Transoral Inferior Maxillectomy

Transoral Inferior Maxillectomy

Paul J. Donald


The inferior maxillectomy is an operation usually employed in the management of malignant tumors that occur below Ohngrens line. The most common cancer is adenocarcinoma of salivary gland origin, followed by squamous cell carcinoma, acinic cell carcinoma, mucoepidermoid carcinoma, and adenoid cystic carcinoma. Less common are malignant melanoma, neuroendocrine tumors, and plasmacytoma. Cancer that invades the maxillary sinus from the oral cavity, primarily from the alveolar ridge or the hard palate, is often accessible to extirpation using an inferior maxillectomy. Mention must be made of one of the most malignant tumors seen arising from the minor salivary glands in the palate, the polymorphous low-grade adenocarcinoma, which is anything but low grade in its behavior. Fortunately, it is rare, but its aggressive behavior belies its blandappearing histology. The advantage of inferior maxillectomy over the standard radical maxillectomy is that it can be done entirely intraorally and should not disturb form or function. If there is an intranasal component to the cancer, this can be managed with either a facial degloving procedure or a separate transfacial alotomy. The alotomy is an exposure of the anterior nasal cavity by incising around the nasal ala down to the underlying pyriform rim, through the nasal mucosa and vestibular skin, and retracting the ala medially.


Cancer of the inferior aspect of the maxillary sinus may remain asymptomatic for a long time before it manifests itself. The cancer may present as a mass or swelling of the alveolar ridge or hard palate, often covered by normal appearing mucosa. An ill-fitting denture or change in occlusion in the dentulous patient may be the only symptom.

As the cancer enlarges, the mucosal surface may ulcerate and eventually result in an oral nasal or antral fistula causing nasal regurgitation of ingested liquids and even food. Numbness of the face due to invasion of the infraorbital nerve or orbital symptoms is rarely seen in cancers confined to the inferior aspect of the maxilla. As always, a complete examination of the head and neck is mandated. Examination of the oral cavity may reveal a mass extending from the floor of the maxillary sinus to the alveolar ridge or palate. Cancers primary in the palate may also present as a mucosal covered mass, especially in the case of a benign tumor such as a pleomorphic adenoma or simply as an ulcer that is more common in malignancy. Cancers of the maxillary alveolar ridge may appear as a heaped-up lesion in an empty tooth socket or heaped-up tissue in the gingival collar around a tooth with or without ulceration or, in an edentulous area, as a mass. Examination of the nose may reveal a pink or red irregular mass often with an ulcer that bleeds when touched. Cancer of the nasal vestibule presents as a nodule and/or ulceration in the vestibular skin usually invading the adjacent musculature of the upper lip. This cancer unlike those that arise from the sinuses and present in the nasal cavity is often tender to the touch.

Thorough examination of the neck is vital with special attention to the submandibular triangle where the first echelon of lymph nodes related to the oral cavity is located.


Distant metastasis is a contraindication to inferior maxillectomy. Lack of physical fitness and lack of patient cooperation are also contraindications to surgery. Invasion into the floor of the orbit or invasion of the infraorbital nerve precludes inferior maxillectomy. These patients need more extended resections.

Patients on anticoagulant therapy should discontinue their medication and go on bridging therapy so that they can be reversed at the time of surgery. Patients with severe comorbidities must have their condition optimized prior to surgery.

Prosthetic rehabilitation is essential, and in those instances where some form of dental rehabilitation is not available to the patients, they should be well aware of nasal regurgitation as well as difficult swallowing and speaking.

Invasion of the pterygoid muscle requires a wider exposure than obtainable by inferior maxillectomy, so that total maxillectomy would be a better surgical option.


Imaging Studies

The most valuable imaging study is the CT scan of the sinuses. The scan will demonstrate a mass often accompanied by bone erosion, and examination of the neck is important. Sorting out whether an opacification in one or more sinuses is tumor or retained secretions is better done with MR scanning.


Incisional biopsy of a mass in the palate, nasal vestibule, or alveolar ridge will usually reveal the diagnosis. Masses confined to the maxillary sinus will usually be accessible by endoscopic examination and biopsy. A small trephine opening in the anterior wall of the sinus or a limited Caldwell-Luc procedure will provide
excellent access to the sinus cavity for biopsy. If a biopsy or surgery has been done elsewhere, the slides must be acquired and be reviewed by a head and neck pathologist prior to surgery.

Maxillofacial Prosthodontics

It is essential for patients to have a consultation with a maxillofacial prosthodontist prior to surgery. The insertion of a prosthetic device at the time of surgery is essential for early rehabilitation. The ability of the patient to speak and take fluids by mouth in the early postoperative period without significant nasal regurgitation facilitates an early recovery from the surgery.

Jun 15, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Transoral Inferior Maxillectomy

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