Journal of Medicine Vol 4 - Amrita Institute of Medical Sciences and ...

Amrita Journal of Medicine
Extended Maxillectomy by Transmandibular Approach
(Fig.1, Fig.2), compartmental resection of the infratemporal
fossa is required to obtain for an oncologically sound
resection. This is difficult to obtain using the standard
anterior approaches using Weber-Ferguson or facial degloving
incisions 4,5 . Mandibulotomy approach is a
well-established technique to approach infratemporal
fossa 6 . Herein we report effectiveness in performing extended
maxillectomy with infra-temporal fossa clearance
using mandibulotomy approach.
OBJECTIVE
The objective of this study was to describe the technique
of mandibulotomy approach for excision of maxillary sinus
tumor with extension to the infratemporal fossa as
well as to evaluate the effectiveness and morbidity associated
with the procedure.
MATERIALS AND METHODS
Head and neck oncology database of Amrita Institute of
Medical Science was reviewed to identify all patients who
have undergone maxillectomy during three-year period
from January 2004 to January 2007. Reviewing of the
patient records identified those patients who have undergone
maxillectomy with mandibulotomy approach.
Patient demographics, treatment details and follow up
disease status were obtained from the patient records.
The preoperative imaging studies were reviewed to assess
the extent of tumour. The surgical resection margin was
recorded from the histopathological report. The patients
were recalled to assess morbidity profile using a pre-defined
data sheet. The data point included- patient
complaints, facial scar, complication at the
mandibulotomy site, occlusal disturbances, mouth opening
and disease status.
SURGICAL TECHNIQUE
A midline lip-splitting incision, which was extended to
the neck, was utilized for the procedure (Fig.3). Intraorally,
the mucosal incision from the lower lip was
extended to the alveolus and then to the ipsilateral premolar
region as an inter-dental incision. After pre-adapting
bone plates, a para-median mandibulotomy was performed
at the premolar and canine inter-dental area. Care
is taken to identify and preserve the mental nerve. The
inter-dental incision was then extended posteriorly on
the medial side of mandible to the retro molar region in
Fig.4: Intra-oral incision extended to the upper gingivobuccal
sulcus anteriorly upto the proposed site of palatal
cut. Medial Pterygoid plate divided at its insertion
a sub-periosteal plane. The incision was extended to the
upper gingivo-buccal sulcus and then anteriorly till the
intended site of palatal incision (Fig.4).
Fig.5: Vessel loop around the lingual nerve and the metal
instrument pointing at the inferior alveolar nerve
Fig.3: Midline lip-split incision extending into the neck
The soft tissues are elevated off the medial side of mandible
in a sub-periosteal plane; the medial pterygoid is
divided at its insertion on the mandible (Fig.4). The inferior
alveolar nerve and the lingual nerve are identified
and preserved (Fig.5). Further the lateral pterygoid muscle
is detached from the condyle of the mandible. The stylomandibular
ligament and periosteal attachment at the
posterior boarder of mandible was then released. The
mandible can then be swung laterally to achieve good
exposure of the infratemporal fossa and the middle cranial
base. The internal maxillary artery can be visualized
24