Complete Maxillectomy

History

May present with primary symptoms including but not limited to nasal congestion, lesion of the palate or alveolar ridge, epistaxis, facial numbness, abnormal tearing diplopia, or loss of vision. Patients may present with nodal metastasis (<10% of time), although the metastasis rate for squamous cell carcinoma of the alveolar ridge and hard palate may be as high as 35%. Symptoms of advanced disease include trismus, airway compromise, complete loss of vision or ophthalmoplegia, and lower cranial nerve palsies.

Physical Examination

• 1.

  A complete examination of the head and neck must be carried out. Special attention should be paid to:

  • a.

    Examination of the oral cavity including the dentition, hard palate, buccal mucosa, and soft palate mobility. Loss of sensation of the palate is an important finding, since it would suggest either perineural spread into the palatine canals or involvement of the pterygopalatine fossa. Trismus is associated with invasion of the infratemporal fossa.

  • b.

    Cranial nerve examination: Special attention should be paid to cranial nerves III, IV, V, and VI, with a focus on testing extraocular motion and infraorbital nerve function.

  • c.

    Eye examination: Hyperglobus may represent lesion expansion and not necessarily invasion; however, severe extra ocular muscle restriction and loss of visual acuity are almost always due to direct intraconal invasion. Abnormal tearing can be due to invasion of the lacrimal system or invasion of the pterygopalatine fossa by disruption of Vidian nerve supply.

  • d.

    Examination of the neck: The rate of metastasis to the cervical lymph nodes is generally low for squamous cell carcinoma (10% to 35%) but can be present. Usually levels 1 or 2 and facial nodes are the levels most commonly involved.

  • e.

    Facial skin changes: Invasion through the anterior wall of the maxillary sinus represents advanced cancer and is important for postsurgical reconstructive considerations.

• 2.

  Nasal endoscopy is also warranted to examine the floor of the nose (nasal side of the hard palate) and the lateral nasal wall. Additionally, involvement of the ethmoid can be identified in the middle meatus. If there is a tumor present in the nasal cavity, endonasal biopsy may be warranted.

Imaging

Accurate preoperative assessment of the extent of disease is important, and the complementary information provided by CT and MRI should not be underestimated. This will drive the extent of any planned surgery and should be reviewed with the patient so he or she understands the extent of the operation, as well as any functional consequences that should be expected, such as oral competency, eye involvement, potential for vision loss, or hypoglobus.

• 1.

  CT ( Fig. 107.1A ): Defines the bony boundaries as well as bone invasion of the palate and posterior wall of the maxillary sinus or orbital floor

  • a.

    Ohngren’s line ( Fig. 107.2 ): An imaginary line drawn from the medial canthus of the eye to the angle of the mandible. It divides the maxillary sinus into an anterior/inferior portion and a posterior/superior portion. This line helps give relative prognostic value (with anterior/inferior being better) as well an idea of adjacent structures at risk for potential spread.

    

  

• 2.

  MRI (see Fig. 107.1 ): Delineates affected soft tissue and provides information on perineural spread, characteristic of some malignant neoplasms. This study provides the best information regarding the orbit, skull base, intracranial extension, and anterior facial skin.

• 3.

  Regional and distant staging: Usually completed with either contrasted CTs of the neck and chest or positron emission tomography (PET) CT.

• 4.

  Angiography: Rarely indicated—only needed when there is a presumed vascular malformation or if the tumor has invaded the carotid artery on the primary site imaging

Indications for Surgery

• 1.

  Malignant tumors

• 2.

  Benign tumors that are either symptomatic or growing

• 3.

  Symptom relief

Contraindications to Surgery

• 1.

  Patient factors: Inability to undergo general anesthesia or have major blood loss

• 2.

  Unresectable tumors (unless palliative surgery indicated)

• 3.

  Diffuse distant metastasis

• 4.

  Lymphomas, plasmacytomas, or other tumors that are highly radiation or chemotherapy sensitive