Endoscopic Medial Maxillectomy
Considerations
When considering inverted papilloma
Be wary of any unilateral process
On CT: hyperostosis corresponds to base in ~90%
Goal of surgery: Resect the tumor and remove the base of attachment
Medial maxillectomy is now the gold standard for IP
Combine with the sublabial approach for anterior and inferior and lateral recess and nasolacrimal duct disease
Combine with open approach for superior lateral orbit disease
Follow up
Clinic endoscopic follow up is critical to detecting recurrence early
Every 4 months for 2 years then every 6 months for 2 years then every year
Preparation
Standard FESS topical 4% Cocaine and local infiltration of 1% Lidocaine with 1:100,000 Epinephrine
Procedure
Remove inflammatory polyps while preserving natural landmarks
Preserve the suspected tumor and identify its base of attachment (stalk)
Note the stalk's location and transect it in order to remove the bulk of the mass
Standard uncinectomy and wide maxillary antrostomy +/- ethmoidectomy
Resect the posterior fontanelle and medial maxillary sinus wall
Resect the inferior turbinate
Preserve the posterior aspect, avoid the SPA
May preserve the anterior most root of the IT
May elevate a mucosal flap along the floor away from the inferior meatus prior to IT resection
Remove the remaining inferior aspect of the medial maxillary sinus wall until flush with the floor to create a contiguous space with the nasal cavity
Some advocate preservation of the IT
Resect the anterior lateral nasal wall
Preserve the lacrimal sac and NLD, palpate the medial canthus as needed
Drill bone anterior to the NLD
Skeletonize the NLD and transect it sharply with turbinate scissors
Intubate the lacrimal sac at the conclusion to prevent stenosis
May remove POD 7
To improve visualization
Anteromedial maxillectomy (Denker's approach), which includes removal of the pyriform rim
Anterior antrostomy (Caldwell-Luc approach) may be performed
Post-op
Standard post op saline starting POD 1
POD 7 and POD 14-21 debridement
High-Yield
Links
eMedicine article on Sinonasal Papillomas
eMedicine article on Maxillectomy includes a description of medial maxillectomy