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Parisa M Sub internship in Otolaryngology, Head and Neck Surgery XXXX Feb 24, 2012

Maxillectomy
Mr W. 78 y/o, 2 month history of discomfort in left upper alveolar ridge, and numerous periodontic procedures with no result. Physical exam was noticeable for a 1.2 x 1.2 cm excoriated lesion on the inner surface of the left alveolar ridge with no lateral or midline extension. Biopsy: Squamous Cell Carcinoma Patient underwent Left Partial Maxillectomy, and placement of pin-borne prosthesis. Pathology report: Invasive SCC, well differentiated, with perineural invasion, and no lymphovascular or bone invasions.

Indications:
Malignant/benign tumors of nose and paranasal sinuses Malignant/Benign tumors of oral cavity that extend in to the hard palate Fulminant invasive fungal sinusitis Combined resection of skull base neoplasm

Contraindications:
Poor general condition Medically amenable malignancies like lymphoma/ rhabdomyosarcoma Bilateral tumor with bilateral orbital involvement Patients refusal to provide consent

Relevant Anatomy:

Innervation: Perineural spread biopsy from infraorbital /greater palatine nerve Lymphatic drainage: Upper cervical (Level I, II) lymphatics, retropharyngeal nodes, periparotid

Ohngren 1933 : Poor prognosis in involvement of posterior and superior walls of maxilla Ohngrens line
Kreeft, AM. et.al. 2012 High risk of incomplete resection and lower survival in patients with invasion to pterygoid space, infratemporal fossa, nasopharynx and floor of orbit. Combining CT and MRI can contribute to better judgment of areas at risk for incomplete resection.

Neck Dissection
Lin, HW. et.al. 2009 725 Patients with hard palate and maxillary alveolus SCC Cervical node metastasis: 4.1% for T1, and 24.7% for T4 Reduced survival by one half in patients with nodal metastasis Morris LGT. et.al. 2011 139 patients with hard palate and maxillary alveolus SCC High rate of regional recurrence Limited number of salvageable recurrence Poor outcome despite salvage surgery

They recommend ND for majority of these tumors with possible exception of localized T1 tumors. (SND of I- III)

Midface Reconstruction

Cordeiro PG, Chen CM. A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes. Plast Reconstr Surg. 2012 Jan;129(1):124-36.

Goals of reconstruction:
Functional Aesthetic

Wound closure Restoration of the barrier between the sinonasal cavity and the anterior cranial fossa Separation of the oral and sinonasal cavities Support of orbital contents and maintenance of ocular globe position Oral continence Speech Mastication Maintenance of a patent nasal airway Facial appearance

References:
Flint PW. (2010) Cummings Otolaryngology: Head & Neck Surgery, 5th ed. Mosby Stenson KM, Haraf Dj. Paranasal sinus cancer. Uptodate. V 19.3 2012 Wu A, Lee NY, Gross ND, Okuno S. Treatment of locoregionally advanced (stage III and IV) head and neck cancer: The oral cavity. Uptodate V19.3 2012 Lin HW, Bhattacharyya N. Survival impact of nodal disease in hard palate and maxillary alveolus cancer. Laryngoscope.2009;119:312315 Cordeiro PG, Chen CM. A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes. Plast Reconstr Surg. 2012 Jan;129(1):124-36. Ohngren LG. Malignant tumours of the maxillo-ethmoid region: a clinical study with special reference to the treatment with electrosurgery and irradiation. Acta Otolaryngol (Stockh). 1933;19(Suppl):1-276. Kreeft AM, Smeele LE, Rasch CR, Hauptmann M, Rietveld DH, Leemans CR, Balm AJ. Preoperative imaging and surgical margins in maxillectomy patients. Head Neck. 2012 Jan 17 Morris LG, Patel SG, Shah JP, Ganly I. High rates of regional failure in squamous cell carcinoma of the hard palate and maxillary alveolus. Head Neck. 2011 Jun;33(6):824-30 Maxillectomy- Iowa Head and Neck Protocols

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