Maxilectomia maxilară medială pentru papilomul inversat

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 maxillectomy.

Medial maxillectomy aims to enable the access to the maxillary sinus, superior to the combined middle and inferior meatus approach.

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 depends 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).
 

The first surgical step includes 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).
 

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).
 

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).
 

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.
 

Final image of the widely opened medial maxillectomy ostium and resorbable sponge applied in the maxillary sinus. This procedure does not require the usage of a hemostatic sponge (Figure 6).
 

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.

The advantages for endoscopic medial maxillectomy include optimal exposure of maxillary and ethmoid sinuses, without the resection of any bony nasal walls, superior visualization of difficult-to-view areas, lower risk of infraorbital nerve paresthesia, lower morbidity and hospitalization, better esthetic outcomes and higher comfort for the patient, as it doesn’t require hemostatic sponges.  

Conflict of interests: The authors declare no conflict of interests.