face the roof of the orbit as well. If tumor consider-
ations required resection of the lower lid, it is possible
to denude the upper lid and close the lids entirely; the
inner aspect of the lid is relined with a split-thickness
skin graft. If resection of the periosteum of the bone
on the roof of the orbit was required, reconstruction
may be facilitated by mobilizing a temporalis muscle
fl ap through a separate incision posterior to the frontal
branch of the freed nerve. An appropriately sized fl ap
is elevated and freed from its attachments in the skull
and mandible, with care taken to preserve its blood
supply from the maxillary artery. It is passed into the
orbit and sutured to the nasal septum medially. The
inferior aspect of the temporalis fl ap is skin-grafted into
the cavity. This serves to ensure coverage of the bone
at the skull base and improves the success rate of the
split-thickness skin graft. Under ordinary circumstances,
the conjunctival margin is denuded on both the upper
and the lower lids, and the lid margins are sutured
together. The entire cavity is then packed with gauze
impregnated with antibacterial ointment. This packing
is maintained in place with a surgical obturator con-
structed preoperatively by the maxillofacial pros-
thodontist. The prosthesis is held in place with either
suspension wires, suturing of the prosthesis to the
remaining tissue, or the use of a lag screw inserted
directly into residual palate. A bulky compressive dress-
ing is applied to reduce postoperative fl ap edema.

Chapter 11
Complete Maxillectomy
85
POSTOPERATIVE MANAGEMENT
Assuming that the surgical split has been satisfactorily
fashioned and secured, the patient is fed a soft diet
orally when the gastrointestinal tract returns to normal
function. Oral hygiene is promoted through the use of
irrigation with half-strength hydrogen peroxide in a
“swish and spit” technique. Administration of periop-
erative intravenous antibiotics may be indicated to
decrease colonization of the antral packing; however,
wound infection is rarely encountered.
Arrangements should be made so that the pros-
thodontist is available on approximately the fi fth post-
operative day when the surgical splint and packing are
removed. After removal of the obturator, the patient
should be seen immediately by the prosthodontist for
insertion of an interim prosthesis, which will allow the
patient to continue with an oral diet as convalescence
proceeds. Signifi cant morbidity will ensue, particularly
dysphasia with the risk of aspiration if the interim
prosthesis cannot be placed at the time of splint
removal. The interim prosthesis is modifi ed as
frequently as needed until the healing process is
complete. When postoperative radiation therapy is
deemed necessary, the changes incurred may prevent
fi nal modifi cation of the prosthesis until the radiation
therapy has been completed and wound contracture
has stabilized. The fi nal prosthetic repair should facili-
tate chewing and help restore appearance when teeth
are added to the prosthesis. The ease with which masti-
catory function is retained is directly related to the
extent of the resection, the care with which the cavity
was prepared operatively, and the status of residual
dentition.
Treatment of maxillary cancer always affects eusta-
chian tube function10; hence patients with middle
A
B
C
D
Figure 11-12. A, The excellent cosmesis that one can expect after use
of the lateral rhinotomy incision. B, The defect after inferior maxillectomy
is well healed. C, The prosthetic device uses clasps on residual teeth for
stabilization. D, Excellent cosmesis is achieved.

86
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Figure 11-13. Coronal computed tomography scan demonstrating
a massive tumor in the maxillary sinus with extension involving the
soft tissue of the cheek and the orbit.
ear effusion benefi t from myringotomy and tube
insertion.
Tissue Reconstruction of Palatal Defects
When the size or location of the cancer requires resec-
tion of more than half the palate, prosthetic repair
becomes increasing diffi cult, especially in edentulous
patients. When the entire hard palate and alveolar ridge
must be removed, retention of the prosthesis may be
facilitated by the placement of osteointegrated pins in
the trimalar complex or infraorbital rim; however,
chewing force may not be tolerated or may result in
fracture of the orbital fl oor. We have found retention
of the prosthetic device in these patients to be nearly
impossible. Accordingly, tissue reconstruction must be
performed.
Temporal Muscle Flap Reconstruction
We prefer the use of free temporalis muscle to provide
oral-nasal separation. The muscle need not be resur-
faced because it re-epithelializes rapidly and assumes an
almost normal appearance. This reconstruction is
usually done with one temporal muscle, but occasion-
ally bilateral fl aps may be necessary. The loss of tempo-
ral bulk results in a moderate cosmetic deformity. The
nasal cavity may also be obstructed by the bulk of the
fl ap. When circumstances allow, the choice of free
tissue transfer may be superior.
Figure 11-14. After resection of the maxilla, anterior cheek skin,
and lower eyelid, as well as orbital exenteration, a major defect is
demonstrated.
Free Tissue Transfer for Palatal
Reconstruction
Soft tissue repair of the palate does not allow the use of
a dental appliance because of the absence of maxillary
bone. Use of an osseocutaneous free fl ap has defi nite
advantages; other fl aps that have been used to recon-
struct the hard palate and inferior maxilla include the
latissimus dorsi myocutaneous fl ap, free latissimus fl ap,
dorsalis pedis fl ap, free scapular osseocutaneous fl ap,
and the rectus free muscle fl ap with a split-thickness
skin graft.
Reconstruction of Extended Maxillectomy
with Orbital Exenteration
We have encountered some patients with massive
tumors involving the maxillary sinus that extend
through the anterior wall to involve the skin of the
cheek and through the orbital fl oor to involve the
orbital soft tissue (Fig. 11-13). Resection requires
removal of the entire maxilla (including the hard
palate), as well as orbital exenteration with removal of
the soft tissues of the cheek (Fig. 11-14). This defect
may be diffi cult or impossible to obturate with a pros-

Chapter 11
Complete Maxillectomy
87
Figure 11-15. The latissimus dorsi free fl ap
is harvested. A portion of skin is resected from
the middle of the skin pedal to create a biped-
icle fl ap.
Figure 11-16. The folded latissimus dorsi fl ap is inset to close the
pedicle defect and cheek-eyelid defect simultaneously.
Figure 11-17. The vesicles are tunneled subcutaneously into the
neck for microvascular anastomosis.
thetic device. We advocate the use of microsurgical
techniques for free tissue transfer in these circum-
stances. A latissimus dorsi myocutaneous fl ap is one
approach to facilitate this reconstruction. After the
myocutaneous fl ap is harvested to conform to the
dimensions of the defect, a strip of skin is removed (Fig.
11-15) to create a bipedicle fl ap that can be folded for
reconstruction of the anterior facial defect and the
hard palate defect simultaneously (Fig. 11-16). The
palatal inset is performed before revascularization of
the fl ap (Fig. 11-17).

88
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Figure 11-18. The fi nal reconstruction provides satisfactory cosme-
sis with simultaneous oral-nasal separation.
the graft is not separated from the recipient bed by
a collection of fl uid. This necessitates absolute
hemostasis before skin grafting, and the graft must
be securely immobilized during the healing phase.
• The inferior turbinates should be resected when the
hard palate is removed to facilitate prosthetic
rehabilitation and avoid the necessity for further
surgical débridement at a later date.
• Secure fi xation of the surgical splint in the operative
site is critical to facilitate oral feeding in the
postoperative period. A lag screw placed directly
into the residual palate is effective.
• Application of a bulky compressive external dressing
serves to further immobilize the soft tissues and
thereby promote good healing of the skin graft. It
also serves to reduce edema in the fl ap, which
improves early postoperative cosmesis.
PITFALLS
• Failure to use a skin graft will result in contracture
of the buccal fl ap with resultant cosmetic deformity.
• Development of a postoperative wound infection
after inferior maxillectomy is exceedingly unusual.
Nevertheless, the use of antibiotic-impregnated
gauze packing helps control the proliferation of
bacteria during the healing phase.
• When the resection has been carried posteriorly to
involve the tensor veli palatini, the patient should be
expected to experience eustachian tube dysfunction
with the development of middle ear effusion.
Insertion of ventilating tubes will restore hearing.10
• Failure to consult a maxillofacial prosthodontist
preoperatively will hamper postoperative care and
rehabilitation.
• Failure to preserve or restore the lacrimal drainage
system will result in postoperative epiphora.
The vessels for the arterial anastomosis are passed
through a subcutaneous tunnel external to the mandi-
ble into the neck for the microvascular anastomoses.
Subsequent to this step, the external portion of the fl ap
is inset to effect closure of both the cutaneous and
palatal defects (Fig. 11-18).
Monitoring of the vascular anastomosis is accom-
plished with the use of pencil laser Doppler ultrasonog-
raphy. The vascularity of the free fl ap can be assessed
clinically by looking for cutaneous blanching. Oral
feeding is withheld until the 10th postoperative day, at
which point fl uids can be reinitiated.
PEARLS
• Inferior maxillectomy may be accomplished with
limited morbidity.
• The soft tissue defect on the medial aspect of the
cheek fl ap must be lined with a split-thickness skin
graft if prosthetic rehabilitation is planned. The
junction between the split-thickness skin graft and
the buccal mucosa also affords a prominent scar
band that facilitates retention of the prosthesis.
• Success of split-thickness skin grafting for defects of
the oral cavity requires that the surgeon ensure that
References
1. Myers EN, Aramany MA: Rehabilitation of the oral cavity follow-
ing resection of the hard and soft palate. Trans Am Acad Oph-
thalmol Otolaryngol 84:941-948, 1977.
2. Ohngren LG: Malignant tumors of the maxilloethmoidal region:
A clinical study with special reference to the treatment with elec-
trocautery and irradiation. Acta Otolaryngol Suppl 19:1, 1933.
3. Keyf F: Obturator prostheses for hemimaxillectomy patients. J
Oral Rehabil 28:821-829, 2001.
4. Jones JW: Reconstruction of a complex hemifacial deformity with
multiple simultaneous free-fl ap transfers: Case report. J Reconstr
Microsurg 19(2):73-78, 2003.
5. Chepeha DB, Moyer JS, Bradford CR, et al: Osseocutaneous
radial forearm free tissue transfer for repair of complex midfacial
defects. Arch Otolaryngol Head Neck Surg 131:513-517, 2005.
6. Villaret DB, Futran NA: The indications and outcomes in the use
of osteocutaneous radial forearm free fl ap. Head Neck 25:475-
481, 2003.

Chapter 11
Complete Maxillectomy
89
7. Yamamoto Y, Kawashima K, Sugihara T, et al: Surgical manage-
ment of maxillectomy defects based on the concept of buttress
reconstruction. Head Neck 26:247-256, 2004.
8. Nakayama B, Hasegawa Y, Hyodo I, et al: Reconstruction using a
three-dimensional orbitozygomatic skeletal model of titanium
mesh plate and soft tissue free fl ap transfer following total maxil-
lectomy. Plast Reconstr Surg 114:631-639, 2004.
9. Lin HS, Wang D, Fee WE, et al: Airway management after maxil-
lectomy: Routine tracheostomy is unnecessary. Laryngoscope
113:929-932, 2003.
10. Hyde NC, Bailey BM: Hearing loss associated with maxillectomy.
Br J Oral Maxillofac Surg 38:283-288, 2000.

Ethmoid Sinus
Chapter 12
The Endoscopic Approach
Berrylin J. Ferguson
The indications for endoscopic ethmoidectomy should
be tailored to the individual patient and the extent of
chronic rhinosinusitis. The goal is to restore function
to the ethmoid cells and frequently to restore function
to the frontal and maxillary sinuses, which can be sec-
ondarily infected or diseased because of obstruction
from disease in the anterior ethmoid cavity. Patients
with limited disease are candidates for endoscopic
sinus surgery (ESS) targeted at the anatomic obstruc-
tion. This may allow return of function to the ethmoid
cavity and the dependent sinuses. An anterior ethmoid-
ectomy is frequently performed in concert with func-
tional surgery involving the ethmoid infundibulum,
which is enlarged by removing the uncinate and
obstructing or diseased agger nasi and infundibular
cells.
Not all ESS is functional. Patients with hyperplastic
sinus disease or disorders such as cystic fi brosis or ciliary
dyskinesia, do not have functional sinuses and never
will. The goal in these patients is to marsupialize the
ethmoid sinuses in continuity with other involved
sinuses to the greatest extent possible to optimize the
application of topical anti-infl ammatory agents, topical
antibiotics, and topical irrigations and débridements.
ANATOMY
An appreciation of the anatomy of the ethmoid sinuses
and its relationship to surrounding sinuses, orbit, and
skull base is critical to performing safe ESS. The anatomy
is complex because of the wide variety of pneumatiza-
tion patterns. Certain landmarks are constant and
should be sought in each patient to ensure safe surgery.
An appreciation of sinus anatomy is facilitated by pre-
operative study of the coronal unenhanced sinus com-
puted tomography (CT) scan and study of reconstructed
sagittal and axial views. Reconstructed images from a
multislice helical scanner performed in the axial plane
at 1-mm intervals with a 50% overlap allow for high-
quality coronal and parasagittal reconstruction. Of all
the sinuses, the ethmoids are most amenable to removal
of all obstructive bony partitions and wide marsupializa-
tion in the case of hyperplastic disease. The dangers of
ethmoid sinus surgery lie in its proximity to the orbit
and skull base. Frequently, there is posterior/superior
pneumatization of a posterior ethmoid cell over the
sphenoid (an Onodi cell), bringing this ethmoid cell
close to the optic nerve and cavernous sinus/carotid.
This occurs in up to 60% of Southeast Asian cadavers,
but is signifi cantly less in other populations.1
The ethmoid sinuses comprise a honeycomb-like
complex of individual cells and are divided into the
anterior and posterior ethmoid cells. The cell complex
varies and ranges from one or two cells to more than
15. The distinction between anterior and posterior
ethmoid cells is based on drainage pathways, with the
anterior cells emptying into the middle meatus and the
posterior cells draining into the superior meatus above
the middle turbinate. The ground or basal lamella of
the middle turbinate separates the anterior and poste-
rior ethmoid cells. Identifi cation of the ground lamella
is thus one landmark in entering the posterior ethmoid
complex (Figs. 12-1 and 12-2).
The anterior ethmoid cells are further divided into
cells associated with the anterior ethmoid bulla and
those associated with the frontal process of the maxilla.
The anterior ethmoid bulla is either one or several
cells and varies in size. It is identifi ed just posterior to
the middle and horizontal portion of the uncinate
process. The space between the uncinate process and
91