Endoscopic medial maxillectomy

The surgical treatment of sinonasal tumors is constantly evolving. Lesions of the medial maxillary wall were traditionally approached through an external approach, usually a lateral rhinotomy incision. With direct visualization, en bloc resection was achieved; however, patients were left with an external scar and prolonged healing times were common. With the advent of endoscopic instrumentation in the 1980s, endonasal tumor surgery that respected oncologically correct resection was possible. The advantages of endoscopic resection included better visualization of the tumor, improved cosmesis, and faster healing times. Inverted papilloma is a benign intranasal tumor that commonly occurs on the lateral nasal wall and middle meatus. This tumor is composed of endophytic or inverted epithelial nests within an underlying stroma [14]. It can invade surrounding structures, have a tendency to recur, and may become malignant in 10-15% of cases [16]. Surgical resection is the treatment of choice and these tumors were traditionally treated with medial maxillectomy via a transfacial or sublabial degloving approach [6]. With the improved visualization of endoscopic techniques and outcomes comparable to those of the external approach, endoscopic transnasal resection of these tumors is quickly becoming the standard of care. For inverted papilloma involving the lateral nasal wall, endoscopic medial maxillectomy is the procedure of choice. The indications are: 1. Benign tumors such as inverted papilloma with involvement of: (a) Lateral nasal wall (b) Ostiomeatal complex (c) Ethmoid sinuses (d) Medial maxillary wall (e) Limited sphenoid sinus 2. Recurrent inverted papilloma 3. Malignancy confi ned to the medial wall of the maxillary sinus 4. Provide access to benign tumors involving: (a) Lateral or posterior maxillary sinus wall (b) Infratemporal fossa The contraindications are: 1. Inverted papilloma with extensive involvement of: (a) Orbit (b) Intracranial invasion (c) Frontal sinus (endoscopic medial maxillectomy may be used in conjunction with a procedure that addresses the frontal sinus, e.g.. modifi ed Lothrop procedure) 2. Malignant tumors with invasion to: (a) Bone of the posterior wall of the maxillary sinus, subcutaneous tissues, skin of cheek, fl oor or medial wall of orbit, infratemporal fossa, pterygoid plates (b) Orbital contents beyond the fl oor or medial wall, including any of the following: orbital apex, cribriform plate, base of skull, nasopharynx, sphenoid, frontal sinuses 3. Lack of experience by the surgeon 4. Lack of proper instrumentation 5. Presence of abundant scar tissue from previous surgery The advantages are: 1. May provide exposure of maxillary sinus and ethmoid sinuses without the removal of the lamina papyracea, medial fl oor of the orbit, anterior maxillary wall and frontal process of the maxilla 2. Provides improved visualization of diffi cult-toview areas such as lateral recesses of frontal, sphenoid and maxillary sinuses 3. No external scar 4. No loss of bony nasal or anterior maxillary support 5. Lower risk of infraorbital nerve paraesthesia 6. Reduced morbidity and shorter hospitalization.