Surgical management of maxillary sinus tumors in a secondary healthcare facility in Nigeria

Olurotimi Clement Olojede; Olawale Olatunbosun Adamson; Olalekan Micah Gbotolorun; Mubarak Mobolanle Emmanuel; Sunday A. Babatunde Oluseye

doi:10.4103/jcls.jcls_47_16

ORIGINAL RESEARCH REPORT

Year : 2018 | Volume : 15 | Issue : 3 | Page : 140-144

Surgical management of maxillary sinus tumors in a secondary healthcare facility in Nigeria

Olurotimi Clement Olojede¹, Olawale Olatunbosun Adamson¹, Olalekan Micah Gbotolorun¹, Mubarak Mobolanle Emmanuel², Sunday A. Babatunde Oluseye³
¹ Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos, Lagos, Nigeria
² Department of Oral Pathology, College of Medicine, Lagos State University, Lagos, Nigeria
³ Oral and Maxillofacial Surgery Unit, General Hospital Lagos, Lagos, Nigeria

Date of Web Publication

1-Nov-2018

Correspondence Address:
Dr. Olurotimi Clement Olojede
Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos, Logos
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcls.jcls_47_16

Abstract

Aim: The aim of this study is to analyze the surgically managed maxillary sinus tumors presenting in General Hospital, Lagos, Nigeria. Methods: Review of cases seen at the General Hospital, Lagos, in 10 years. Data were obtained from the patients' case notes. The biodata investigations done, diagnosis and treatment were recorded. Results: A total of 16 patients were treated with maxillary sinus tumors. There were nine males and seven females. Ages range from 6 to 72 years with the mean age of 44.3 years. There are 10 benign tumors and six malignant tumors in the study. The most common tumor is squamous cell carcinoma of the maxillary antrum represent 25% of maxillary tumors seen in this study. Conclusion: Maxillary sinus tumors represent a common group of neoplasm in the oral cavity. It poses a diagnostic and therapeutic difficulty to clinician due to the late presentation and proximity to vital structures such as the eyes and base of the skull. Maxillectomy with preservation of floor of the orbit is a safe procedure even for malignant lesions not involving the orbit.

Keywords: Healthcare, maxillary, sinus, surgical management, tumor

How to cite this article:
Olojede OC, Adamson OO, Gbotolorun OM, Emmanuel MM, Oluseye SA. Surgical management of maxillary sinus tumors in a secondary healthcare facility in Nigeria. J Clin Sci 2018;15:140-4

How to cite this URL:
Olojede OC, Adamson OO, Gbotolorun OM, Emmanuel MM, Oluseye SA. Surgical management of maxillary sinus tumors in a secondary healthcare facility in Nigeria. J Clin Sci [serial online] 2018 [cited 2023 Jun 9];15:140-4. Available from: https://www.jcsjournal.org/text.asp?2018/15/3/140/244745

Introduction

Tumors originating in the maxillary sinus are relatively rare.^[1] Malignant tumors of the maxillary sinus are rare neoplasms that account for approximately 3% of head-and-neck cancers and 0.5% of all malignant diseases.^[1],[2] The annual incidence of maxillary sinus cancer is 0.5–1.0 case per 100,000 of the population. Squamous cell carcinoma is the most common histologic type, accounting for approximately 70%–80% of the cancers.^[1] Head-and-neck cancer, predominantly head-and-neck squamous cell carcinoma, is the sixth most common cancer, with a mortality rate of approximately 50%.^[3] The other histologic types of maxillary sinus cancer include adenoid cystic carcinomas, adenocarcinomas, mucoepidermoid carcinomas, sarcomas, and lymphomas. Smoking and histories of chronic sinusitis are the most common risk factors for maxillary sinus cancer.^[4]

Most patients with maxillary sinus cancer have no symptoms in the early stage, and therefore, many of these patients are diagnosed in the advanced stage of the disease.^[5]. This is because the antrum is a closed bony space not easily assessable. Thus, any tumor would have grown to a considerable size before it affects adjacent structures. The complexity of the anatomy and the proximity of the eyes, brain, and cranial nerves renders complete surgical resection difficult, which leads to local recurrence, a major cause of treatment failure.^[6]. The other issues pertaining to maxillary sinus cancer include the functional aspects of eyesight and the cosmetic aspects of facial contours, which make patients avoid surgical resection.^[7]

Maxillary antral malignancies are very difficult tumors to treat and traditionally have been associated with a poor prognosis. One reason for these poor outcomes is the close anatomic proximity of the nasal cavity and paranasal sinuses to vital structures such as the skull base, brain, orbit, and carotid artery.^[1],[5]

The purpose of this article was to review our experience with maxillary sinus tumors and to evaluate the results of treatment and rehabilitation of the patients that were managed in our hospital. It is a retrospective study of surgical management of maxillary tumors seen in secondary healthcare facilities in Lagos, Nigeria.

Methods

This is a retrospective review of cases seen at the General Hospital, Lagos, in a period of 10 years (2002–2011). Data were obtained from the patients' case notes. The biodata investigations were done, diagnosis and treatment were recorded.

Study design

This was a retrospective study of cases done in a period of 10 years.

Study setting

The study was done in the Oral and Maxillofacial Surgery Unit, of General Hospital, Lagos Island, Lagos, Nigeria.

Protocol

Case notes of patients with maxillary sinus tumors were retrieved and only those with final histology were analyzed. The biodata of the patients were recorded and this includes the age, sex, and ethnic group.

The presenting complaints were also recorded which include swelling, pain, and nasal congestion. The outcome of the physical examination was also recorded. This includes the extent of the swelling and other associated symptoms such as ocular symptoms, inability to move the mouth, and mobility of teeth. The result of imaging studies taken was recorded, which was computed tomography (CT) scan. The result of initial histologic diagnosis was noted after the biopsy. Records of the treatment received were noted, and the postoperative rehabilitation and radiotherapy if needed were also recorded.

Results

A total of 16 patients were treated with maxillary sinus tumors. There were nine males and seven females. Ages range from 6 to 72 years with the mean age of 44.3 years. There are 10 benign tumors and six malignant sinus tumors in the study. The most common tumor is squamous cell carcinoma of the maxillary sinus which represents 25% of maxillary tumors seen in this study [Table 1].

Table 1: The biodata, diagnosis, and treatment(s) received by the patients in the study

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Symptoms initially included nasal obstruction, epistaxis, pain, and episodes of sinusitis. In all patients, tumor expansion inferiorly toward the oral cavity was associated with swelling of the gingiva or palate with loose teeth, while no patient had orbital invasion leading to ocular symptoms such as proptosis, diplopia, decreased acuity, and restriction of ocular movement. The most benign lesions present with painless swelling with associated nasal congestion with esthetics being their major concern; however, malignant lesions present with swelling with the associated mobility of teeth, ulceration, and pain in some cases.

CT scan was imaging technique used on all the cases. Benign lesions usually show well-defined borders which may be mixed density to hyperdense mass; however, malignant lesions always show infiltrative pattern of surrounding bony structures without definite border, and most lesions were hypodense.

Once the site of the tumor was identified, tissue diagnosis was required. A fundamental principle was to obtain representative tissue by the least invasive method possible. A biopsy was obtained using buccal vestibular incisions for tumors extending into the oral cavity or Caldwell-Luc antrostomy for tumors limited to the maxillary antrum.

Treatment of all cases was by maxillectomy using Trotter–Weber–Ferguson incision extraorally under general anesthesia. All patients had functional rehabilitation with prosthesis (Obturators) using the standing teeth on opposing jaw as anchor for retention. The patients with malignant tumors had postoperative radiotherapy after surgical treatment as shown in [Table 1].

Discussion

Management of maxillary sinus tumors is a multidisciplinary approach which involves various disciplines including the oral and maxillofacial surgery, prosthodontics, ophthalmologists, ear, nose, and throat surgeon, and radiotherapist and may involve the neurosurgeons. The surgical management of maxillary sinus tumors is maxillectomy which can be partial, subtotal, total or extended depending on the extent of the tumor. Maxillectomies leave a defect causing oronasal communication with functional deficiencies.^[1],[2] This can be reconstructed with microvascular free flaps or use of obturators which are easy to fabricate.^[4]

Maxillary sinus tumors are rare, constitute <1% of all the malignancies in the body, and about 3% in the aerodigestive tract.^[1],[5] Men were affected more than women with a ratio of 2:1.^[8] This is in consonant with our study, a male-to-female ratio was 1.3:1. In this study, ages range from 6 to 72 years with the mean age of 35.6 years. This is similar to what has been reported in other studies with mean age of 42 years.^[7],[8],[9]

Tumors in these areas are both therapeutically and diagnostically challenging; in view of their initial presenting symptoms which are often similar between the benign and malignant tumors. Due to the confined maxillary antrum, early tumors are difficult to detect as they do not present with symptoms. The most tumors present with effects of pressure on adjacent structures if benign and infiltration of structures with malignant tumors with late nodal involvement.^[8],[9] None of the patients with malignant tumors in this study had any clinical and radiological evidence of nodal involvement.

In general, signs and symptoms of maxillary sinus tumors can be divided into several major categories: oral, nasal, ocular, facial, and auditory. Oral presentations occur in 25%–35% of patients and include pain involving the maxillary teeth, trismus, palatal and alveolar ridge swellings, and frank erosion into the oral cavity in malignant lesions. In this study, 10 (62.5%) of patients presented with oral symptoms.^[7],[9],[10] This may be due to the late presentation of patients until there is impairment of function or pain from affected teeth. Nasal findings such as persistent sinusitis, unilateral nasal obstruction, nasal discharge, and epistaxis were seen in 1 (16.6%) patient.^[9] This is in consonant with the report from the Santos et al. in a research carried out among the Brazilian population.^[8] Andrade, Faria, and Cardoso et al. reported similar signs and symptoms in their clinical, pathological report of 10 years' experience of adenoid cystic carcinoma of the maxillary sinus.^[11]

Ocular symptoms arise from upward extension into the orbit such as unilateral tearing, diplopia, fullness of lids, pain, and exophthalmos.^[10],[12] None of our patients presented with the ocular symptom. However, the most of our patients complained of cheek swelling 13 (83.3%). This is contrary to the report from work done by Won et al. They reported that 10 out of 44 patients in their study had orbital invasion.^[13] Auditory complaints include hearing impairment secondary to otitis media due to nasopharyngeal extension. The intracranial extension may lead to headache, mental status, or personality changes (frontal lobe involvement). None of our patients had any auditory symptoms or intracranial extension of tumor. Radiographic evaluation is essential, as the full extent of an antral neoplasm cannot be established even with modern fiber-optic technology. CT of the paranasal sinuses with contrast is, therefore, compulsory for initial assessment of sinus malignancies. CT scan for benign lesions shows different ranges of density depending on the type of tumor. They usually range from mixed density lesions to hyperdense lesions; however, present with well-defined borders and pressure effect on surrounding structures. Involvement of adjacent structures is usually in the medial wall affecting the nasal cavity and the ethmoid bone. Moreover, this is similar to reports of other studies.^[14],[15]

The factors that determine the extent of surgical approach to tumors maxillary sinus include the histology, size, and location of the tumor in relation to the orbits, skull base, and internal carotid artery.^[16],[17] All our patients had maxillectomy done using the extraoral Trotter–Weber–Ferguson incision, though some authors prefer the midfacial degloving incision especially for small benign lesion. This has the advantage of preventing scarring of the face and the upper lip with upward pull of the alar of the nose and nasolabial fold. However, the access with this incision is limited making unsuitable for very large tumors.

[Figure 1], [Figure 2], [Figure 3], [Figure 4] demonstrate the maxillary defect that was created after the surgery and the use of obturator to rehabilitate the patient. Obturator with artificial teeth was fabricated for the patient after some level of healing has been achieved with ball-like Sofra-Tulle gauze dressing. This was possible using adjacent and/or opposing teeth for retention. The patients with malignant lesions were followed up with postoperative radiotherapy which was done after healing of the maxillary defects. Local recurrence is an important cause of failure of the curative treatment of maxillary sinus carcinoma after maxillectomy. Pattern of failure analysis for curative treatment has been reported to be about 49% of patients failed at the primary site.^[18] Isolated local failure occurred in 28.2% of patients and is the most common pattern of recurrence.^[18],[19] Therefore, strategies to improve local control are imperative in the management of this disease. Analysis of the treatment characteristics in the local control of maxillary sinus carcinoma has been reported that the type of treatment to the primary site was a significant variable.^{[20],[21],[22]} The patients who underwent a combination of surgery and adjuvant radiation therapy had a 5-year local control rate of 63.8% compared with 38.9%, 28%, and only 26%, respectively, for those who received neoadjuvant radiation therapy and surgery, radiation alone, and a combination of chemotherapy and radiation.^{[10],[14],[23]} All the patients with malignant lesions in our study received postoperative radiotherapy. There has been no recurrence of any of the malignant lesions treated so far in this study with follow-up ranging from 2 to 8 years. This may be due to the fact that most malignant lesions treated are usually Stage II–III tumors as higher staged tumors were referred to tertiary institutions. This in agreement with the report from the review done by Ashraf et al.^[7] They reported that a lower 5-year local control rate (38.9%, n = 59) and higher postoperative complication rate (64% fistula rate) in preoperative radiation group of patients as compared to 5-year local control rate of 63.8% (n = 225) and postoperative complication rate of 15.6% (orocutaneous fistulae) in postoperative radiation group.

Figure 1: The preoperative photograph of a patient with tumour in the maxilla

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Figure 2: Defect in the maxillar after ablative surgery

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Figure 3: Fabricated obturator used to rehabilitate the patient with defect in the maxilla

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Figure 4: The patient's facial profile after rehabilitation with obturator

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Conclusion

Maxillary sinus tumors are uncommon; however, present when adjacent structures are involved. The most maxillary sinus tumors seen were benign in nature; however, the squamous cell carcinoma was the most common malignant lesion noted. Treatment of early-stage maxillary sinus malignancies with maxillectomy with adjuvant radiotherapy is an effective measure of managing maxillary sinus malignancies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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