|SYMPOSIUM: HEAD AND NECK
|Year : 2012 | Volume
| Issue : 2 | Page : 209-214
Preservation of palatal mucoperiosteum for oronasal separation after total maxillectomy
Charles Paki Molumi1, Siba Prasad Dubey2, Matupi Lorenzz Apaio3
1 ENT Department, Port Moresby General Hospital, Boroko-Papua New Guinea
2 Department of Ear, Nose Throat, Port Moresby General Hospital and Division Otolaryngology, School of Medicine and Health Sciences, University of Papua New Guinea
3 Department of Oromaxillofacial surgery, Port Moresby General Hospital, Natinal Capital District, Papua New Guinea
|Date of Web Publication||25-Oct-2012|
Charles Paki Molumi
ENT Department, Port Moresby General Hospital, Boroko-Papua New Guinea
Source of Support: None, Conflict of Interest: None
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.
Keywords: Maxillary cancer, oronasal separation, palatal mucoperiosteal flap, temporalis muscle flap, total maxillectomy
|How to cite this article:|
Molumi CP, Dubey SP, Apaio ML. Preservation of palatal mucoperiosteum for oronasal separation after total maxillectomy. Indian J Cancer 2012;49:209-14
| » Introduction|| |
Various open surgical techniques have been described in the literature for resection of advanced paranasal sinus malignant tumors. These techniques include radical maxillectomy, extended radical maxillectomy with orbital exenteration and craniofacial resection. ,, These techniques of surgical resection of malignancy in the sinonasal region leaves defects with exposed dura, brain, nasal and oral cavities that require adequate cover. The aims of reconstruction after tumor resection are to have adequate cranionasal and oronasal separation, restore dental and facial defects, provide cheek and orbit support so that the important functions of vision, deglutition, speech and nasal airway passage are maintained.  Support of the orbit after removal of the maxilla is important to maintain the normal functions of the preserved eye. Various ways of orbital support include the use of pericranial flap, bone grafts and alloplastic implants. For oral separation from the nasal and cranial cavity, regional and free flaps have been used. These procedures carry the complications of flap failure and infection and increase morbidity. Maxillary obturators for oronasal separation are usually made from polymethlymethacrylate and can be made with prosthetic teeth giving good cosmetic appearance. However, it has to be removed and reinserted every time after feeding, and crusting within the maxillary cavity needs regular cleaning. We modified the conventional way of doing maxillectomy by preserving the palatal mucoperiosteum to close off the oral cavity instead of a maxillary obturator. We used a temporalis muscle flap to support the preserved palatal mucoperiosteum and to support the orbit when the eye was preserved after total maxillectomy. In this article we present the usefulness of these modifications of total maxillectomy.
| » Materials and Methods|| |
A comprehensive retrospective review was undertaken in 43 patients with advanced paranasal sinus malignant tumors who underwent open surgery at our hospital from 1995 to 2010. Thirty-one (72%) patients underwent the conventional technique where the palatal mucoperiosteum was included with the resected maxilla and the resultant maxillary cavity closed off with a maxillary obturator, while 12 (28%) were operated by the modified approach. The inferior wall of the maxilla was not involved by the tumor in these 12 cases.
The following were the modifications of the conventional approach for total and extended total maxillectomy. The gingival mucosa of the upper alveolus from the central incisor to the last molar of the involved side was reflected and elevated together with the cheek flap thereby avoiding the loss of mucosa which happens with the standard gingivobuccal incision [Figure 1]a. The palatal mucoperiosteum on the involved side was reflected down to the level of the hard and soft palate junction posteriorly and just beyond the midline medially [Figure 1]b. The elevated gingival mucosa was made continuous with the reflected palatal mucoperiosteum across to the last molar tooth, on the involved side. The greater palatine artery was coagulated and cut in the process.
|Figure 1: (a) Reflected gingival mucosa of upper alveolus from central incisor to last molar; (b) Palatal mucoperiosteum reflected down to level of hard and soft palate junction; (c) Straight osteotome placed between V- shaped notch of anterior nasal spine (d) Palatal halves opened in midline. There is no loss of bone between central incisor teeth; (e) Anterior segment of temporalis muscle sutured to periorbita and remaining frontal process of the maxilla; (f) Temporal defect after anterior segment of temporalis muscle directed to orbit (g) Transposition of posterior segment of temporalis muscle to anterior temporal defect (h) Gingivolabial and palatal mucoperiosteum sutured together with the buccal fat in between|
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In cases where the inferior wall of the maxilla was not involved by the tumor the anterior part of the nasal septum was dislocated from the anterior nasal spine; the midline palatotomy was done by placing a straight osteotome between the arms of a small V-shaped notch located on the anterior nasal spine [Figure 1]c. The osteotome was gently and repeatedly hammered in both the anterior and posterior direction, thus opening the palatal halves in the midline and the osteotome was used to separate them [Figure 1]d. A curved osteotome was placed in the pterygomaxillary fissure with the concavity of the blade facing upwards and hammered to free the pterygomaxillary suture; alternatively, the pterygomaxillary separation was achieved by cutting through the articulation using an oscillating saw and L-shaped saw blade. In this manner the whole maxilla with the nasal bone, ethmoid sinus and pterygoid plates were removed with the specimen.
After the specimen was removed, the full length of the temporalis muscle was raised as described by Shagets et al.  The anterior 40% of the muscle passed under the zygoma or alternatively the zygoma was removed and placed back with miniplate and screws after passing the muscle under it to the defect. It was sutured to the periorbita and to the holes made in the remaining frontal process of the maxilla thereby supporting the orbit when the eye was preserved [Figure 1]e. When the eye was removed, the upper and lower lids (without eye lashes and tarsal plates) were sutured with each other with the anterior part of the muscle in between, and the medial end of the muscle was similarly sutured to the remaining frontal process of the maxilla. The posterior 60% of the temporalis muscle flap was transposed and sutured to the margin of the anterior part of the temporal fossa [Figure 1]f, g. The gingivolabial mucoperiosteum and the palatal mucoperiosteum was sutured with the buccal fat and the inferior end of the temporalis muscle flap in between thereby separating the oral from the nasal cavity [Figure 1]h. The cheek flap was placed back and the standard Weber-Fergusson or Weber-Dieffenbach incision was closed.
| » Results|| |
Among the 43 patients 27 (62.7%) were males and 16 (37.3%) females whose age ranged from 7 to 70 years. Among these, 39 (90.7%) cases involved the maxillary sinus and four (9.3%) the ethmoid sinus. All the cases were Stage T3. Histological diagnosis was squamous cell carcinoma in 29 (67.4%) cases, adenocarcinoma in six (13.5%), adenocystic carcinoma in two (4.6%), and one (2.3%) each of mucoepidermoid carcinoma, fibrosarcoma, rhabdomyosarcoma, malignant fibrous histiocytoma, malignant hemangiopericytoma and spindle cell sarcoma.
Among the 43 cases, the anterolateral wall of the maxilla was breached by the tumor in 38 (88.3%) cases, medial wall in 34 (79.1%), superior wall in 21 (48.8%), posterior wall in 16 (37.2%) and inferior wall in eight (18.6%). The inferior wall was not breached in all the 12 patients who were operated by the modified technique. The pattern of destruction of the walls of the maxillary sinus by the malignant maxillary and ethmoidal sinus tumor in each of the 43 cases is shown in [Figure 2].
|Figure 2: Pattern of destruction of the walls of maxillary sinus in the patients (n= 43), indicating the representation of letters in the pie chart, (a) Medial and anterolateral, (b) Medial, anterolateral, superior and posterior, (c) Medial, anterolateral and superior, (d) Medial, anterolateral, superior, posterior and inferior, (e) Medial, anterolateral and inferior, (f) Anterolateral and superior|
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In the 31 cases those were operated by the conventional technique, total maxillectomy was performed in 13 (33.3%) cases, extended total maxillectomy with orbital exenteration in 12 (30.7%) cases, total maxillectomy with cheek skin excision in four (10.2%) cases and total maxillectomy with orbital exenteration with craniofacial resection in three (7.7%) cases.
In the 13 patients who underwent total maxillectomy, support to the orbit was provided by the anterior segment of the temporalis muscle in six (15.4%) cases, medial rotation of the temporalis muscle insertion with part of the coronoid process in three (7.7%) cases, lateral rotation of the superiorly based septal cartilage mucoperichondrial flap, and free bone graft from the mandibular cortex in two (5.1%) cases each. Cheek flap tip necrosis and consequent medial canthal fistula was seen in four (10.2%) of the 11 cases which had orbital exenteration. In all these cases both eyelids were stitched together. They required a paramedian forehead flap to close the defect.
In four cases with facial skin defects, three (7.7%) radial forearm free flaps and one (2.5%) lattissmus dorsi free flap were used to close the defects. Galeal pericranial flaps were used in all three (7.7%) cases which underwent craniofacial resection. For postoperative ventilation, tracheostomy was required in four (10.2%) cases due to the combined effect of the bulky free flap, edema of soft palate and uvula, surgical packing and obturator. All patients with tracheostomy were decanulated without complications. In 30 (76.9%) patients obturator and subsequently, a palatal prosthesis with dentures were needed to close the palatal defects. In one (2.5%) patient palatal defect was closed with radial forearm free flap. The postoperative complications noted in these 31 operated cases are shown in [Figure 3].
|Figure 3: Post operative complications of conventional total maxillectomy and extended total maxillectomy (n = 31). C = Crusting in cavity, NR = Nasal regurgitation, CSR = Cheek skin retraction, T = Trismus, IDS= Infection of skin graft donor site, CM = Cheek movement during respiration, IFP = Ill fitting prosthesis, MCD = Medial canthal defect, E= Enophthalmos, TFD= Temporal fossa depression|
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The mucoperiosteum over the hard palate was separated from the maxillectomy specimen in 24 (61.5%) patients with total and extended total maxillectomies. These mucoperiosteums were sent for separate histopathological examinations. None of these specimens showed any involvement of the palatal mucoperiosteum by maxillary or ethmoidal malignancy when the hard palate was intact morphologically.
The last 12 patients were operated by the modified approach. Total maxillectomy was done in five (41.6%) cases and extended total maxillectomy with orbital exenteration was done in seven (58.4%) cases. In all these 12 cases the oral cavity was closed off from the nasal cavity by suturing the gingivolabial and palatal mucoperiosteum with the buccal fat in between when the inferior wall (hard palate and alveolar process) was not eroded by the tumor. The orbital floor was reconstructed by the anterior 40% of the temporalis muscle in those cases which underwent total maxillectomy. In those who underwent total maxillectomy with orbital exenteration the muscle was sutured to the upper and lower lids . Nasal endoscopic examination after healing in these eight cases those had the modified approach showed depressed epithelialized area in place of the maxillary sinus. No complications encountered by the conventional techniques were encountered postoperatively in these 12 patients.
| » Discussion|| |
With early detection, endoscopic resection is becoming common with acceptable outcomes in the developed countries.  On the contrary, advanced malignant tumors of the sinonasal tract are still encountered in societies with poorer socioeconomic conditions and with less than adequate healthcare delivery system.  Because of the silent nature of the paranasal sinus malignant tumors, many patients present late at an advanced stage of the disease when open (nonendoscopic) surgical resection becomes mandatory. Traditionally, reconstructive procedures following maxillectomy include skin grafting to line the raw area of the post-excision cavity and palatal prosthesis to maintain oronasal separation. These procedures were performed in 31 cases.
Support of the orbital floor is essential to prevent complications of diplopia, globe malposition, enophthalmos and hypophthalmos. , Ducic and Oxford  used precontoured positioning plates and pericranial flaps. Calvarial bone grafts, alloplastic material and temporoparietal fascia were used by Pollice and Frodel.  Porous polyethylene orbital implants  and Marlex mesh  have also been used with good results. We used anterior segment of the temporalis muscle flap in six cases, part of the coronoid process with temporalis muscle swung medially in three cases, septal mucoperichondrium cartilage flap and bone graft harvested from the outer cortex of the mandible in two cases each to reconstruct the floor of the orbit. Both the septal mucoperichondrial flap and coronoid process with temporalis muscle did not cover the entire area of the orbital floor. On the other hand, it was difficult to maintain the normal curvature of the orbital floor with the free bone graft from the mandibular cortex. We were able to stitch the pliable temporalis muscle to the periorbita to cover the entire orbital floor; at the same time the bulk of the muscle provided the firm support needed by the orbital content. Extensive midfacial skin defects after sinonasal surgery have been reconstructed with better results using free flaps. ,, We also observed similar results in our cases.
In the modified approach the oral cavity was closed off from the surgical cavity by suturing the gingivolabial flap and palatal mucoperiosteum with buccal fat and the inferior end of the temporalis muscle flap in between. We used the buccal fat and inferior end of the temporalis muscle flap to prevent wound breakdown with resultant oronasal fistula. The patients maintained excellent palatal functions of feeding and speech immediately after operation. Konno et al.,  used delayed deltopectoral flap to close the maxillary cavity and reconstruction of the palate. They incorporated a segment of the clavicle to reconstruct the zygoma in extended maxillectomy.  Many used free flaps to close the palatal defects. , While free flaps provide excellent speech and deglutition, the sensation and taste functions of the palate are lost. Moreover, there is color difference between the free flap and the remainder of the palate and the oral cavity mucosa. Funk et al.,  observed hair growth in palatal defects reconstructed by radial forearm free flap which was not comfortable to the patients. By maintaining the palatal mucoperiosteum in the modified approach we did not observe any of these disadvantages [Figure 4].
The use of free flap also has the disadvantage of prolonged operative time, flap failures, complications at donor site, and prolonged hospital stay. With the modification we had less operative time. Small depressions were noted in the nasolabial and adjacent cheek areas due to the missing upper alveolus and teeth; these were corrected by a dental prosthesis with dentures fitted to the contralateral upper jaw thereby giving a normal looking outline of the face. The following accessory procedures during the operation by the conventional approach were avoided by the modification: i) a split-thickness skin grafting of the raw operated area, ii) cavity packing and placement of the dental obturator, iii) occasional tracheostomy to maintain oropharyngeal airway, and iv) a second general anesthesia for removal of surgical pack. Consequently, the modified techniques reduced the morbidity and hospital stay of our patients. None of the 12 patients operated by the modified technique had difficulty of feeding, speech and the postoperative complications encountered in the conventional approach mentioned in [Figure 3]. Tracheostomy to maintain airway with bulky free flaps, surgical-packing and soft palate and uvula edema done by some authors.  We also encountered similar problems in four patients following the conventional techniques; but these were avoided by the modified procedures.
Post-maxillectomy trismus occurs as a result of scar contracture of the masseter muscle, loss of tissue and drying effect in the open cavity, and fracture of the pterygoid processes with resultant spasm of the pterygoid muscles. We observed mild to moderate degree of trismus in nine cases after the conventional maxillectomy. By closing off the open cavity with the modified technique we were able to prevent infection and drying of the masseter muscle. Careful osteotomy at the pterygomaxillary fissure avoided fracture of the pterygoid plate which in turn reduced the postoperative trismus.
Lack of support of the flap in the medial canthus area resulted in cheek flap tip necrosis with medial canthal fistula which was observed in four of our patients who underwent total maxillectomy and orbital exenteration by the conventional approach. They required paramedian forehead flaps to close the defect. Many curve the incision in the medial canthal region forward over the nasal bones for additional support.  We used the anterior segment of the temporalis muscle and sutured it in between the lids and to holes created in the remaining frontal process of the maxilla to provide a bed at the medial canthal area for the flap to sit on in the modified approach. No cheek flap tip necrosis was seen in the patients by this modified approach. Rest of the bulk of the temporalis muscle helped to obliterate the cavity that resulted following removal of the maxilla and the orbit.
Using a giggly or oscillating or reciprocating saw to do midline palatotomy led to the loss of bone between the adjacent medial surfaces of the central incisor teeth thereby leaving the tooth root exposed. Hence, during maxillectomy by conventional approach upper central incisor teeth on either side used to be removed. This resulted in difficulty in anchoring of the prosthesis. Using the modified approach to do the midline palatotomy, the palate split in the midline and at the same time there was no loss of bone between adjacent medial surfaces of the central incisor teeth. Hence, there was no necessity to remove the central incisor tooth of the non-pathological side.
Temporary palatal insufficiency with nasal regurgitation was seen in 16 patients. The pterygoid plates were removed as part of the specimen in these patients. The loss of tension in the mascular sling action of the soft palate by the tensor veli palatine muscle results in soft palate insufficiency.  The tensor veli palatine muscle passes down on the lateral surface of the medial pterygoid plate to end in a tendon which passes round the pterygoid hamulus. We avoided injury to the pterygoid muscles in the modified approach by using a curved osteotome and doing the posterior osteotomy at the pterygomaxillary suture while preserving the pterygoid hamulus in cases where the posterior wall was not eroded by the tumor.
The transposition of the entire temporalis muscle results in a large hollow in the temporal fossa. Rapidis and Day  used prefabricated porous high-density polyethylene (HDPE) to reconstruct the donor site. Due to financial constraints our patients were not able to afford prosthetic implant to improve this cosmetic impairment. For this reason we used buccal fat and preserved the posterior part of the temporalis muscle. The modified technique of traspositioning the posterior 60% of the temporalis muscle flap and suturing to the anterior margin of the temporal fossa avoided the temporal fossa depression. Anterior 40% of the temporalis muscle is nearly equal to the posterior 60% as the fossa is deeper in its anterior part than in the posterior.
The ability to remove the palatal prosthesis during follow-up in the conventional technique allows direct visual access for surveillance of tumor recurrence. Olsen et al.,  closed off the palatal defect with free flap and used routine postoperative computed tomography scan to detect recurrence. They recommend immediate reconstruction of the palate to achieve good function of speech and deglutition as local recurrence would not be managed differently if the defect had been left open.  Malignant tumors of the paranasal sinuses rarely erode the hard palate and involve the palatal mucoperiosteum because i) the hard palate is a very strong bone; ii) a considerable part of the hard palate forms the floor of the nasal cavity than the floor of the maxillary sinus; and iii) once the tumor comes out through the medial wall of the maxillary antrum the malignant tumor expands in the free space of the nasal cavity and postnasal space rather than eroding the nasal floor. In roughly 20% of our cases we found that the inferior wall was eroded by malignant sinus tumor. In the remaining 80% cases the palatal mucoperiosteum was free from any microscopic involvement by the malignancy. Hence, the palatal mucoperiosteum was preserved in the modified approach in cases where the hard palates were intact morphologically. Consequently we achieved oronasal separation by keeping the palatal mucoperiosteum intact and at the same time oncological negative margins were obtained when the ipsilateral hard palate was not eroded.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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