The outcome of transnasal endoscopic total maxillectomy in the treatment of sinonasal adenoid cystic carcinoma / 临床耳鼻咽喉头颈外科杂志

Objective:To assess the prognosis of sinonasal adenoid cystic carcinoma with hard palatine invasion treated by transnasal endoscopic total maxillectomy. Methods:Clinical data of twenty-six patients with sinonasal adenoid cystic carcinoma invading hard palatine treated by transnasal endoscopic total maxillectomy between May 2014 and December 2020 was analyzed retrospectively. Survival rate, local recurrence and distant metastasis were analyzed using Kaplan-Meier method. Cox regression was used to investigate the prognosis factors. Masticatory function after maxillectomy has also been assessed using the questionnaire of patients' satisfaction about masticatory function. Results:Margins in 8 patients（30%） were positive. The median time of follow-up was 38 months（6 to 85 months）. Twenty-five patients recurred. Four patients died of distant metastasis. The 5-year overall survival rate and relapse-free survival rate was 79.5% and 89.1%, respectively. Independent predictors of outcome on multivariate analysis were positive margin（P=0.018）, recurrence（P=0.006） and distant metastasis（P=0.04）. Conclusion:Transnasal endoscopic total maxillectomy could be performed for the treatment of the sinonasal adenoid cystic carcinoma with hard palatine invasion. Positive margin, local recurrence and distant metastasis were important predictors for patients' prognosis.

Preservation of palatal mucoperiosteum for oronasal separation after total maxillectomy.

Background: Oronasal communication occurs after total maxillectomy for advanced sinonasal cancers. This results in feeding, breathing and cosmetic impairment. Various methods have been described to close off the palatal defect from the oral cavity to improve the function of speech and deglutition. Aims: The object of this article is to describe our experience of preservation of palatal mucoperiosteum for oronasal separation. Materials and Methods: Retrospective review of clinical and operative records of 31 total maxillectomy patients where oronasal separation was achieved by the conventional technique of applying a maxillary obturator. The postoperative complications arising from the use of maxillary obturator for oronasal communication after total maxillectomy in these 31 patients were analysed. To avoid the complications encountered in these 31 patients we preserved and used the ipsilateral palatal mucoperiosteum for oronasal separation. This new technique was applied in 12 patients. The results are presented and compared. Results : A total of 43 patients underwent total maxillectomy for advanced sinonasal tumors. In 31 patients the conventional maxillary obturator was used for oronasal separation. Among these patients, 30 had crustation of the maxillary cavity, nasal regurgitation and cheek skin retraction in 15 each, trismus in eight, infection of skin graft donor site in seven, cheek movement during respiration in five and ill-fitting prosthesis in three. In 12 patients palatal mucoperiosteum was preserved and used for oronasal separation. The complications encountered in oronasal separation by palatal prosthesis were avoided in the modified procedure. Conclusions: We found that oronasal separation by preservation of palatal mucoperiosteum following total maxillectomy allowed excellent palatal function, prompt rehabilitation and minimal complications without compromising the prognosis.

Clinical Experience of Three-dimensional Reconstruction Using Free TRAM Flap after Total Maxillectomy with Orbital Exenteration

PURPOSE: Extensive midface defect following total maxillectomy with orbital exenteration and cheek skin resection should be three dimensionally reconstructed with a large flap that have a sufficient volume of tissue and multiple skin islands. We describe our transverse rectus abdominis myocutaneous(TRAM) free flap with three skin islands which was successfully used in this situation. METHODS: A 58-year-old man was performed enbloc total maxillectomy including orbital contents and wide cheek skin because of invasive maxillary squamous cell carcinoma. He was immediately reconstructed with TRAM flap that was designed not vertical but transverse fashion for providing sufficient skin area. Also, deepithelialization procedure making for multiple skin islands was done in flap insetting period when appropriate modification according to the intraoperative situation was possible. Dead space was completely obliterated by bulky muscular tissue, and three skin islands were used for lining of lateral nasal wall, palatal surface, and cheek skin restoration. RESULTS: Postoperative course was satisfying. Maintaining of proper ipsilateral nasal airway, loss of rhinolalia and oronasal regurgitation of food particles, and restoration of cheek contour were successfully obtained. CONCLUSION: We report clinical experience of threedimensional reconstruction using free TRAM flap after total maxillectomy with orbital exenteration.

A Case Report of Maxillary Reconstruction by Using Vascularized Calvarial Bone and Free Rectus Abdominis Myocutaneous Flap

Total maxillectomy usually results in defects on anterior, posterior, medial and lateral wall of the maxilla besides the palate and the orbit floor. The traditional reconstructive approaches to maxillectomy include skin grafting to line the internal cavity and palatal prosthesis to obturate the palate and serve as a denture. This method is easy to detect tumor recurrence by direct examination. The drawback of this method is that the infection rate is very high and it can not yield structural support to the upper midface. It is not possible to repair the maxillary defects effectively when using only the hard tissue like bone. The reconstruction by using soft tissue makes it possible to repair the defects on the medial nasal wall, eye socket and the palate, but it is impossible to reconstruct the malar eminence. Therefore, the transfer of soft and hard tissue is recommended for the ideal and effective reconstruction of the defect after the total maxillectomy. We have acquired satisfactory results for both fuctional and aesthetical purposes in the cancer patient who received the maxillectomy by using the vascularized calvarial bone and the free rectus abdominis myocutaneous flap.

Surgical Outcome of Radical Maxillectomy in Advanced Maxillary Sinus Cancers

We investigated the surgical outcome of radical maxillectomy in advanced maxillary sinus cancers invading through the posterior wall and into the infratemporal fossa. Twenty-eight patients with maxillary sinus squamous cell carcinoma, who visited the Otorhinolaryngology Department at Severance Hospital from March, 1993 to February, 2001 and underwent the surgery, were analyzed retrospectively by reviewing clinical medical records and radiologic test results. The mean follow- up period was 78.8 months. (26 -162 months) Local recurrence, sites of local recurrence, and the 2-year disease-free survival rate were analyzed. Of the total 28 cases, 9 cases were T3, and 19cases were T4. Total maxillectomy was performed in 12 cases (42.9%) and radical maxillectomy in 16 cases (57.1%). Regardless of staging, radical maxillectomy was performed only when cancers invaded through the posterior wall and into the infratemporal fossa. When cancers only maginally or did not invade the posterior wall, total maxillectomy was performed. The 2-year disease-free survival rate was 75% for both total and radical maxillectomy, and the local recurrence rates were 8.3% and 18.7% respectively. All recurrence occurred at the posterior resection margin of the maxillectomy. We strongly recommend the use of radical maxillectomy in the cases of advanced maxillary sinus cancers invading the infratemporal fossa. Radical maxillectomy can provide sufficient safety margins and lower the local recurrence rate.

The three Dimensional Facial Reconstruction of Maxillary Defects using Latissimus Dorsi Musculocutaneous Free Flaps

Surgical reconstruction of malignancies of the head and neck often leave large defects that demands reconstruction. A maxillectomy defect creates a communication from oral cavity to nasal cavity that may extend to the orbit. This can leave a large anatomical defect that invades surrounding anatomical boundaries including the oral cavity, nasal cavity, orbital cavity, soft tissues of the face, and anterior skull base. Surgical repair of maxillary defects has been widely reported. Skin graft, local and regional flaps such as local mucosal flaps, buccal fat pad, temporalis muscle and pectoralis major muscle pedicled flaps, and free tissue transfer can be used depending largely on the size of the defect. We performed facial reconstruction using a latissimus dorsi musculocutaneous free flap for covering large defects that involved exposed orbit, nasal, and oral cavities in seven patients after total maxillectomy for maxillary cancer. One case was immediate reconstruction and the others were secondary reconstruction during the follow up period after primary cancer surgery. The skin of the latissimus dorsi musculocutaneous flap was pliable and its texture was similar to that of the face. The muscle bulkiness was sufficient to reconstruct the soft tissue of the intraoral and nasal lining and external skin deficits. All flaps had survived and serious complications were not developed. None of the patients need secondary defatting procedures later for the excessive bulkiness, but oronasal fistulas developed in two patients and one patient had cicatrical ectropion of lower eyelid. All donor defects were closed primarily and there has been no noticeable residual functional problems or discomfort in the shoulder area.