Berghaus, Alexander

Jovanovic, S.

English

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R H I N O L O G Y Vol. 29 - No . 2 June 1991 CONTENTS FREE CONTRIBUTIONS Hiroshi Moriyama, Masashi Ozawa, Yoshio Honda Endoscopic endonasal sinus surgery. Approaches and post-operative evaluation 93 Desmond A. Nunez Presentation of rhinosinugenic intracranial abscesses 99 A. Berghaus, S. Jovanovic Technique and indications of extended sublabial rhinotomy ("midfacial degloving") 105 GJ. Nolst Trenite Trauma reduction in rhinoplasty surgery I l l D: Dokic, S. Jovanovic, A. Berghaus, T.Brunnee Diagnosis of nasal allergy to the house dust mite . . . . . . . . 117 Keiichi Ichimura, Wataru Okita, Toshiyoshi Tanaka Vasoactivity of endothelin in nasal blood vessels 125 C o n t e n t s c o n t i n u e d H. Malmberg, E. Holopainen, M. Simola, I. Boss, N. Lindqvisi A comparison between intranasal budeson ide aerosol and budeson ide dry powder in the t rea tment of hay fever symptoms 137 K. fchikawa, M. Okucla, F. Naka, H. Yago The sources of chemical subs tances in allergic nasal fluid . . . 143 CLINICAL C O N T R I B U T I O N Ron Milo, Jucuia Schiffer, Julio Karpuch, Shlomo Sarfaty, Sara Shikar Frontal bone osteomyeli t is complicating frontal sinusit is caused by Haemoph i lus influenzae type a 151 H I S T O R I C A L C O N T R I B U T I O N R.A. Tange Some historical aspects of the surgical t r ea tment of the infected maxillary s inus 155 BOOKS 163 A N N O U N C E M E N T S 167 This journal is cited in Index Medicus and Excerpta Meclica Rhinology . 29, 105-110, 1991 Technique and indications of extended sublabial rhinotomy ("midfacial degloving") A. Berghaus and S. Jovanovic Dept . o f O .R.L . , S teg l i t z Med ica l Center , Free Un ivers i ty Berl in , G e r m a n y S U M M A R Y Midfacial degloving is an extended sublabial rhinotomy, which permits good bilat-eral access to the nasal and paranasal cavities, the base of the skull, and the clivus. The incisions leave no visible scars. The access is suitable for large benign tumours (such as nasopharyngeal fibromas or inverted papillomas), but can also be used for malignant tumours. It can be enlarged by supplementary incisions to meet the demands of tumour surgety. I N T R O D U C T I O N Midfacial degloving is an operative technique for sublabial access to the deeper midfacial regions, particularly to the nasal cavities, the paranasal sinuses, the nasopharynx, the retrotnaxillary space, the base of the skull and the clivus. The procedure has two main advantages: 1. The incision leaves no externally visible scars. 2. The access nevertheless permits an extensive overview and is bilateral, if necessary. In the past years, midfacial degloving has been elaborated and propagated primarily by Conley and Price (1979) and Maniglia (1986) in the U.S.A. O P E R A T I V E P R O C E D U R E The performance of this sublabial rhinotomy requires four connecting incisions: 1. The transfixion incision that separates the nasal columella from the septum. 2. Bilateral intercartilaginous incisions. 3. A bilateral circumvestibular incision that connects the intercartilaginous with the transfixion incision via the floor of the nose. 4. A bilateral sublabial incision extending beyond the midline. Paper p resen ted at t he 13th Congre s s of the E u r o p e a n Rhinologic Society inc luding the IXth I .S.I .A.N., L o n d o n (Uni ted K i n g d o m ) , J u n e 1990. 106 Berghaus and Jovanovic The intercartilaginous incision is followed by separation of the dorsum of the nose and notching of the periosteum at the edge of the piriform aperture. From the vestibule of the mouth , the soft parts of the midface are separated sub-periosteally; dissection extends to the edge of the piriform aperture and the incisions already performed intranasally. This permits the upper lip to be lifted together with the tip of the nose. Mobilization of the midfacial soft parts is then continued transnasally and transorally up to the orbital margin or nasofrontal angle. The infraorbital nerve is generally preserved. After complet ion of the dissection, the soft parts of the midface with the upper lip, cheeks and nose, including the alar cartilages, can be lifted from the osseous substratum in one piece. The midfacial skeleton with the triangular cartilages and septum then lies fully exposed. In order to advance into deeper regions, bone resections can now be performed as required. Thus the medial and anterior maxillary sinus wall can be removed through a cranial and caudal osteotomy of the piriform aperture ("medial maxill-ectomy"). This provides a wide access to the septum as well as to the e thmoid and sphenoid bone. The retromaxillary space is reached by temporary resection of a lateral bone segment including the anterior and laterodorsal maxillary sinus walls with the zygomatic insertion, as shown by Berghaus (1990). The accessible region is bordered laterally by the coronoid processes of the man-dibles and dorsally by the carotids passing through the sphenoidal sinus. The lower border is generally the palate. However, a resection of the palate, an inferior maxillectomy and even a total maxillary resection with orbital exentera-tion can be achieved via this access without particular difficulties. The resected bone walls can be repositioned after excision of the pathological processes. C A S E R E P O R T S The indications for this surgical technique will be illustrated by some examples: Case I: Inverted papilloma (Figures I and 2) The CT shows a tumour with extension in the right maxillary sinus, the right nasal cavity and the nasopharynx. Preoperative!}7, the histological examinat ion of a biopsy specimen gave rise to the unconfirmed suspicion of a squamous cell carcinoma. After midfacial degloving and temporary resection of parts of the maxillary sinus walls, the tumour was clearly demonstrable . The histological examinat ion now yielded the diagnosis of inverted papilloma. Postoperatively, the patient 's face showed no noticeable changes even though an extensive access had been created to provide a good overview. Technique and indications of extended sublabial rhinotomy 107 Figure 1. C T scan of inver ted pap i l loma of right nasal cavity and nasopha rynx . Figure 2. T h e resec ted t u m o u r Case 2: Carcinoma of the left maxillaiy sinus (Figures 3 and 4) The tumour had perforated the anterior and dorsal maxillary sinus wall and reached the floor of the orbit. 108 Berghaus and Jovanovic Figure 4. I n t r aope ra t i ve s i t ua t ion after left max i l l ec tomy and orbi tal exen t e r a t i on via midfacial degloving . Exposure of the midface by degloving was followed by maxillary resection with orbital exenteration. Dura also had to be resected and submitted to plastic treat-Technique and indications of extended sublabial rhinotomy 109 ment in the area of the ethmoidal roof because of destruct ion at the base of the skull. After resection of the wings of the sphenoid, there was no longer any macroscopic evidence of a tumour . Case 3: Juvenile angiofibroma The CT showed a tumour of the epipharynx, sphenoidal s inus and retromaxillary space. T h e structure, consisting of two main parts connec ted via the pterygo-maxillary fissure, was dumbell-shaped. It was the recurrence, in a 17-year-old patient, of a juvenile angiofibroma that had been submi t ted to transpalatal surgery several years previously. An embolizat ion was performed prior to operation of the recurrent tumour ; shortly thereafter, the intervention was carried out via midfacial degloving. After extensive transoral exposure of the midfacial region while preserving the intraorbital nerves, the frontal and lateral maxillary s inus wall was temporarily resected together with a part of the zygoma (Figures 5 and 6). From the described access, the tumour was then clearly demonst rab le and could be removed in one piece. The tumour spread amoun ted to nearly 8 cm. At the end of the intervention, the temporarily removed bone fragment was repo-sitioned and fixed again. Even the patient himself not iced no appreciable post-operative changes except for a slight soft-tissue swelling that receded completely with a few weeks. Figure 5. Do t t ed l ine: Parts of maxil lary wall and zygoma to be resected for access to re t romaxi l lary space via midfacial deg-loving. F igure 6. A n t e r i o r opera t ive access to re t romaxi l la ry space after b o n e resec t ion (F igure 3a) t h r o u g h midfacial degloving. 110 Berghaus and Jovanovic R E S U L T S Having applied midfacial degloving 14 t imes so far, we should like to summarize our experience as follows: Midfacial degloving provides an extensive overview by wide and, if necessary, bilateral access to the midface and its deeper regions. External facial scars are avoided. The procedure is suitable not only for larger benign tumours but also for malignant ones. For otobasal processes, the temporal paths of access according to Fisch or Obwegeser are more appropriate. However, retromaxillary tumours situated more towards the middle of the skull base can be reached well via sublabial rhinotomy. An interesting indication arises in connection with deepseated processes of unclarified histology. Then an external incision is avoided by midfacial de-gloving, while, at the same t ime, a radical operation can be performed via the same access if a malignant process is found. According to our experience, no particular condit ions of an unfavourable nature occur as a consequence of midfacial degloving. This technique represents an advance for head and neck surgeons who perform more extensive interventions in the midfacial area. R E F E R E N C E S 1. Berghaus A. Midfacial degloving. H N O , 1990; 38: 7 -11 . 2. Con ley J, Price JC . Sublabial approach to the nasal and nasopharyngea l cavities. A m J Surg 1979; 138: 615-618. 3. Manigl ia AJ. Ind ica t ions and t e c h n i q u e s of midfacial degloving. A 15-year exper ience . Arch Otolaryngol Head Neck Surg 1986; 112: 750-752. 4. Fisch U, Mat tox D. Microsurgery of t he skull base . Stut tgar t , New York: T h i e m e , 1988. 5. Hadj ianghe lou O, Obwegese r HL. T e m p o r a l e r Z u g a n g z u m relromaxillären-infra-kranialen R a u m und zur Orbi ta in der T u m o r c h i r u r g i e . Lar Rhinol Otol (1986); 65: 46-56 . Prof. Dr. A. Berghaus Dr. S. Jovanovic HNO-Abtei lung Universitätsklinikum Steglitz Hindenburgdamm 30 D-1000 Berlin 45 Germany 

Indications and techniques of midfacial degloving. A 15-year experience. Arch Otolaryngol Head Neck Surg

Microsurgery of the skull base.

Sublabial approach to the nasal and nasopharyngeal cavities.

Temporaler Zugang zum relromaxillären-infrakranialen Raum und zur Orbita in der Tumorchirurgie. Lar Rhinol Otol

Technique and indications of extended sublabial rhinotomy ("midfacial degloving")

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Technique and indications of extended sublabial rhinotomy ("midfacial degloving")

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