Avoiding Midface Degloving or Lateral Rhinotomy via Endoscopic Resection of the Ascending Process of the Maxilla and Nasal Bone

Background: Adenoid cystic carcinoma is the most common sinonasal tumor of minor salivary gland origin and comprises 6 to 10% of paranasal sinus malignancies. Of note is its high rate of perineural invasion and distant metastases over time. The high rate of recurrence can take many years to manifest. As a result, 5-year survival ranges from 73 to 90%, while 15-year disease-specific survival is as low as 40%. Surgical resection alone can be an acceptable modality of treatment for early lesions, particularly those localized to the lower nasal cavity, septum, or maxillary sinuses. One must consider appropriate exposure, need for immediate or future reconstruction, and ability to obtain a complete resection with clear margins. The endoscopic approach has become a viable option for appropriately selected patients, and not only avoids cosmetic concerns associated with facial incisions, but can also facilitate a magnified, high-definition view of the lesion with angled scopes that otherwise would not be possible with traditional open approaches.

Objective: To review a case of adenoid cystic carcinoma of the nasal sidewall in close relation to the ascending process of the maxilla and nasal bone treated with endoscopic resection and avoidance of midface degloving or lateral rhinotomy.

Case Report: A thirty one year old female presented for evaluation of a several month history of right intranasal mass causing epiphora. She underwent biopsy of a right nasal sidewall mass by another otolaryngologist, which revealed adenoid cystic carcinoma. We decided to proceed with radical resection to obtain free margins, and the patient underwent endoscopic endonasal right partial maxillectomy with resection of the ascending process of the maxilla and medial maxillary wall; resection of the right nasal bone, lacrimal bone, and nasolacrimal duct; total ethmoidectomy, middle turbinectomy, and drill out of the right frontal sinus floor.

Conclusion: Avoidance of midface degloving and facial incisions is possible for definitive surgical treatment of early localized sinonasal malignancies. An endoscopic endonasal approach through the piriform aperture or resection of the ascending process of the maxilla and nasal bones is a viable option that preserves function and cosmesis.