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 Subtotal Maxillectomy ENT Operative Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:  Mucoepidermoid carcinoma of the left maxilla and hard palate.

POSTOPERATIVE DIAGNOSIS:  Mucoepidermoid carcinoma of the left maxilla and hard palate.

OPERATION PERFORMED:  Subtotal maxillectomy, left 

SURGEON:  John Doe, MD

ANESTHESIA:  General and local, 10 mL of 1% Xylocaine with 1:100,000 epinephrine.

ESTIMATED BLOOD LOSS:  Approximately 350 mL.

COMPLICATIONS:  None.

DISPOSITION:  Postoperatively, the patient was taken to the PACU in stable condition.

DESCRIPTION OF OPERATION:  After the patient was identified and marked for the proper side as well as potential for Weber-Fergusson incision, the patient was taken to the operating room and placed on the operating room stable in a flat supine position. The members of the anesthesiology service were present for monitoring as well as administration of the anesthesia. After discussion, the patient was intubated using an oral endotracheal tube that was taped off to the right side for adequate exposure. Once the patient was adequately anesthetized, the patient was placed in a semi-seated reverse Trendelenburg position. Local was infiltrated intranasally along the buccogingival sulcus along the anticipated incision of the hard palate and along the gingiva on the left side. A sphenopalatine block was not able to be performed due to the presence of the mass in the region of the greater palatine foramen. Neo-Synephrine was applied intranasally preoperatively. IV Decadron and IV antibiotics were administered as well in the preoperative period. Neo-Synephrine-impregnated cottonoids were placed in the left nasal cavity and allowed to take effect. In the region of the sphenopalatine foramen, local was infiltrated using a spinal needle as well as the anterior and posterior attachment of the inferior turbinates. Betadine prep was completed. Oral Betadine prep and suctioning was completed. The patient was thoroughly prepped and draped in the routine fashion.  Lubricating jelly and corneal protectors were applied and a left tarsorrhaphy suture was applied. On the second stitch, there was a small hematoma that developed in the upper lid, the suture was removed and pressure was applied. The suture was not left in place. Palpation of the mass intraorally revealed that this extended just inferior to the hard palate to just posterior to the tooth #13 in the coronal plane. It did not extend over the midline but within half a centimeter. Photo documentation was taken. A vestibular incision over the previous incision leaving an adequate cuff of tissue on the gingival border was completed just lateral to the nasal septal spine and carried to the 13th tooth where the incision was carried down to the gingival dental border. The soft tissue was elevated off the maxilla following superiorly on the nasomaxillary buttress and then along the alveolar bone and then superiorly to the zygomatic arch preserving the infraorbital neurovascular bundle. There was significant granulation tissue adherent from the previous Caldwell-Luc procedure. This was taken off the soft tissue of the cheek as it was elevated fully. The tissue was collected and sent with the remainder of the granulation tissue that had essentially sealed the previous Caldwell-Luc, collected and sent to pathology separately.  Endoscopic evaluation was completed of the maxilla and the borders of the tumor was identified. The gingiva was elevated off the maxilla along the labial aspect, as this was uninvolved with tumor to the most posterior to lateral aspect of the maxilla. Then, the wound was carried superiorly, including the soft tissue along the posterior aspect with the specimen. A #15 blade was employed and incision was made in the mid portion of the 13th tooth, carried in a curvilinear fashion to essentially the middle line of the hard palate and then carried posteriorly and then onto the soft palate taking a cuff of tissue around the palpable mass onto the soft palate. The hamulus was not dissected. The velopharyngeal muscles of the soft palate were left intact. The incision was initially carried inferiorly; however, with additional palpation, this incision was modified more superiorly and carried laterally and then onto the retromolar trigone region, carried minimally onto the buccal mucosa where there was some herniation of the buccal fat pad. This was then carried superiorly to meet the previously described incision along the posterior alveolar ridge. The gingival mucosa was elevated. The tissue was elevated along the hard palate as well without disruption of the tumor itself. Stryker saws using various blades and angles were employed and incision was made along the zygomaticomaxillary buttress immediately superior to the root and to the tumor as visualized. An additional incision through the hard palate/maxillary floor was completed and carried posteriorly. Chisel mallet was employed as well. The soft tissues were dissected both directly as well as with endoscopic view to circumferentially excise the tumor. The posterior wall was taken down. There was a fracture along the posterior superior aspect of the bone despite chisel mallet, drill and saw dissection. The specimen was collected. The pathology service was asked to attend in the operating room. Suspicious in the posterior, superior and medial aspect of gross tumor present. This was confirmed on frozen section. In this region, there was a fragmented bone. Additional margins were taken and were positive in the posterior and superior aspect. The inferior and posterior aspects were all reported negative. We have requested additional evaluation of mucosal borders which were all reported to be negative on evaluation of the margins. The additional posterior and superior bone and soft tissue was taken down. This became fragmented and we were not able to excise this portion en bloc. Once this was excised, there was no gross tumor left in place. We suspected that the tumor was removed at that juncture. Additional posterior and superior margins were taken and those returned as negative for tumor. There were some inflammatory changes identified however. During the course of the dissection, clips were applied to venous bleeders. Bipolar cauterization was able to be employed for hemostasis of the anterior, posterior and superior alveolar blood vessels as well as the branches from the sphenopalatine artery. Ultimately, the hamulus was left intact. There was a palpable firmness to the arch of the soft palate, much of the muscular structure inferior to the hamulus was intact. Dissection was carried along the nasal septum, including the inferior aspect of the lateral nasal wall extending from the anterior one-third of the inferior turbinate to the posterior wall of the maxilla. The inferior turbinate attachment to the lateral nasal wall was secured, and therefore, the middle turbinate was not excised, discussed with the patient preoperatively there may be issues related to nasal respiration. There is already some deflection of the septum appreciated. At a later juncture, an inferior turbinectomy may ultimately be undertaken; however, with the resection undertaken, it is hoped that the patient will have adequate nasal function. The nasolacrimal duct apparatus in fact was left intact, dissection into the piriform aperture was not required for excision of the tumor anteriorly; therefore, a dacryocystorhinostomy was not undertaken. Additional hemostasis was obtained using bipolar cautery. Copious irrigation and suction was completed once negative margins were obtained. We removed much of the posterior wall of the maxilla, all of the inferior aspect of the maxilla and lateral aspect of the maxilla leaving the anteromedial aspect that was uninvolved with the tumor in place. This allowed for left additional dentition anteriorly in place and allowed us to maintain the patient's nasal base proportions.  Certainly, there may be some shifting because of the elevation of the soft tissue and disruption of the facial musculature and absence of the facial bones as the patient was made aware preoperatively. Gauze was used to pack the maxillary sinus while we waited for the frozen sections. This allowed for additional hemostasis. The mucosal lining of the maxilla was taken down and approximated to the dissection. A dermal graft was not harvested. Preoperatively, the patient requested that we avoid skin grafting as much as possible. There was a small laceration encountered in the lateral aspect of the middle and third of the inferior turbinate. This was cauterized and bleeding was controlled. This did not disturb the structure of the inferior turbinate as noted above and was completed during the course of cutting through the soft tissue of the maxilla during the resection portion of the procedure. Gelfoam was applied to the remaining sinus passage. Vaseline gauze with overlying iodoform gauze was applied and packed within the sinus. Silk suture was used to maintain the gauze in the maxillary sinus. A single strip was brought through the mouth and taped to the cheek. At the conclusion, there was no active bleeding encountered. Once again, at the conclusion of the procedure, as best could be determined grossly, there was no residual tumor identified. Frozen sections supported our clinical evaluation intraoperatively. The patient, however, is aware of the need for continued surveillance and potential for recurrence. Blood loss was followed during the course of the procedure and at the conclusion amounted to approximated 350 mL. Significant amount of irrigation was employed. Urine output was as noted. SCD boots were applied and operational prior to induction and were used throughout the course of the procedure. Once the procedure was completed, the table was flattened. The patient was awakened and extubated and then taken to the recovery room in stable condition. The patient will be observed in the intensive care unit because of the risks of placement of the maxillary packing. Anesthesiology was requested to initiate the PCA and that has been completed. We will continue the patient on IV antibiotics as well as IV Decadron. At the conclusion of the procedure, the corneal protector and tarsorrhaphy suture was removed. 

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