Carcinoma of the Maxillary Sinus *

ROBERT S. POLLACK, M.D. San Francisco, Calif.

DESPITE THE FACr that cancer of the nasal cavity and paranasal sinuses comprises only 0.2 per cent of all malignant tumors it presents such a vexing and serious problem in diagnosis and treatment that it deserves constant study and re-evaluation. At least 80 per cent of these tumors arise in the maxillary sinus. Due to the anatomy of the region, and the low incidence of malignant disease here, which makes for a low index of suspicion, the majority of cancers of the antrum are seen in a late or moderately advanced stage. The crowded anatomy of this region causes early involvement of orbital and nasal structures, as well as surrounding muscles and bone. Contrariwise, distant metastases are rare and cervical lymph node involvement late. Autopsy studies reveal that not over 25 per cent of patients with antral cancer show spread beyond the local area.3' 5 Death is usually caused by the local effects of the tumor: infection, necrosis, hemorrhage and inanition. In order, therefore, to increase the survival rate of patients with cancer of the maxillary sinus recent emphasis has been placed on treatment which will eradicate the disease locally. Many surgeons and roentgenologists have described their methods, and reported their results.1 6 In great part these have dealt with surgical or radiation experience alone. The present report includes a group of patients in which the maximum in extensive surgical treatment is combined with the highest possible dosage of radiation therapy. Such combined methods appear to be the best means of eradicating the local disease.
* Submitted for publication June

METHOD OF TREATMENT

It had been customary to treat antral cancer initially with irradiation therapy and

5, 1956.
68

follow thereafter with the surgical removal of diseased and necrotic tissue. Such surgical procedures, however, amounted to little more than debridement, and left large areas of necrotic bone and infected spaces improperly drained. Whenever irradiation therapy was used alone surgical drainage always had to be performed later. Initial intensive irradiation increased the necrosis of the bony walls and lining of the antral cavity. When a radium source was used, which was very frequent, large openings had to be made into the antrum in order to insert the applicator. It became apparent that surgery played an integral part in the treatment of this disease, and that the best results appeared to be in those patients where surgical treatment of one kind or another was used, irrespective of the role played by irradiation.2'3 Additional observation of these patients showed that sooner or later an extensive surgical procedure was performed. It seems logical, therefore, for the surgeon to proceed initially with a well planned operation which will allow him to follow the spread of the tumor and specifically determine the areas where he may not have removed all the cancer, as at the cribriform plate, pterygoid muscles or sphenoid sinus. He can then direct the roentgenologist to these special areas, and also present him with a wide open, exposed surface instead of a hidden, bone enclosed cavity. The steps of the operation are shown in Figures I through IV. The initial incision di-

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FIG. 1.

vides the upper lip in the midline and is then continued paranasally and infraorbitally. The gingivobuccal gutter within the mouth is incised, and the cheek dissected free and pulled laterally exposing the maxillary bone (Figure 1). With chisel and mallet the maxillary process is separated from the nose, and the infraorbital ridge divided. The hard palate is split in the midline and separated from the soft palate with a scissors (Fig. I, 3A). The maxillary bone, now free, is lifted out with the gross aspects of the tumor attached, and accurate visualization of the full extent of the cancer can be determined. When cancer extends into the orbit, removal of the eye is a necessity. If, however, the floor of the orbit appears intact, or is only superficially involved, thorough curettement and stripping of the bony floor may be justified in order to save this vital organ. Such a

decision is a matter of surgical judgment, in the majority of instances made easy by the frank invasion of orbital contents. When this is the case the incision is carried around the orbit and its contents swept downward
and removed en bloc (Fig. 2, 6). With the major portion of the tumor and bony structures removed secondary trimming and resection of the nasal bones, nasoantral wall, ethmoid and sphenoid sinuses and the posterior wall (pterygoid plate) can be easily performed (Fig. 3, a through d). On completion of these maneuvers one leaves a wide open, clean cavity without overhanging edges or pockets. At this point a free split thickness skin graft may be taken (usually an entire Padgett dermatome size) and placed over the raw inner surface of the cheek and bony prominences. Suitable, tight, dry, petrolatum gauze packing filling the cavity and placed on top

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Annals of Surgery January 1957

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CARCINOMA OF THE MAXILLARY SINUS

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of the graft acts as an excellent stint. The cheek flap is then replaced, and the mucosa of the upper lip and skin margins sutured (Fig. 4, 9 and 10). A nasogastric feeding tube is used for postoperative nutrition until a suitable dental prosthesis can be made which covers the oral defect. This is frequently only a matter of several days. Many patients learn to swallow satisfactorily with the one remaining side of the hard palate. When a graft has been placed within the cavity the packing or stint is removed in about a week. Otherwise, the packing is removed and a clean one reinserted within four or five days. Early ambulation and antibiotics are essential for rapid convalescence.
ROENTGEN THERAPY

graft, and for this is not practiced. Radiation is given by many and devious methods, but is concentrated in the questionable areas as determined by the surgeon at operation. Multiple biopsies of these areas, taken during the operation, aid materially in directing accurate therapy. In general, radium (or cobalt 60) plaques, moulages or interstitial needles are used locally with x-ray therapy externally across the cheek to "homogenize" the dosage. Radiation is given to the limit of tolerance whether gross evidence of tumor is present or not. With open, flat surfaces within the cavity infection and necrosis has not been a problem, and recovery from therapy has been rapid with little increased morbidity.
ANALYSIS OF DATA AND RESULTS

cause separation of the reason routine grafting

As soon as satisfactory healing has taken place irradiation therapy is started. In patients in whom a graft has been inserted this may not be for two or three weeks. Heavy irradiation through a large port may

There are 31 patients in the present series, of which seven were females. They were operated upon at Stanford University Hospital and Mt. Zion Hospital in San

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Annals of Surgery January 1957

FIG. 6. Postoperative view with orbital patch of patient who had a resection of maxilla and exenteration of orbit.

years). Three additional patients are alive with disease (one to three years) and two
FIG. 5. Postoperative view of patient who had bilateral resection of the maxillary bones and nasal vestibule. The incision was identical on each side. The major portion of the hard palate was preserved on the right.

Francisco, and at the Veteran's Administration Hospital in Oakland, California. The patients ages ranged from a boy of three with a malignant teratoma, to an aged
woman

of 78 with a not unusual epidermoid

carcinoma. The histologic types of tumors were: epidermoid carcinomas 19; adenocarcinomas 6; adamantinomas 2; fibrosarcoma 1; melanoma 1; hemangioendothelioma 1; and malignant teratoma 1. Fifteen patients had some previous form of therapy, mostly x-ray treatments. In 22 the stage of disease was estimated to be advanced as judged by the size of the tumor, its degree of invasion, the involvement of surrounding structures, the general physical condition of the patient, and the duration of the disease. Thirteen of the 31 patients are alive and well, showing no evidence of disease be+ween one and five years (seven over three

patients died of another cause, each free of after one year. There was one operative death, a cerebrovascular hemorrhage in a 78-year -old woman. Of the 12 patients who died of cancer three died after three years, and one after two years; the rest within 18 months. Despite the small number of cases, and the difficulty in arriving at a survival figure, the results suggest an over-all improvement in the treatment of this difficult group of patients. This seems especially so in view of the large number of advanced cases. Included in the surviving group are patients who were deemed by some to be hopeless and not candidates for an extensive operation. In those who died of disease the palliation alone in removing infected, necrotic structures was worthwhile. During the early part of this study postoperative irradiation was given only to those patients who had proven residual disease. However, as more and more patients with advanced cancers were operated upon and followed the supplemental use of radiation became a necessity. For
cancer

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this reason its use postoperatively in all but the early tumors, or the frankly resistant ones, is recommended.
SUMMARY

1. Cancer of the nasal cavity and paranasal sinuses comprise about 0.2 per cent of all malignant tumors. At least 80 per cent of these lesions arise in the maxillary sinus. 2. The majority of patients with antral cancer are seen in an advanced stage of the disease. This makes the primary tumor a difficult therapeutic problem. However, distant metastases are rare. 3. A method of treatment is described combining the maximum in surgical resection with the highest possible dosage of irradiation. 4. The operation is planned so that the surgeon can follow the spread of the tumor and resect it along with necrotic tissues and infected bone. This leaves a wide open, flat cavity without undrained purulent pockets. The roentgenologist is then directed by the surgeon to specific areas where residual disease may be present.

5. Thirty-one patients form the basis of this report. The majority of tumors were of the epidermoid type. In 22, the stage of disease was judged to be advanced. Of the total group, 13 show no evidence of disease between one and five years after operation; seven over three years. 6. The use of postoperative irradiation is recommended in the advanced cases. It is not used in the frankly radioresistant tumors.
BIBLIOGRAPHY

1. Cade, Sir S.: Malignant Disease and Its Treatment by Radium. Vol. II. John Wright & Sons, Ltd., 194-223, 1949. 2. Collins, V. P. and J. L. Pool: Treatment of Antral Cancer by Combined Surgery and Radium Therapy. Radiology, 55: 41, 1950. 3. Perzik, S. L.: Management of Cancer of Nasal Cavity and Paranasal Sinuses. California Med., 74: 374, 1951. 4. Phillips, J. W.: Antral Carcinoma Treatment. Pacific Coast Oto-Ophth. Soc., 29: 197, 1948. 5. Seelig, C. A.: Carcinoma of Antrum. Ann. Otol., Rhin. & Laryng., 58: 168, 1949. 6. Windeyer, B. W.: Malignant Tumors of Upper Jaw; Skinner Lecture, 1943. Brit. Joum. Rad., 16: 362, 1943; 17: 18, 1944.

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