Dr T Balasubramanian Otolaryngology online1

  Concept described by Lazars in 1826  Syme first performed it in 1829  Portman described sublabial transoral approach in 1927  Smith described extended maxillectomy in 1954  Fairbanks & Barbosa described infratemporal fossa approach for advanced maxillary sinus tumors in 1961  Midfacial degloving approach was popularized in 1970 History Otolaryngology online2

  Bleeding was the most common danger  Complications due to anesthesia  Post op sepsis  Secondary deformity due to poor prosthesis support Dangers - Historic Otolaryngology online3

  Malignant tumors involving maxilla  Benign tumors of maxilla causing extensive bone destruction (fibrous dysplasia)  May be performed as a part of combined resection of skull base neoplasm  May be needed in patients with extensive fungal / granulomatous infections (rare)  Malignant tumors of oral cavity with extensive involvement of palate Indications Otolaryngology online4

  Not indicated in the management of lymphoreticular tumors which are better managed medically  Tumors involving inferior aspect of maxillary sinus can be managed by performing partial maxillectomy  Rehabilitation and prosthesis issues should be planned well in advance in consultation with dental surgeons Tips Otolaryngology online5

  Poor general condition of the patient  Bilateral tumors with bilateral orbital involvement  Malignant tumors with skull base extension.  Patient not consenting to undergo the procedure  Systemic disorders like uncontrolled diabetes / poor cardio respiratory reserve Contraindications Otolaryngology online6

  Involvement of orbits on both sides – This could compromise the vision because orbital exenteration will have to be performed  Removing bilateral tumors is not only a surgical challenge but also a challenge to design appropriate prosthesis. Since it is rather difficult to design prosthesis for patients who undergo bilateral total maxillectomy it is a relative contraindication Bilateral tumors Otolaryngology online7

  Both axial and coronal CT scans will have to be performed in order to ascertain the extent of lesion  MRI will have to be performed in patients with erosion of skull base to rule out intracranial extension  Imaging helps in deciding osteotomy location. Superior osteotomy above the level of frontoethmoidal suture line will result in intracranial injury and CSF leak Imaging Otolaryngology online8

 CT Otolaryngology online9

  Vision should always be tested before taking the patient up for surgery  Tumor involvement of orbit is an indication of orbital exenteration  If orbital exenteration is planned appropriate prosthesis should be designed to fill up the defect Ocular evaluation Otolaryngology online10

  Bleeding  Infection  Epiphora  Break down of skin graft  Numbness of cheek area  Atrophic rhinitis Complications Otolaryngology online11

  Can be minimized by coagulating bleeders  Angular vessels should be secured properly  Breaking maxilla from pterygoid process will cause bleeding from internal maxillary artery. Simple hot packs will help in reducing bleeding during this stage  When lip splitting incision is used bleeding from labial vessels is common and should be secured at the earliest Bleeding Otolaryngology online12

  Can be minimized by following strict asepsis  Avoiding undue use of cautery will minimize tissue necrosis / infection  Post op antibiotics  By conserving skin as much as possible without compromising tumor margins Infection Otolaryngology online13

  Nasolacrimal duct is transected during maxillectomy thus causing epiphora  Simple transection of nasolacrimal duct rarely causes epiphora unless followed by stricture which usually occurs following radiotherapy  Insertion of silicone tube after transection of nasolacrimal duct  Marsupialization of nasolacrimal duct Epiphora Otolaryngology online14

  Caused due to transection of infraorbial nerve  Infraorbital nerve can be conserved if not involved by the tumor Numbness of cheek area Otolaryngology online15

Otolaryngology online16

 Consent issues  Dental extraction  Tracheostomy  Prosthesis issues  Cosmetic defects Otolaryngology online17

  General anaesthesia  Infiltration with 1% xylocaine with 1 in 100,000 adrenaline  Marking incision site  Reflection of skin flap over maxilla  Bone cuts  Disarticulation of maxilla Surgical steps Otolaryngology online18

 Incision  Weber Ferguson’s incision is used  Lateral rhinotomy incision with horizontal infraorbital component and midline lip split Otolaryngology online19

 Sublabial component  Sublabial incision is performed after splitting upper lip in midline  This facilitates elevation of flap from anterior wall of maxilla  Extends through entire bucco gingival sulcus up to maxillary tuberosity Otolaryngology online20

 Infraorbital component  This is the horizontal component of weber Ferguson’s incision  Made about 1 mm below the infraorbital rim Otolaryngology online21

 Flap Otolaryngology online22

 Bone cuts Otolaryngology online23

 Palatal cut Otolaryngology online24

 Zygoma cut Otolaryngology online25

 Maxilla removal Otolaryngology online26

 Prosthesis Otolaryngology online27

 Specimen Otolaryngology online28

 Closure Otolaryngology online29

  Temporary tarsorraphy  Corneal shield  Significant laceration of periorbita should be sutured Eye protection Otolaryngology online30

Otolaryngology online31