Combined Endoscopic and Transoral Approach for Total Maxillectomy
Abstract
The technique of maxillectomy has been revised since it was first described in the 1820s. During the past decade, the endoscopic approach has been widely practiced for resecting maxilla. Compared with the traditional approaches, the combined endoscopic and transoral approach has many advantages such as avoiding facial incisions and postoperative scars and better visualization of the surgical margin. However, this technique is complicated to master and possess several challenges. Here, we demonstrate this approach step-by-step to show how to perform a total maxillectomy. We also reported nine cases with malignant tumors originating from the maxilla, and for all of them total maxillectomy was performed with combined endoscopic and transoral approach. Our data showed that the combination of the endoscopic and transoral approach could be used to resect the total maxilla successfully, though the tumor extended to the infratemporal and pterygopalatine fossa should be treated very carefully to avoid its spread in the local area. Furthermore, besides denture, other reconstruction methods should be attempted to improve the postoperative quality of life after the total maxillectomy.
Introduction
The squamous cell carcinoma from the maxillary sinus reports the highest incidence among the tumor developments within the sinonasal compartment1. Besides squamous cell carcinoma, the pathological patterns of maxillary tumors also include various histological types, such as adenocarcinomas, melanoma, and esthesioneuroblastoma, etc.2. Since the symptoms in the early phases are dormant and nonspecific, most of the patients diagnosed with malignant tumor originating from the maxilla are in an advanced stage during the time of diagnosis. This makes the maxillary malignant tumors one of the worst in comparison with other head and neck tumors.
The therapeutics options for the patients with malignant tumors involves maxilla surgeries combined with radiotherapies, and in some cases chemotherapies3,4,5. Many approaches of maxillectomy have been developed to resect the maxilla since it was first demonstrated in 18266. Recently, the maxillectomy can be divided into an approach with and without a skin incision. Among these approaches, lateral rhinotomy and midfacial degloving are still practiced in total maxillectomy. However, the drawbacks of these procedures include leaving a facial scar, and difficulties in treating the lesion located at or beyond the posterior margin of the maxilla due to the restricted field of visualization, limited working space, and significant bleeding of these areas7. Compared to these traditional approaches. A combined endoscopic and transoral approach has been presented for total maxillectomy without facial incision8,9. This approach, taking advantage of the better visualization of the endoscopy, might lead to the better magnification of the operative field, especially for the surgical margins, resulting in potentially similar scales of resection but with less morbidity8. In addition, no facial scars are left with this approach, which might accelerate its application for the total maxillectomy in the future. However, the technique is complicated to master and possesses several challenges. Therefore, we present a step-by-step visual protocol of a combined endoscopic and transoral approach, which may help in shortening the learning curve of this approach.
Protocol
Representative Results
Discussion
In this work, we demonstrated an endoscopic approach to resect the total maxilla. Our results showed that this approach was effective and safe to achieve its goal, which is consistent with previous cadaveric8 and clinical studies9. Nine patients with malignant tumor originated from maxillary sinus were treated with this endoscopic approach. All of their information was recorded, and the length of their follow-up ranged from 2 months to 32 months. During the follow-up period…
Divulgations
The authors have nothing to disclose.
Acknowledgements
This work was sponsored by the Shanghai Municipal Commission of health and Family Planning (201740187), Shanghai Science and Technology Committee Foundation (19411950600 and 19441900300), Research Units of New Technologies of Endoscopic Surgery in Skull Base Tumor (2018RU003, Chinese Academy of Medical Sciences), New Technologies of Endoscopic Surgery in Skull Base Tumor: CAMS Innovation Fund for Medical Sciences (CIFMS) (2019-I2M-5-003), National Nature Science Foundation of China for Young Scholars (81300810), Natural Science Foundation of Shanghai (20ZR1410000), National Natural Science Foundation of China (81970856).
Materials
| Carborundum drill | Medtronic, Inc. | REF15BA60D | |
| Curved sinus blade | Medtronic, Inc. | REF1884006 | 11 cm x 4 mm |
| Dynamic planing system | Medtronic, Inc. | REF1898001 | |
| Electrocoagulation | Shanghai Hutong Electronics. Co.,Ltd | GD350-B5 | |
| Epinephrine | Shanghai Harvest Pharmaceutical Co., Ltd | 10170405 | |
| Fret Saw Wire Instruments | Shanghai Medical Instruments (Group) Ltd., Corp. Surgical Instruments Factory | N30030 | |
| Gauze | Ningbo Shenyuan Medical Material Co., Ltd | 6 cm x 60 cm | |
| Mastoid Retractor | Shanghai Medical Instruments (Group) Ltd., Corp. Surgical Instruments Factory | NH6F090 | Lengh: 16 cm |
| Mayo scissors | Shanghai Medical Instruments (Group) Ltd., Corp. Surgical Instruments Factory | J22040 | Lengh: 16 cm |
| Metzenbaum scissors | Shanghai Medical Instruments (Group) Ltd., Corp. Surgical Instruments Factory | JC2514 | Lengh: 25 cm |
| Nasal Endoscopy | Karl Storz-Endoskope | 7230 AA | |
| Plasma (EVAC 70 Xtra HP With integrated Cable) | Smith & Nephew | EIC5874-01 | |
| Quadcut blade | Medtronic, Inc. | REF1884380HR | 4.3 mm |
| Suction Elevator | Zhejiang Tian Song Medical Products Co., Ltd | B2117.1 | Width: 4 mm |
| Tetracaine | Eye & ENT Hospital of Fudan University | 180130 | |
| Trans-Nasal Skull Base Bur | Medtronic, Inc. | REFTN45RCD | 13 cm x 4.5 mm |
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