6.2.1 Anatomic Landmarks

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  Frontal process of maxilla (anterior lacrimal crest).

  
  
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  Lacrimal “bulge.”

  
  
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  Inferior turbinate.

  
  
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  Uncinate process.

  
  
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  Maxillary sinus floor.

  
  
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  Vertical process of palatine bone.

6.2.2 Description

The procedure starts by applying topical cocaine powder in cotton buds soaked in 1 mg/mL epinephrine. Topical cocaine is not allowed in some countries, so vasoconstriction solution could be used. The cotton buds should be placed into the nasal cavity, where they stay until the patient is draped and the surgical field is prepared. A solution of 1:80,000 adrenaline/lignocaine is subsequently injected under the inferior turbinate and over the ridge of the frontal process of the maxilla ( Fig. 6.1 ).

The extent of the procedure is defined by the extension of the tumor. For those limited to the medial wall of the maxillary sinus, a wide middle meatal antrostomy with inclusion of the tumor and the involved part of the wall is usually enough. In the case that the tumor involves the lateral or posterior wall of the maxillary sinus, a “conservative” medial maxillectomy with or without the excision of nasolacrimal duct is performed (we call this “conservative, type 1 medial maxillectomy”; Fig. 6.2 ). If the tumor involves the anterolateral wall and/or the inferior part of the maxillary sinus, an endoscopic Denker is performed (as described by Draf)—radical or extensive medial maxillectomy (including the piriform aperture and part of the anterior maxillary sinus wall, until the infraorbital nerve is exposed; we call this “extensive, type 2 medial maxillectomy”; Fig. 6.3 ).

Initially, the mucosa over the frontal process of the maxilla and the anterior lacrimal crest is incised with a 45-degree ophthalmology slit/phaco knife, down to the level of the nasal floor ( Fig. 6.4 ). A no. 15 blade is then used to continue the initial incision under the inferior turbinate, up to the level of the posterior maxillary wall ( Fig. 6.5 ). The incised mucosa is then reflected over the projected osteotomy sites with a Freer elevator ( Fig. 6.6 ). A 3-mm chisel is used to cut the bone following the route of the initial mucosal incisions, always first anterior to the nasolacrimal duct and then under the inferior turbinate ( Fig. 6.7 ), all the way to the posterior wall of the maxillary sinus ( Fig. 6.8 ). The medial wall of the maxillary sinus is subsequently reflected medially en bloc with the inferior turbinate. The nasolacrimal duct is identified and resected horizontally with a sharp scissors to prevent postoperative stenosis ( Fig. 6.9 ). If necessary, the maxillectomy opening is further enlarged anteriorly, laterally, and inferiorly with a 15-degree diamond burr and a Kerrison punch, aiming always to completely visualize the anterior wall (including the lateral part of it) of the sinus. The final margins of resection are the nasal floor inferiorly, the orbital floor superiorly, the posterior wall of the maxillary sinus posteriorly, and the (lateral part of the) anterior wall of the maxillary sinus anteriorly. At this stage, in cases of inverted papilloma or other benign tumors, the whole attachment of the tumor in the maxillary sinus should be clearly visualized. We find that malleable suction elevators (Wormald set) are very helpful for removing a 10-mm cuff of normal mucosa around the attachment of the tumor. Before the tumor is removed, the sphenopalatine artery is often ligated. The bony maxillary wall where the tumor was attached is drilled using a 70-degree diamond drill and the cavity is inspected with a 30- or 45-degree endoscope.1

We send all the specimens (including that in the debrider trap) for histology, to avoid missing a synchronous malignant tumor.5