**9. Orbital exenteration with medial maxillectomy**

Orbital exenteration with addition of the operative procedure to include part of maxilla is used when the orbital tumors invade adjacent ethmoid sinuses or the nasolacrimal duct system. Various additional surgical procedures are used to remove such tumors depending on the clinical scenario. The demonstrated patient shown in **Figure 29**, has lympho-epithelial carcinoma of the left lacrimal sac. An axial T1-weighted magnetic resonance imaging (MRI) scan, reveals a multi-lobular, slightly hyperintense lesion in the medial aspect of the right orbit with loss of plane

#### **Figure 29.**

*Clinical picture of lymphoepithelial carcinoma of the left lacrimal sac. Incision encompasses the involved portion of the skin overlying the lacrimal fossa.*

#### **Figure 30.**

*An axial T1-weighted MRI scan, reveals a multi-lobular, slightly hyperintense lesion in the medial aspect of the right orbit with loss of plane with medial rectus.*

with medial rectus (**Figure 30**). An axial T2-weighted MRI scan demonstrates space occupying mass in the medial orbit with extension to the ethmoid sinuses (**Figure 31**). An axial view post-contrast fat-suppressed T1-weighted image shows peripheral enhancement and a lack of central enhancement (**Figure 32**). The operative procedure therefore will entail an orbital exenteration with a medial maxillectomy. The medial wall of maxilla is accessed through lateral rhinotomy incision that extends from the floor of the nasal cavity along the alar groove and the lateral aspect of the nose up to the medial canthus. Upper and lower eyelid incisions are made 2 mm away from the lid margin and are extended along the nasolabial fold to encompass the involved portion of the skin overlying the lacrimal fossa and nasolacrimal duct (**Figure 29**). Skin incision and flap elevation up to the periosteum is done as described above in the first case except that a generous portion of soft tissue is sacrificed at the medial aspect of the incision where the skin is involved. Here the skin incision is deepened straight down to the nasal bone medially and the anterior wall of the maxilla laterally. In the inferomedial quadrant of the orbit the soft tissues along the lacrimal sac region are retained on the specimen. No attempt is made to mobilize the periosteum on the lower medial wall of the orbit at the lacrimal apparatus and the lacrimal fossa as medial wall of maxilla will be resected en-bloc with the orbital contents. At the lower end of pyriform aperture of the nose

#### **Figure 31.**

*An axial T2-weighted MRI scan demonstrates mass lesion in the medial orbit extending to the ethmoid sinuses.*

#### **Figure 32.**

*An axial view postcontrast fat-suppressed T1-weighted image shows peripheral enhancement with lack of central enhancement.*

#### **Figure 33.**

*The planned bone cuts are outlined on a skull superior cut is along the nasal bone and inferior cut is made lateral to the inferior orbital foramen.*

mucosal incision is made with the monopolar cautery till the posterior choana below the inferior turbinate. After periosteal elevation of the superior, lateral and the inferior orbital walls, a oscillating power saw is used to make bone cuts for the proposed medial maxillectomy (**Figure 33**). The inferior rim of the orbit is divided

*Extended Orbital Exenteration: A Step-by-Step Approach DOI: http://dx.doi.org/10.5772/intechopen.104763*

#### **Figure 34.**

*The postoperative appearance of the patient approximately 2 month after surgery shows excellent healing within the orbital socket.*

lateral to the infraorbital foramen to keep the lower medial quadrant in the specimen with adequate bone margins. This bone cut extends through the floor of the orbit up to the inferior orbital fissure and the anterior wall of the maxilla is divided in the plane extending up to the pyriform aperture (**Figure 33**). Superior bone cut is made above the meridian of the orbit so that entire lacrimal fossa can be resected with the specimen with satisfactory margins. This extends posteriorly along the lamina papyracea up to the posterior ethmoids. Medial bone cut is made on the lateral aspect of the left nasal bone from the orbit up to the nasal vestibule (**Figure 33**). Inferiorly along the pyriform aperture, osteotome is used to make a bone cut along the lower border of the lateral wall of the nose, below the inferior turbinate. Once all the osteotomies are completed, the surgical specimen remains attached only at the cone of the orbit posteriorly through the attachments of the extraocular muscles and the optic nerve. Rest of the steps are similar as described above. Additional attention is paid to the sphenopalatine artery as brisk hemorrhage may result from it and is easily controlled with electrocoagulation. In this particular case due to adjuvant radiotherapy, necrosis of the skin flaps resulted in the open orbital defect (**Figure 34**). The surgical defect following healing of the socket shows the medial one-third of the orbital rim has been resected to encompass the tumor of the lacrimal apparatus, which is removed in an en bloc fashion with the contents of the orbit and lateral wall of the nasal cavity (**Figure 34**). Such cases can be rehabilitated best by prosthetic replacement and glasses as shown in the **Figure 35** and **Figure 48**.

**Figure 35.** *(A) Rehabilitation of the orbital socket with prosthesis. (B) Glasses are used to enhance appearance.*
