1. TUMORS OF MAXILLA AND THEIR MANAGEMENT
DR KAMLESH DUBEY

2. INTRODUCTION
Nose and PNS are rarest sites of origin of head & neck tumors.
Accounts for < 1% of all malignancies.
More common in 5th & 6th decade.
M:F = 2:1
Late presentation with advanced disease is more common.
Great variety of different histological types.
Overall prognosis is poor.
Distal mets is seen in 10 % at presentation

3. ANATOMY
Maxillary tumors because of its close proximity to orbit, ethmoids, skull base, ITF always challenging to treat.

4. ANATOMY
Orbit is the key to management of tumors of maxilla always work in subperiosteal plane.

5. ANATOMY
Ohngren line- imaginary line between medial canthus ligament and angle of mandible.

6. ANATOMY Lymphatics ; Anterior pathway; Post pathway;
Facial , parotid, submandibular node
- upper deep cervical nodes.
Post pathway;
retro/ lateral pharyngeal nodes- upper deep cervical nodes.
Primary lymph drainage is to retropharyngeal nodes , clinical e/o early mets is absent
Only 10 % have nodal mets at presentation.
Clinically palpable node is poor prognosis.

7. AETIOLOGY Inhalant carcinogens- 40% sinonasal malignancies. Chemicals
Wood dust – adenocarcinoma (1000 times )
Hard wood- adenocarcinoma
Soft wood – SCC
Nickel – SCC
Chemicals
Chromium
polycyclic hydrocarbons
aflatoxin
mustard gas
Radiation – thorotrast
Viruses - HPV
24 % inverted papilloma
4 % SCC

8. TUMORS OF MAXILLA Benign Inverted papilloma
Osteoma ( Gardner’s syndrome )
Chondroma
Fibrous dysplasia
Hemangioma
Leiomyoma
Schwannoma

9. TUMORS OF MAXILLA MALIGNANT; Dental origin; Sarcoma; Others; lymphoma
Squamous cell carcinoma (80%)
Adeno carcinoma (5%)
Adenoid cystic carcinoma (5%)
Hemangiopericytoma
Melanoma
Undifferentiated carcinoma
PNET
Malignant fibrous dysplasia
Dental origin;
Ameloblastoma
Sarcoma;
Rhabdomyosarcoma
Fibro sarcoma
Angiosarcoma
Chondro / osteo sarcoma
Others; lymphoma

10. PATTERNS OF TUMOR SPREAD
Maxillary sinus
Anterior- cheek , skin
Posterior- PPF, ITF,MCF, temporal bone
Medial – nasal cavity, ethmoids
Superiorly- orbit
Inferiorly- palate, alveolus.

11. CLINICAL FEATURES Nasal obstruction Epistaxis Facial pain
Protosis, vision disturbance
Epiphora
Hearing loss
Cheek swelling, parasthesia
Trismus
Cranial nerve deficits

12. INVESTIGATIONS Endoscopy Imaging CT scan; Diagnostic Biopsy
Site & extent
Bone, skull base erosion
Orbit invasion
Neck- nodal status

13. INVESTIGATIONS MRI Better soft tissue delineation
Differentiate between secretions, tumor
Dural / intracranial involvement
Vascularity- flow voids
MRA- great vessel encasement, cavernous extension
Angiography;
Proximity to great vessels , sphenoid
Vascular tumors
Embolisation.

14. INVESTIGATIONS PET Biopsy HPE, Immunohistochemistry FNAC USG- B mode
Distant metastasis
Follow up
Biopsy
endoscopic guidance
Sublabial approach
HPE, Immunohistochemistry
FNAC
Neck Node
USG- B mode
Assesment of orbit

15. TNM staging Primary tumor (T) TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone
T2: Tumor causing bone erosion or destruction including extension into the hard palate and/or the middle of the nasal meatus, except extension to the posterior wall of maxillary sinus and pterygoid plates
T3: Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses
T4a: Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
T4b: Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus

16. TNM staging NX: Regional lymph nodes cannot be assessed
Regional lymph nodes (N)
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but 6 cm or less in greatest dimension, or in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension, or in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension
N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but 6 cm or less in greatest dimension
N2b: Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension
N2c: Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension
N3: Metastasis in a lymph node more than 6 cm in greatest dimension

17. TNM staging
Stage 1 - T1 N0 M0
Stage 2 - T2 N0 M0
Stage 3 - T1,2 N1 M0
T3 N0,N1 M0
Stage 4a- T4 N0,N1 M0
any T N2 M0
Stage 4b- any T N3 M0
Stage 4c- any T anyN M1

18. SCC 50 % arise in the antrum Advanced disease at presentation
Local recurrence, distal metastasis more common
Main treatment modality- Sx- PORT
Primary Irradiation- inoperable tumors
Chemotherpy – palliative

19. ADENOCARCINOMA Aetiology; Wood dust, furniture machinery, leather work
Well defined tumor- better survival
Long term survival poor
Management; as that of SCC

20. ADENOID CYSTIC CARCINOMA
Common in antrum
Perineural spread
Distal metastasis more common
HPE;
High grade- bad prognosis
Low grade- better prognosis

21. radiotherapy- surgery
TREATMENT
T1/ T2
surgery or radiotherapy
T3, T4
surgery- radiotherapy
radiotherapy- surgery
combined CT+ RT

22. SURGICAL APPROCAHES Lateral rhinotomy Weber Ferguson incision
Mid facial degloving

23. ANASTHESIA Orotracheal intubation Throat Packing in oropharyngx
Hyperventilation, mannitol- if cranial cavity is opened
Adequate arrangement of blood & blood products

24. PRE OP PREPARATION Broad spectrum antibiotic cover
Dental evaluation ( prosthesis, obturator)
Neurosurgeon review; intra cranial extension, CFR
Plastic surgeon; pre op decision for flaps

25. Lateral rhinotomy Moure`s incision (1902)
Excellent exposure to nasal cavity, medial maxillary wall
Indication; medial maxillextomy
Cosmetically acceptable

26. Weber Ferguson incision
Vertical limb- Weber
Horizontal- Ferguson 5mm below lid margin
Useful in total maxillectomy, combined orbital exenteration.

27. Mid facial degloving Denker & Kahler 1926 ( modified CWL approach )
1927 Portmann & Retrouvay – mid facial degloving
Mucosal incision- b/l upper GBS between maxillary tuberosity.
Nose- full trans fixation , inter cartilaginous incision
Excellent exposure to nasal cavity, antrum, post nasal space, pterygo palatinefossa.
Combined with Le Fort 1 osteotomy – wide exposure to clivus, skull base

28. MID FACIAL DEGLOVING

29. MAXILLECTOMY Types Total Partial Infra structure Supra structure
medial
Subtotal

30. It involves removal of entire maxilla along with pterygoid plates
TOTAL MAXILLECTOMY
It involves removal of entire maxilla along with pterygoid plates
Indication;
Tumors from mucosa, filling entire antrum
Soft tissue & bone sarcomas
Approach;
Weber ferguson
Mid facial degloving

31. TOTAL MAXILLECTOMY Removal of entire maxilla and pterygoid plates
Supine position, 15 ̊ head extension
Ant wall of maxilla exposed – elevating cheek flap.

32. TOTAL MAXILLECTOMY
Subciliary incision- Orbital periosteum elevated from floor of orbit
Lacrimal sac retracted laterally after cutting medial canthus ligament, NLD
Post dissection continued upto post ethmoidal artery.

33. TOTAL MAXILLECTOMY
ORAL CAVITY – PALATAL INCISION

34. BONE CUTS

35. TOTAL MAXILLECTOMY
Bony cuts;
Frontal process of maxilla
Palate
Zygoma
Ethmoidal cells, pterygoids
Brisk hemorrage

36. TOTAL MAXILLECTOMY
SSG applied over cheek mucosa defect
Cavity packing over palatal prosthesis
Skin closed in 2 layers

37. TOTAL MAXILLECTOMY
POST OP CARE
Pack removal
Cavity irrigation
Oral exercises
Permanent obturator

38. MEDIAL MAXILLECTOMY
Enblock resection of lateral wall of nasal cavity including inf/ mid turbinate, lamina papyraceae
Indication;
Inverted papilloma
Low grade tumors confined to lateral wall on nasal cavity
Approach;
Lateral rhinotomy
Mid facial degloving

39. MEDIAL MAXILLECTOMY Lateral rhinotomy incision
Antero lateral wall of maxilla exposed
Nasal cavity entered, tumor assesd for resectability.

40. MEDIAL MAXILLECTOMY Antero lateral wall opening made Bony cuts;
Supt to alveolus , lateral to pyramid
Vertical – medial to inferior orbital nerve
Fronto ethmoidal suture
Post- post wall of antrum

41. MEDIAL MAXILLECTPMY Bone cuts

42. MEDIAL MAXILLECTOMY Cavity packed Primary closure
Post op – irrigation of cavity
Endoscopic medial
maxillextomy
Acheives same success rate
Avoids scar

43. INFRA STRUCTURE MAXILLECTOMY
It involves removal of
alveolus ,
floor of antrum,
inferior part of
pterygoid plates
Indication;
Tumor limited to alveolus, hard palate with no bony erosion
No postero superior extension
Approach;
Mid facial degloving
Lateral rhinotomy

44. INFRA STRUCTURE MAXILLECTOMY
BONY CUTS;
Horizontal- midway between alveolus & ION
Palate- midline
Medial- lateral nasal wall below middle meatus
Post- inferior portion of pterygoid plates

45. INFRA STRUCTURE MAXILLECTOMY
POST OP CARE;
Cavity irrigation
Palatal prosthesis

46. Orbital exenteration;
MANAGEMENT OF ORBIT
Orbit preservation;
No e\o tumor in orbital floor
Breech in floor with intact periosteum
Minimal periosteal invasion
Orbital exenteration;
Breech in orbital periosteum
Orbital apex extension

47. RADICAL MAXILLECTOMY WITH ORBITAL EXENTERATION
Indication;
Tumor invading through orbital periosteum
Approach;
Weber Ferguson with sub & supra ciliary extension

48. RADICAL MAXILLECTOMY WITH ORBITAL EXENTERATION
Skin of upper lid elevated upto suprior orbital rim.
Orbital perioseteum seperated from roof of orbit
EOM , optic nerve cut at level of orbital apex
Defect lined with SSG
Facial prosthesis applied

49. ORBIAL EXENTERATION
POST OP DEFECT
PROSTHESIS IN PLACE

50. RECONSTRUCTION SSG Palatal prosthesis Obturators Flaps; Free flaps;
Temporo pareital galeal flap
Temporalis
Free flaps;
Rectus abdomoinis
Lattissimi dorsi
Composite flap;
Fibula osteo cutaneous flaps

51. RECONSTRUCTION
FOREARM FREE FLAP
DENTAL IMPLANTS

52. RADIATION IN TUMORS OF MAXILLA
Various combiations
Primary irradiation alone
T1,2 lesions
In operable tumors
Patient unfit for surgery
Combined with surgery
T3,4 lesions
Surgery – RT
RT- surgery
CT+ RT

53. Areas to be covered;
1* site, areas of tumor extension , other routes of local spread (i-e)
Maxilla, alveolus, nasal cavity, ethmoids, PPF, often orbit, neck
Anterior field
Lateral field

54. RADIATION FIELDS
ANTERIOR FIELD
LATERAL FIELD

55. Protect;
Contra lateral eye
Brain stem
Upper cervical cord

56. Dose 50-55 Gy/ 20#/ 4 wks 60-65 Gy/30-33#/ 6-6.5 wks Lymphoma;
Complications
Mucositis
Eye
Cataract
Keratitis
Optic nerve damage
Osteo radio necrosis
hypopituitarism

57. Intra arterial infusion – 5- FU along with RT Topical 5- FU ;
CHEMOTHERAPY
Cisplastin & 5- FU
SNUC, RMS, lymphoma
Intra arterial infusion – 5- FU along with RT
Topical 5- FU ;
Surgical debulking + topical 5 FU weekly
Adenocarcinoma- ethmoids
(knegt et al, Arch of otolarygology,2007 ).
Palliation.

58. INOPERABLE TUMORS
Irradiation;
6000 rads- 6 wks
Salvage surgery
CT+ RT
Intra arterial 5-FU

59. PNS TUMORS IN CHILDREN Commonest malignant tumor is rhabdomyosarcoma
Treatment; triple modality
Tumors; radioinsensitive
Rad >3000 rads retards facial skeletal growth

60. THANK YOU