Medial maxillectomy involves removal of the lateral nasal wall and the adjoining maxillary bone medial to the plane of the infraorbital nerve. A complete sphenoethmoidectomy is also usually performed. This can be accomplished using a transfacial exposure (lateral rhinotomy), sublabial approach (facial degloving), or endoscopic endonasal approaches. This chapter discusses in detail the transfacial exposure using the lateral rhinotomy incision, which is the most widely practiced surgical approach for medial maxillectomy.

Comprehensive examination of the nasal cavity should be done after topical decongestion and anesthesia using rigid or flexible endoscopy (Fig. 17.1). The presence of intranasal masses, ulcers, or areas of contact bleeding should be noted. Although unilateral “polyps” may be inflammatory, they are more commonly neoplastic. Tumors may also present as a submucosal mass without changes in the mucosa, other than displacement. Any suspicious lesions should be biopsied, preferably after high-resolution imaging has been obtained to avoid severe bleeding and/or cerebrospinal fluid (CSF) leak.

Detailed examination of the head and neck may reveal signs of extension of the tumor to adjacent structures. Soft tissue swelling of the face may indicate tumor extension through the anterior bony confines of the nose and sinuses. Inferior extension toward the oral cavity may present with an ulcer or a submucosal mass
in the palate or the alveolar ridge. Middle ear effusion may indicate tumor involvement of the nasopharynx, Eustachian tube, pterygoid plates, or tensor veli palatini muscle. Extension to the skull base may lead to involvement of the cranial nerves resulting in anosmia, blurred vision, diplopia, or hypoesthesia along the branches of the trigeminal nerves. The presence of an associated mass in the neck may represent cancer metastatic to the cervical lymph nodes.

Evaluation of the patient with a sinonasal neoplasm and suspected extension into the orbit should include a detailed neuro-ophthalmologic examination. This usually includes detailed assessment of visual acuity, visual fields, and ocular motility.