|Year : 2018 | Volume
| Issue : 1 | Page : 32-37
Maxillectomy: Indications and outcome at a tertiary hospital in Nigeria – A review of 113 cases
Timothy O Aladelusi1, Segun A Ogunkeyede2, Victor I Akinmoladun1
1 Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
2 Department of Otorhinolaryngology, College of Medicine, University of Ibadan, Ibadan, Nigeria
|Date of Web Publication||14-Mar-2019|
Dr. Timothy O Aladelusi
Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ibadan, Ibadan
Source of Support: None, Conflict of Interest: None
Background: Maxillectomy is the surgical procedure often indicated for the management of tumours and some non-neoplastic conditions arising from or involving the maxilla. This procedure is associated with significant functional and aesthetic deficits with concomitant psychological effect. The aim of this study is to evaluate maxillectomies carried out in our facility over a 16-year period.
Patients and Methods: This is a retrospective study of cases of maxillectomy carried out in the Departments of Oral and Maxillofacial Surgery and the Ear, Nose and Throat (ENT) of our hospital from 2000–2016. The clinical data retrieved from the records of patients included age, gender, presentation, site of lesion, surgical intervention and rehabilitation options.
Results: A total of 113 maxillectomies were performed in 52 males and 61 females. The age range was 13–82 years with a mean age of 37.4 ± 16.1 years. Majority of participants are of a low-socioeconomic status. The mean duration of symptoms before presentation was 12.4 months. Malignant lesion (59/113) accounted for the majority of cases seen. Total maxillectomy was the most frequent procedure (53.1%). Recurrence was seen in 20.4% of all cases. Major limitations to therapeutic intervention were lack of fund and late presentation.
Conclusion: Delay in presentation and lack of fund remains the main challenges in the management of sinonasal tumours. Management of the maxillectomy defect remains largely limited to rehabilitation with an obturator in our environment.
Keywords: Maxillectomy, rehabilitation, sinonasal malignancy
|How to cite this article:|
Aladelusi TO, Ogunkeyede SA, Akinmoladun VI. Maxillectomy: Indications and outcome at a tertiary hospital in Nigeria – A review of 113 cases. Arch Int Surg 2018;8:32-7
|How to cite this URL:|
Aladelusi TO, Ogunkeyede SA, Akinmoladun VI. Maxillectomy: Indications and outcome at a tertiary hospital in Nigeria – A review of 113 cases. Arch Int Surg [serial online] 2018 [cited 2019 May 23];8:32-7. Available from: http://www.archintsurg.org/text.asp?2018/8/1/32/254145
| Introduction|| |
The two maxillae are the most important bones of the midface and form the central component of the midface articulating with the other bones to give the height and projection of the face. Apart from its obvious aesthetic role, the maxilla serves important functions in mastication, phonation, breathing and in providing support for the contents of the orbit., Maxillectomy is indicated for surgical excision of tumours arising from or involving the maxilla. Tumours involving the maxillary sinus may either be benign or malignant and may arise from varied origin. Maxillectomy is often employed in the management of face disfiguring benign tumours and non-neoplastic conditions like invasive fungal sinusitis. The most common malignancy requiring maxillectomy is squamous cell carcinoma, although a wide variety of other malignancies including sarcoma and adenoid cystic carcinoma may also be encountered., The management of a maxillectomy patient is multidisciplinary involving the maxillofacial surgeon, otolaryngologists, radio-oncologist, reconstructive surgeon, prosthodontist, speech pathologists and clinical psychologist; depending on the extent of the surgery.
The aim of this study is to audit maxillectomy in our centre vis-a-vis indication/disease presentation, types of surgery, outcome of diseases and intervention.
| Patients and Method|| |
This is a retrospective study of patients who had maxillectomy procedures conducted at a tertiary hospital in the South-western Nigeria consisting of patients seen in the Oral and Maxillofacial Surgery and the Ear, Nose and Throat (ENT) Departments, over a 16 year period (2000 – 2016). Data were obtained from both departments, as cases were managed in either of them. The clinical data retrieved from the records of patients included age, gender, socioeconomic status, clinical presentation, duration of symptoms before presentation, site of lesion, surgical intervention and complications. Challenges associated with the procedure and surgical outcomes were also recorded. Data were analysed with the SPSS statistical software.
| Results|| |
A total of 113 maxillectomy procedures performed in 52 males and 61 females had adequate record for analysis. The age range was 13–82 years with a mean age of 37.4 ± 16.1 years [Table 1]. The mean age of patients that presented with malignant disease was 43.45 ± 14.8 (range 13–68) compared to 30.9 ± 14.8 (range 14–82) that presented with benign disease, this difference is however not statistically significant (P = 0.66). Majority (75.2%) of participants are categorised as being from a low-socioeconomic status based on academic qualification and family gross income [Figure 1].
The mean duration of symptoms before presentation was 12.4 months but ranged from 1–96 months with malignant lesions presenting earlier at 7.2 (±4.5) months while the mean duration of presentation for benign lesions was 19.1 (±19.9) months (P = 0.001). The commonest primary complaints were facial swelling, pain and bleeding and were present in 85.0%, 40.7% and 21.2% of the patients, respectively [Table 2].
[Table 3] shows the distribution of the indication for maxillectomy in our centre. Malignant lesion (59/113) accounted for the majority of cases seen within the study period; squamous cell carcinoma (25) and adenocystic carcinoma (20) being over 40% of indication for maxillectomy procedures. About 54% of the maxillectomy procedure was carried out on the right, while the left accounted for 42.0% of the procedures and 4.0% of cases involved the maxilla bilaterally. Weber-Fergusson incision was the most commonly used approach to the maxillae and was employed in 86 patients while intraoral access was adequate for tumour exposure in 19 patients. Total maxillectomy was the most frequent procedure (53.1%), while 10 patients required extended maxillectomy [Figure 2].
The main factors influencing outcome of management were lack of fund and late presentation.
| Discussion|| |
Maxillectomy, the surgical removal of a part or the whole of the maxilla as treatment for a maxillary neoplasm, is a procedure that results in a defect that can significantly affect function, aesthetics and the individual's overall well-being.
This study reports more cases of maxillectomy than previous Nigerian studies, as it reviews 113 cases compared to previous reports of Eziyi et al. and Fomete et al. of 11 and 66 cases, respectively. This may be due to the fact that data had been acquired from the two specialities involved with the conditions treated by maxillectomy in a major tertiary institution. We observed that there were more female patients requiring maxillectomy in this study than males. This is similar to the findings of Eziyi et al. and Baliarsing et al. who reported higher affectation of female patients. This is, however, at variance with the observations of Fomete et al., Mazlina et al. and Souza et al. who observed more males in their studies. No reason can be advanced for these gender differences.
The overall mean age in this study is similar to those of previous Nigerian studies., When stratified for disease type, we noted that patient with malignant disease presented at an older age, compared to those with benign lesions. The mean age for presentation of malignant disease seen in this study is much less than that reported in previous studies from Nigeria,, and other parts of the world., Fomete et al. opined that this lower mean age in Nigerian study may be a reflection of the low average life expectancy in Nigeria. We, however, suspect a lowering in mean age that may be related to earlier exposure to the risk factors for sinonasal malignancies. It is therefore important to research factors responsible for increasing incidence of sinonasal malignancies in people <50 years in Nigeria.
Previous reports have given varying incidence of maxillectomy procedures on the right and the left,,, however, the factors responsible for side affectation are not known as the reports are equivocal. Although, we performed more maxillectomy procedures on the right than on the left, similar to Ogunlewe et al. and in contrast to Eziyi et al. and Fomete et al., the difference in side affectation is marginal.
The most common indication for maxillectomy in this study was malignant lesions affecting the maxillary sinus. Malignant tumours of the maxillary sinus are rare accounting for <3% of the head and neck cancers and 0.5% of all malignant diseases. The annual incidence of maxillary sinus cancer is 0.5–1.0 cases per 100,000 of the population worldwide. However, they are the most common malignancies of the anterior base of skull and they constitute a significant cause of morbidity and mortality worldwide.,, Because of the concealment of the sinus, malignancies in this site usually progress with minimal symptoms until an advanced stage with considerable involvement of the contiguous tissue. Symptoms related to the affectation of these structures often inform seeking help, therefore, majority of the patients present with late stage disease. This was evident in this study as the mean duration of symptoms was >12 months with some patients presenting as late as 96 months after the onset of symptoms. This may also be due to low level of awareness in the populace. However, these tumours present both diagnostic and therapeutic dilemma requiring a high index of suspicion for diagnosis at the early stage, this level of competence may also not be available especially at the primary healthcare facilities where patient often present with poorly defined symptoms and basic imaging modalities are usually unavailable. The most common primary complaint at presentation was facial swelling, pain and bleeding. These were similar to previous reports.,,, The non-aesthetic acceptance and appearance of the facial swelling appears to be the major prompt that get the patient to seek intervention [Figure 3].
|Figure 3: Clinical photographs of patients with obvious facial swelling prior to presentation. (a) Adenocarcinoma (b and d) SCC, (c) Fibromyxoma|
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The extent of maxillary resection is dependent on the pathological nature of the tumour, site of the maxilla involved and the involved adjacent structures. Hemi-maxillectomy has been reported as the most commonly performed surgical procedures for patients with maxillary antral pathologies.,, We found a similar result in the present study with more than half of the participants requiring hemi-maxillectomy. However, close to 10% of the patients in our study required extended maxillectomy due to an advanced disease.
Lateral rhinotomy, Weber-Fergusson approach and its modifications constitute the classical approach to the midfacial skeleton and were the favoured approaches in this study. These conventional approaches are transcutaneous and crosses the superficial muscle-aponeurotic layer and the facial muscles. Complications of these incisions include formation of scar tissue in the facial zones of high social significance. Furthermore, ectropion and lower eyelid lymphoedema may occur. To alleviate these complications, Dikarev et al. reported the combined transoral–transconjunctival approach for tumour resection in the midface which promises good aesthetic outcome. This approach is, however, inappropriate in cases of extended maxillectomy as seen in many of our patients.
Surgical resection of benign or malignant neoplasms of the maxilla often results in a defect that lead to functional and psychological impairments. Open communication between the oral and nasal cavities may be accompanied by hypernasal speech, low speech intelligibility, nasal regurgitation of food and liquids, inability to masticate and facial disfigurement. Consequently, social behaviour and quality of life (QoL) may be adversely affected., In the present study, a maxillary prosthesis is provided for majority of the patient to occlude the defect in the area of resection, thereby restoring masticatory efficiency, swallowing, speech and aesthetics. Generally, using an obturator prosthesis to rehabilitate patients after a maxillectomy is still regarded as a good treatment option because it offers immediate rehabilitation along with the feasibility of examining the surgical site for timely detection of tumour recurrence. Prosthetic rehabilitation of patients with limited maxillectomy and an open defect could enhance the restoration of their masticatory function and general oral health-related QoL (OHRQoL) to a level comparable with that of patients with a closed defect. Most of our patient reported improved functional outcome with the use of prosthesis [Figure 4].
|Figure 4: Clinical photograph showing pre (b and d) and post (a and c) prosthetic rehabilitation of maxillectomy defects|
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Postoperatively, it is important to reconstruct the maxillary defects and restore oronasal functions and facial contour. Midface defects represent some of the most challenging defects for reconstructive microsurgeons. Tumour extirpation may include the palate with the alveolar ridge, the maxillary sinus and, in some circumstances, the orbit, cheek skin, lips and nose. While some defects can be adequately treated with an obturator or prosthesis, many defects require advanced microsurgical skills to achieve the optimal result.,, Complete midfacial restoration mandates a multi-disciplinary team approach including the head and neck surgeon, prosthodontist, speech and swallowing therapist. While the required specialties exist in many settings; it is noteworthy that such a team is unavailable in many centres at present, including ours.
A number of different classification systems of maxillectomy defects exist that can help guide reconstruction; however, the basic premises are founded on maintaining adequate midfacial projection, restoring normal dental occlusion, obliterating dead space, preserving baseline visual acuity and providing coverage for vital structures.
Reconstruction with a flap can potentially overcome the problems associated with prosthetic obturators, particularly nasal leakage and the need to clean and repeatedly refine the obturator. Various flaps have been advocated, most commonly the osteocutaneous scapular, iliac crest and fibular flaps; and the fasciocutaneous radial forearm and anterolateral thigh flaps. There is, however, an appreciable potential morbidity for patients in undertaking free flaps in terms of both the donor site, the potential for failure and the increased anaesthetic time and duration of hospital stay.
Varying factors affect the outcome of this disease worldwide. In our environment, the interplay of factors like poor awareness of symptoms, late patient presentation, inaccessible health facilities, limited diagnostic/therapeutic modalities and high cost of treatment contribute to poor outcome in the management of patients with the head and neck malignancies., The commonest challenges encountered during the management of our patients include limited or unavailable diagnostic and treatment facilities and the inability of the patients to afford the cost of investigations and treatment. From this observation, it is believed that if the government improves on healthcare funding by equipping cancer centres with modern facilities, increase coverage of the National Health Insurance Scheme and incorporate cancer treatment into basic healthcare services; many more patients will have an access to better resources, diagnostic tests, treatment and, therefore, better prognosis and outcome. Oral healthcare providers should also intensify surveillance and awareness of sinonasal tumours.
| Conclusion|| |
Delay in presentation and lack of fund remains the main challenges in the management of sinonasal tumours, majority of which are malignant. Management of the maxillectomy defect remains largely limited to rehabilitation with an obturator in our environment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]