Maxilectomia maxilară medială pentru papilomul inversat
The procedure implies surgical excision of the lateral nasal wall and ethmoid sinus. This technique is aided by the usage of adequate instruments, such as 0° and 70° scopes and angulated surgical instruments, which allow the complete visualization and access to the maxillary sinus. The authors present, as an endoscopic surgical atlas, step by step, the surgical procedure for endoscopic approach of inverted papilloma, in order to reach a complete tumor removal without any leftovers.
Keywords medial maxillectomy, inverted papilloma, endoscopic sinus surgery Rezumat Tehnica maxilectomiei mediale reprezintă standardul de aur în tratamentul chirurgical al papilomului inversat, deoarece oferă o expunere adecvată a peretelul nazal lateral şi a inverted papilloma surgery removal maxilar. Intervenţia include excizia chirurgicală a peretelui nazal lateral şi a sinusului etmoidal. Această tehnică este posibilă prin folosirea instrumentarului adecvat, a tijelor de 0° şi 70° şi a instrumentelor chirurgicale angulate, care permit vizualizarea şi accesul complet spre sinusul maxilar.
Autorii prezintă, ca un atlas de chirurgie endoscopică, paşii acestei tehnici chirurgicale de abord endoscopic al papilomului inversat, în vederea exciziei complete a tumorii, fără nicio restanţă. Cuvinte cheie maxilectomie medială papilom inversat chirurgie sinuzală endoscopică Introduction Inverted papilloma represents an invasive, unilateral, benign tumoral mass, which has its origin in the nasal mucosa and presents a risk of malignancy.
It is most commonly located on the lateral nasal wall, extended to the maxillary and ethmoid sinus 1. When it has its origin in the maxillary sinus, the elected technique is represented by endoscopic medial inverted papilloma surgery removal. Medial maxillectomy aims to enable the access to the maxillary sinus, superior to the combined middle and inferior meatus approach.
Frontal Sinus Inverted Papilloma
In the last decades, with the development of endoscopic and imagistic techniques, the endoscopic approach replaced the external procedures, as it presents similar success rates, lower morbidity and better esthetic outcomes for the patient 2.
Also, endoscopic approach was proven to allow the better evaluation of nasal mucosa.
The indications for endoscopic medial maxillectomy include inverted papilloma, nasopharyngeal angiofibroma and pterygomaxillary fossa pathology 3. The diagnostic protocol inverted papilloma surgery removal on a computed tomography, which illustrates the extension and place of attachment of the tumor. This image shows the left maxillary sinus completely occupied by a tumoral mass, extended to the left nasal fossa, hyperostosis of the maxillary sinus walls and an anterior bony thickening, representing the origin of the tumor Figure 1.
Figure 1. CT image, coronal section, showing complete blockage of the maxillary sinus, hyperostosis and tumoral origin arrow The first surgical step inverted papilloma surgery removal antero-posterior ethmoidectomy, with the excision of the tumor from this level and from the middle meatus. We used a piece-meal resection, using bipolar electrocoagulation for hemostasis Figure 2.
Figure 2. Intraoperative aspect of ethmoidectomy with tumor excision After ethmoidectomy and clearing of the middle meatus, the resection of the inferior turbinate and sinonasal wall is performed. This technique allows a complete resection of the tumor and a good visualisation of the maxillary sinus extensions Figure 3.
Figure 3. Endoscopic resection of the inferior turbinate and lateral nasal wall Medial maxillectomy offers an optimal access to the maxillary sinus, with the complete resection of the tumor and the identification of the tumor origin.
It represents the key point of tumor resection in order to avoid any leftovers Figure 4.
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Figure 4. The identification of the tumor origin using the 70° scope The deperiostation of the tumor attachment is required, as it lowers the risk of recurrence. We can succeed in this procedure using an angulated curette Figure 5 or an angulated diamond burr, depending on the position of the bony stalk or hyperostosis. Figure 5. Inverted papilloma surgery removal deperiostation of tumor origin Final image of the widely opened medial maxillectomy ostium and resorbable sponge applied in the maxillary sinus.
Endoscopic medial maxillectomy for inverted papilloma
This procedure does not require the usage of a hemostatic sponge Figure 6. Figure 6. Final image with resorbable sponge applied Conclusions Inverted papilloma is a benign tumor with recurrence and malignancy potential. Recurrence is in fact a tumoral residue.
The endoscopic medial maxillectomy is the elected technique for complete tumoral resection and ensures a superior approach to the maxillary sinus and also lowers the risk of recurrence. Conflict of interests: The authors declare no conflict of interests.
Sinonasal inverted papilloma: A case report and mini review of histopathological features. Journal of Oral and Maxillofacial Pathology. Cunningham K, Welch K.
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Endoscopic medial maxillectomy. Operative Techniques in Otolaryngology.