Surgical Technique

trostomy is first performed removing the medial maxillary wall all the way up to the level of the floor of the orbit. The microdebrider or a Stammberger punch is then used to remove tissue inferiorly through the inferior middle turbinate until the nasal floor is reached (Fig. 12.2). Tumor is removed and is followed to its point of origin. The medial maxillary wall is resected posteriorly as far as needed for tumor removal until the posterior maxillary wall is reached. Bleeding from a sphenopalatine branch is handled if it occurs or the sphenopalatine artery may need clipping.

Next, backbiting forceps are used to make a cut along the floor of the orbit, and the cut is directed anteriorly until the anterior maxillary wall is reached (Fig. 12.3). Similarly, a cut is made at the floor of the nose, under the inferior turbinate, in an anterior direction until the anterior maxillary wall is encoun-

The patient is placed under general anesthesia. The nasal cavity is decongested with 2% oxymetazoline or cocaine-soaked neurosurgical pledgets. Infiltration of 1 or 2% lidocaine in 1:100,000 epinephrine into the inferior turbinate, middle turbinate, and area of the sphenopalatine artery is performed.

The key to the success of endoscopic surgery for the management of inverted papilloma is locating the specific site of tumor origin and its attachment, defining the extension of the tumor, and completely removing all affected tissue [7]. Intraoperative endo-scopic evaluation is essential in delineating the origin of attachment and the extent of the tumor. It may be determined whether the tumor has invaded tissue, or has simply "dumbbelled" into the sinus with associated retention of secretions [9]. Endoscopic evaluation is considerably better than a CT scan in its ability to differentiate between disease and normal membranes and therefore has a better specificity [13]. Normal-appearing mucous membranes found on endoscopic examination can be spared.

While en bloc resection is usually possible with smaller tumors (Krouse stage I or II), larger tumors usually require sequential segmental endoscopic surgery (Krouse stage III). Tumor debulking with a powered microdebrider may be required to determine tumor origin (Fig. 12.1). A suction trap should be used to collect the specimen for histological determination. Subsequent resections should be tailored to the extent of tumor origin and should provide an adequate margin of surrounding normal mucosa. Complete removal of the intranasal portion of the tumor is performed and the origin of the tumor is identified. A medial maxillectomy is necessary if the tumor originates from the medial maxillary wall or from within the maxillary sinus itself. This assists in the removal of the tumor and also allows easy endoscopic surveillance in the office setting. A wide middle meatal an-

Fig. 12.1. Debulking of tumor using a microdebrider
Fig. 12.2. Inferior extension of antrostomy through the inferior turbinate until the floor of the nose is reached
Fig. 12.4. Remnant medial maxillary wall reflected medially

Fig. 12.3. Anterior cuts in the medial maxillary wall along the floor of the orbit until the anterior maxillary wall is reached tered. In the process, the lacrimal bone with the nasolacrimal duct is transected. All cuts can be made with an osteotome if needed. Occasionally, a lacrimal stent may be used to keep the sac open, but in our experience, most often this step is not necessary.

The freed medial maxillary wall is now only attached anteriorly at the junction between the medial and anterior maxillary walls. It is reflected medially and this anterior attachment is sharply resected (Figs. 12.4, 12.5, Video 12.1). The origin of the tumor is identified using angled endoscopes if necessary (Fig. 12.6) and the tumor is resected. The surgical margins as well as the maxillary sinus are inspected for residual tumor, through this large access to the maxillary sinus that has been created (Fig. 12.7). If needed, residual tumor can be removed from the superior, lateral, inferior, and anterior walls of the maxillary sinus through an accessory antrostomy through the canine fossa. Diseased bone can be drilled away with a cutting burr. If involved, the anterior wall of the sphenoid is resected separately. Figure 12.8 shows the

Fig. 12.5. Resected medial maxillary wall
Anterior Medial Maxillectomy
Fig. 12.6. View of tumor after medial maxillectomy. The tumor originates in the medial-inferior portion of the posterior maxillary wall
Septoplasty Turbinectomy

Fig. 12.7. Tumor is resected and the thin bone of the maxillary wall drilled with a diamond burr

Fig. 12.8. Left nasal cavity 2 years after endoscopic medial maxillectomy for inverted papilloma

Tips and Pearls

■ Complete tumor resection at the site of attachment, preserving healthy tissue, is the key to successful treatment.

■ Most recurrences are thought to develop because of an inadequate resection at the site of origin.

Tumor debulking with a powered microdebrid-er may be required to determine tumor origin. The posterior limit of the resection is the posterior maxillary sinus wall. The surgeon should be mindful of the sphenopalatine artery in this area, and once it has been identified, this vessel should be clipped or cauterized to prevent hemorrhage. If resection involves the nasolacrimal duct, endoscopic dacryocystostomy and stenting may be necessary to prevent postoperative epiphora.

Fig. 12.7. Tumor is resected and the thin bone of the maxillary wall drilled with a diamond burr

Fig. 12.8. Left nasal cavity 2 years after endoscopic medial maxillectomy for inverted papilloma healed maxillary cavity 2 years after endoscopic medial maxillectomy.

The surgical cavity is dressed with hemostatic agents if needed or with nasal hyaluronic acid, especially in the areas of exposed bone.

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