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Surgical Treatment for Intranasal Squamous Cell Carcinoma
JANUARY 1996, VOL 63, NO 1
Home Study Program SURGICAL TREATMENT FOR INTRANASAL SQUAMOUS CELL CARCINOMA
T
he article “Surgical treatment for intranasal squamous cell carcinoma” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), professional education specialist, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn two contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is June 30, 1996. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-5711
BEHAVIORAL OBJECTIVES
After reading and studying the article on surgical treatment for intranasal squamous cell carcinoma (SCC), the nurse will be able to discussthe diagnosis and treatment of intranasal SCC, describe perioperative care for patients undergoing extensive surgical resections (eg, rhinectomy, palatectomy, maxillectomy) for intranasal SCC, discuss the treatment stages (eg, surgery, radiation therapy, rehabilitation) for patients diagnosed with intranasal SCC, and describe perioperative nurses’ roles when caring for patients undergoing extensive surgical resections for intranasal SCC.
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Surgical Treatment for Intranasal Squamous Cell Carcinoma Epidemiology. Carcinoma of the upper aerodigestive tract accounts for 5% of all human tumors, with 95% of these tumors having a squamous cell hi~tology.~ Fifty-nine percent of the tumors occur in the maxillary sinus, 24%are in the nasal cavity, 16% form in the ethmoid sinuses, and 1% develop in the frontal and sphenoid sinuses. Anterior tumors tend to be well differentiated, but tumors that arise from the posterior nasal cavity and ethmoids are poorly differentiated. Nasal and sinus carcinomas are characterized by local growth, and nodal metastases are unusual and tend to occur late in the disease process, GENERAL CONSIDERATIONS Squamous cell carcinoma of the upper aerodi- even with extensive local disease. Approximately gestive tract is not considered to be a major public one third of patients who develop SCC of the upper health problem in the United States. Incidence and aerodigestive tract die from their d i ~ e a s e . ~ Risk factors. Associated risk factors for the mortality rates have remained stable during the past 40 years in white males; however, mortality and development of malignancies of the upper aerodigesmorbidity rates have increased dramatically in non- tive tract include the concomitant, chronic use of white males and in white and nonwhite females. tobacco (eg, cigarette, cigar, pipe smoking; chewing This increased incidence of SCC in the upper tobacco; snuff) and alcohol (eg, distilled beverages, aerodigestive tracts of females is probably due to beer, wine, mouthwash with high alcohol content). the increase in cigarette smoking among women Although the chronic abuse of either tobacco or alcohol alone increases the likelihood of SCC of the during the past 30 years.2 upper aerodigestive tract, the cumulative effects of both habits greatly increase patients' risks. Chemical exposures to A B S T R A C T Surgical treatment for aggressive intranasal squamous cell car- chloroprene, isopropyl oil, and cinoma (SCC) requires a multidisciplinary team approach to ensure chloromethyl and work-related optimal patient outcomes. Surgical procedures for the removal of exposures to industrial contamiintranasal malignancies may include rhinectomy, palatectomy, and nants used in the manufacture of maxillectomy. These procedures leave patients with significant facial furniture, textiles, nickel, and radidefects that are corrected with staged surgical reconstructions or um-dial paints also have been applications of facial prostheses. This article describes the etiology implicated in the development of of intranasal SCC, discusses treatment options, and presents a case malignant tumors in the nose, study that chronicles the events from diagnosis through rehabilita- sinuses, and nasopharynx. Reverse tion of a patient undergoing rhinectomy, partial bilateral maxillecto- smoking (ie, smoking cigarettes and cigars with the lighted end my, and partial palatectomy. AORN J 63 (Jan 1996) 163-182.
eceiving a diagnosis of cancer, under any circumstances, is a devastating event. For the patient diagnosed with intranasal squamous cell carcinoma (SCC), the devastation may be coupled with concerns about his or her physical appearance after surgical treatment to eradicate the malignant tumor. As the nose is the most prominent feature of the face, surgical resection carries important aesthetic, physiologic, social, and psychologic implications.'
DONNA R. M v E W E N . R N : SUSAN A. M A R E N I I A , MI)
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Figure 1 Preoperative view of patient showing induration of maxilla and stenosis of nares.
inside the mouth) contributes to the high incidence of upper aerodigestive tract carcinomas seen in India and some parts of Central and South America: Diagnosis. Diagnosis of intranasal carcinoma may be difficult because the malignancy may mimic autoimmune diseases of the skin, inflammatory dermatosis, cutaneous infections, or trauma. These factors may contribute to the late diagnosis of SCC, allowing the cancer cells to spread and invade adjacent structures. Presenting patient symptoms may include reports of nasal obstruction, epistaxis, localized pain, and dental pain. The otorhinolaryngologist determines the extent of the disease through physical examination of the patient, x-rays, computed tomography (CT) scans, and biopsies that are performed under local anesthesia.6 Treatment options. Otorhinolaryngologists determine patients’ treatment options by classifying head and neck carcinomas according to criteria developed by the American Joint Committee on Cancer. This tumor classification method assesses three basic components: the size of the tumor (T), the absence or presence of regional lymph nodes (N), and the absence or presence of distant metastatic disease (M). Each component is followed by a letter or number that further defines the component (eg, stages T1 to T4 indicate increasing size or extent of tumor, NO indicates no lymph node involvement, MO indicates no distant spread of disease).’ The five-year survival rate for patients with T1 and T2 tumors is 70%, and the five-year survival rate for patients with T3 and T4 tumors is 15% to 20%. These tumors can be described based on tumor size and spread. Characteristics of the four stages of upper
aerodigestive tract carcinomas include the following. Stage T1: The tumor is confined to the inferior antrum without bone erosion. Stage T2: The tumor is confined to the superior antrum without bone erosion of the inferior or medial walls. Stage T3: The tumor is extensive and involves the skin of the cheek, the orbit, the anterior ethmoids, and/or the pterygoid muscles. Stage T4: The tumor is massive (ie, more than 4 cm in diameter) and involves the cribriform plate, posterior ethmoids, sphenoid, nasopharynx, pterygoid plates, and/or the base of the skull.8 Tumors less than 4 cm in diameter (ie, T1 and T2 tumors) are treated with surgical resections and radiation therapy if cancer cells are left at the surgical margins or if the carcinoma recurs. Aggressive intranasal SCCs (ie, T3, T4 tumors) must be treated with extensive surgical resections (eg, rhinectomy, palatectomy, maxillectomy) and radiation therapy followed by staged reconstructions or prosthetic rehabilitation. PATIENT PROFILE
Mr R was a 68-year-old, Latin-American male who came to the otorhinolaryngologist with a threemonth history of swelling and mild tenderness in his left nasal caudal septum. Mr R’s general practitioner previously had prescribed antibiotics; however, they did not resolve the facial swelling and tenderness. Patient findings. On physical examination of Mr R, the otorhinolaryngologist noted minimal tenderness and swelling of Mr R’s nasal septum and hardening of the surrounding upper lip and maxillary alveolar mucosa. The tip of the Mr R’s nose was prolapsed and fixed with some stenosis of the external nares (Figure 1). The otorhinolaryngologist also observed swelling and mild erythema of the premaxillary area. A radiographic sinus series demonstrated bilateral calcifications in Mr R’s maxillary sinuses. Mr R denied any personal history of diabetes mellitus, hypertension, liver disease, or cancer. He denied the use of prescribed or over-the-counter medications other than antibiotics. Mr R’s only previous surgery was for the removal of a mole from his back. He admitted to the concomitant use of cigarettes and alcohol. Using a local anesthetic agent, the otorhinolaryngologist performed a biopsy of the swollen area at the anterior margin of Mr R’s nasal septum to 165
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obtain a preliminary diagnosis. Mr R continued taking his antibiotics and returned to the otorhinolaryngologist’s office one week later, at which time the otorhinolaryngologist informed Mr R of the biopsy results, which demonstrated SCC. Hospitalization. The otorhinolaryngologist arranged for Mr R’s admission to the hospital to perform further diagnostic tests, to develop a treatment plan, and to determine the extent of the disease. Computed tomography - . . scans Figure 2 A computed tomography scan of the patient‘s paranasai sinuses. of Mr R’S maxillofacial sinuses revealed densities in the floors of both maxillary sinuses and fullness in the base of his increased risk for developing an infection during nares and upper lip (Figure 2). Other CT scans radiation therapy. The otorhinolaryngologist also informed Mr R revealed no disease or abnormalities in Mr R’s orbital or intracranial structures. Medical technicians per- that he would have to undergo radiation therapy to formed routine laboratory tests (ie, urinalysis, com- the head and neck region that could compromise plete blood count, prothrombin and partial thrombo- blood flow to the bone and soft tissues of the plastin times), and all laboratory results were within mandibular and maxillary regions. She explained that normal limits. Using the results of Mr R’s physical this compromise in blood flow could weaken the examination, CT scan results, radiographic reports, bone and tissue, decrease Mr R’s ability to respond to and pathology findings, the otorhinolaryngologist infection, and place him at risk for tissue t r a ~ m a . ~ classified Mr R’s tumor as a type “T4NOMO” (ie, 4cm or greater tumor without lymph node involvement PREOPERATIVE NURSING CONSIDERATIONS Given the nature of Mr R’s proposed initial suror distant spread of the disease). Treatment recommendations. The otorhino- gical procedure, the circulating nurse faced many laryngologist recommended that Mr R undergo sur- challenges in developing a perioperative patient care gical resection of the tumor and its margins, which plan to meet Mr R’s special needs. The circulating would include rhinectomy, partial palatectomy, and nurse arranged for extra time during the preoperative bilateral partial maxillectomy. The surgeon outlined interview for Mr R to verbalize his fears and anxiher plan to reconstruct Mr R’s upper lip, which eties about the procedure. would be resected with his nose. The reconstruction Day of surgery. The circulating nurse conwould occur at the time of the initial surgery using firmed Mr R’s identity and reviewed his chart to veran advancement technique known as a Gilles fan ify the presence of a signed and witnessed informed flap. She further recommended that Mr R undergo surgical consent, current laboratory reports, and prosthetic rehabilitation instead of facial reconstruc- other test results. She determined Mr R was not tion after surgery, because Mr R would need postop- allergic to medications or iodine and reinforced preerative radiation therapy to treat any residual disease. vious preoperative teaching that included informaThe surgeon informed Mr R that he would have tion about the surgical environment and experience. to undergo a total odontectomy and alveoloplasty (ie, The anesthesia care provider met with Mr R, inserted removal of the teeth, surgically smoothing the rough a peripheral IV line, and placed invasive monitoring surface of the tooth-bearing bone) before radiation lines (eg, radial arterial line, central venous pressure therapy would begin. A complete odontectomy and line). During this time, the circulating nurse returned alveoloplasty was performed 10 days after Mr R’s to the OR to collaborate with the scrub person and primary surgical procedure because his carious den- surgeon in preparing for the surgical procedure. Surgery preparations. The circulating nurse tition and early gingival disease placed him at 166 AORN JOURNAL
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knew the surgical procedure would be lengthy, so she took appropriate measures to protect Mr R from hypothermia and potential injury related to positioning. She obtained a circulating warm-air unit and a temperature regulating blanket and furnished the anesthesia care provider with two IV fluid warmers. The circulating nurse placed a full-length, table-sized gel pad over the OR bed and obtained egg crate foam to aid with patient positioning. The scrub person assembled the necessary nasal and plastic reconstruction instruments and supplies for the rhinectomy, maxillectomy, and palatectomy procedures. Central sterile supply personnel gas sterilized and aerated a custom-made, palatal prosthetic splint before surgery, according to hospital policy and procedures and the manufacturer’s guidelines. The scrub person gathered and tested a multifunction, air-powered handpiece with oscillating saw and rotating burr attachments so the surgeon could adapt the splint during surgery. The circulating nurse prepared a small table of supplies the otorhinolaryngologist would use to administer a preoperative application of 4% topical cocaine solution and injection of local anesthetic medication to Mr R’s surgical site. INTRAOPERATIVE NURSING CONSIDERATIONS
After the circulating nurse returned to the preoperative holding area, she and the anesthesia care provider transported Mr R to the OR and assisted him from the transport stretcher onto the OR bed. The circulating nurse secured Mr R to the OR bed by placing a safety strap two inches above his knees. She activated the temperature-regulating blanket and placed a warm blanket over Mr R to ensure his comfort and reduce heat loss. Patient preparation. The circulating nurse remained at the head of the OR bed during the induction of general anesthesia and the subsequent intubation to provide emotional support for Mr R and to assist the anesthesia care provider. After a successful orotracheal intubation, the circulating nurse inserted a Foley catheter into Mr R’s bladder and connected the catheter to a metered urine collection bag, which she placed by the anesthesia care provider. While the circulating nurse catheterized Mr R, the otorhinolaryngologist injected a 2% lidocaine solution into Mr R’s bilateral nasal vestibule, nasal ala regions, and gingivobuccal sulci. The surgeon then placed 4%topical cocaine-soaked neurosurgical patties into Mr R’s nasal passages. These preoperative measures were performed to promote venous
Figure 3 Line of surgical resection through the (A) nasal bone, (B) superior turbinate, (C) middle turbinate, (D) inferior turbinate, and (E) maxilla bone. (Court0sy of Lani McEwen, Sun Antonio)
constriction and reduce intraoperative bleeding. The surgical team members carefully positioned Mr R by padding all his bony prominences and pressure points with egg crate foam, and they placed a small pillow beneath his knees to prevent back strain. After confirming that Mr R was in correct anatomical alignment, the circulating nurse selected a site on Mr R’s anterior thigh for placement of the electrosurgical unit dispersive grounding pad, making sure the site was free of hair for adequate pad adhesion. The anesthesia care provider placed a circulating warm-air blanket on Mr R’s torso and lower body and activated the warming unit. The circulating nurse used two separate povidone-iodine prep trays to prep Mr R’s face and oral cavity. She placed sterile towels along each side of Mr R’s neck to prevent pooling of the prep solution. The scrub person assisted the surgeon and surgical assistant with gowning and gloving and facilitated placement of the sterile drapes on the patient. Surgical technique. The surgeon began the procedure by marking bilateral, lateral rhinotomy incision lines that would incorporate approximately 90% of Mr R’s upper lip (Figure 3). She carried these incisions laterally and intraorally over Mr R’s maxillary sinus antrums and created openings into the antrums to observe the interior of Mr R’s sinus cavities. The surgeon noted invasion of tumor in Mr R’s left sinus cavity. The surgeon continued the procedure by making medial and lateral alotomy incisions into Mr R’s nasal 168
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Figure 4 Initial incision lines for resection of tumor.
vestibule. She observed an extensive amount of tumor in Mr R’s nasal vestibule and anterior septum. Using Mayo scissors, the surgeon cut through the vomer at the level of the upper lateral cartilages and above the inferior turbinates. Next, she used a chisel to connect the antrostomies to the septa1 cuts, and she made additional chisel cuts to incorporate the anterior two thirds of the hard palate in the resection (Figure 4). After completing the osteotomies, the surgeon used a gentle rocking motion to remove the specimen in one piece (Figures 5 and 6 ) . The circulating nurse, acting on the surgeon’s orders, sent several samples of the tumor’s margins for frozen-section analysis. The pathologist verified that the tumor had been resected completely by noting that the tumor samples did not show evidence of further malignancy. Figure 7 shows the tissue defect after tumor removal.
The surgeon progressed to the next phase of the surgical procedure by placing the palatal splint inferior to the resection site in Mr R’s oral cavity, noting the fit and position. She removed the splint and refined it by using an oscillating saw and a cutting burr before securing it to the remainder of Mr R’s hard palate with three titanium screws. The surgeon made a circumferential incision from the remainder of Mr R’s upper lip down to the latter one third of his lower lip (ie, 2.5 cm lateral to the outer edge of the vermilion border) to reconstruct the upper lip. The surgeon carried these incisions to the level of the orbicularis oris muscle and subcutaneous tissue (Figure 8) and continued her blunt dissection of the area parallel to the neurovascular bundle. She made back cuts into each Gilles fan flap to release tension and began to reapproximate the flaps by
Figure 5 Anterior view of resected tumor showing the patienf‘s palate and the floor of maxillary sinus.
Figure 6 Posterior view of en bloc specimen. Ruler measures a massive tumor more than 4 cm in diameter. 169
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Figure 7 Facial defect after tumor removal for intranasai squamous cell carcinoma.
Figure 9 Gilles fan flap incision partially sutured with palatal splint visible below the tumor resection site.
Figure 8 Giiies fan flap incisions for upper lip reconstruction after intranasai tumor resection.
Figure 10 Reconstructed lip and open nasal defect with 8-Fr feeding tube inserted into left nasal cavity.
closing them in layers with absorbable suture. The surgeon made further modifications in the back cuts and closed the back cuts with nonabsorbable sutures using a Z-plasty technique. She reapproximated Mr R’s skin incision and vermilion border with silk and nonabsorbable nylon sutures (Figure 9). After the circulating nurse and scrub person verified that the sponge and sharp counts were correct, the surgeon lightly packed Mr R’s sinus and nasal cavities with one-half-inch iodoform gauze. The scrub person applied antibiotic ointment to the remaining incision sites and placed a large piece of petroleum gauze over the nasal defect. The surgeon placed an 8-Fr, pediatric-sized feeding tube through
Mr R’s left nasal cavity opening and sutured the feeding tube to Mr R’s face (Figure 10). The surgical team members moved Mr R onto a transport stretcher and transferred him to the postanesthesia care unit (PACU). Mr R remained intubated en route to the PACU, and the anesthesia care provider gave respiratory support to Mr R during the transfer. POIFMPWRATIW NURSING C0NSIDUIATH)NS
Mr R remained intubated while he was in the PACU and after he was transferred to the surgical intensive care unit (SICU) to avoid airway compromise from the nasal packing and postoperative 170
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edema in the oral cavity. Also, the small size of Mr R’s reconstructed mouth opening would make reintubation difficult. The anesthesia care provider successfully extubated Mr R on the first day after his surgery, and Mr R was transferred to the postoperative nursing unit after two days in the S K U . Postoperative nurses administered enteral nutrition through Mr R’s feeding tube after his transfer to the SICU. The surgeon removed Mr R’s nasal packing three days after the surgery and repacked Mr R’s nasal defect daily to promote granulation of his wound edges. Mr R’s recovery from surgery went smoothly, and he progressed to the point where he took responsibility for performing his own wound care and dressing changes. SUBSEQUENT TREATMENT
Mr R underwent a second surgical procedure, radiation therapy, and extensive rehabilitation after his initial surgery. Second surgical procedure. Oral maxillofacial surgeons performed odontectomy and alveoloplasty procedures under general endotracheal anesthesia 10 days after Mr R’s rhinectomy procedure. A root tip from one of Mr R’s teeth was retained after the odentectomy, which necessitated Mr R’s return to the OR for surgical removal of the tip. Mr R was discharged the day after the procedure to remove the retained root tip. Radiation therapy. Approximately one month after Mr R’s second surgical procedure, he returned to the hospital for radiation therapy. The radiation therapy focused on Mr R’s nasopharynx, lateral face, and lateral nares. Mr R tolerated the radiation therapy without complications, except for a mild case of conjunctival hyperemia (ie, blood located in the conjunctiva of the eye) that developed early in the treatment. An ophthalmologist successfully treated the conjunctival hyperemia with steroid ophthalmic drops. A CT scan was performed five days after the completion of radiation therapy, and it showed no evidence of tumor recurrence. Rehabilifation.Mr R kept his nasal defect covered with sterile gauze pads. He did not undergo speech therapy because a palatal prosthesis enabled him to be understood by others. Five months after completing his radiation therapy, Mr R traveled to St Louis to meet with the anaplastologist (ie, individual specially trained in the art of reconstructing body parts) who would create his facial prosthesis. Benefits of nasal prostheses. There are approxi-
mately 300 people who create various facets of maxillofacial prosthetics in the United States. This technology is associated closely with the dental laboratory industry (ie, prosthodontics), as the materials and construction methods parallel those used by dental prosthodontists. Anaplastologists, dentists, maxillofacial dental technicians, ocularists, and some medical sculptors are involved with this specialty.1° The use of a nasal prosthesis is the cornerstone of rehabilitation after a rhinectomy procedure because the nasal prosthesis offers the patient an immediate solution for the facial defect and can be used without further surgical intervention.Il Staged surgical reconstruction, using an advancement or free-flap tissue graft, may not produce the same superior result as a prosthesis sculpted by a skilled anaplastologist. The authors of one clinical study suggest that staged surgical reconstruction not begin until at least two years after a rhinectomy procedure to allow for the possibility of further surgery for the recurrence of the original lesion.’* Patient education. The anaplastologist discussed the step-by-step procedure for constructing Mr R’s nasal prosthesis with Mr R and his family members and told them that the prosthetic construction process would require three to five days. The anaplastologist worked closely with Mr R and his family members to achieve an aesthetically pleasing end product. Mr R brought photographs of himself before surgery to provide the anaplastologist with an idea of his preoperative appearance. Facial impression. The prosthetic construction process began with a facial impression. After reinforcing his previous explanation of the procedure, the anaplastologist positioned Mr R comfortably in a semireclining position in a chair. The anaplastologist placed towels around Mr R’s hairline and neck areas and coated Mr R’s eyebrows with petroleum jelly to prevent adhesion of the casting material in that area. The anaplastologist then placed petroleum-coated gauze into Mr R’s open nasal cavity and positioned small tubes in Mr R’s mouth to facilitate breathing. The anaplastologist mixed alginate, an irreversible hydrocolloidal impression material widely used for dental impressions, into a thin solution and poured it over Mr R’s face. While this mixture covered Mr R’s face, the anaplastologist placed a thicker mixture of the same material over the first layer. The anaplastologist then placed multiple loose strips of gauze into the exposed alginate to strengthen the 172
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Figure 1 1 Full frontal view of nasal prosthesis.
Figure 12 Semilateral view of nasal prosthesis.
mixture before he covered the mask with quick-set plaster of paris. Depending on the viscosity of the alginate mix, the impression mask requires 20 to 25 minutes to set. The anaplastologist carefully removed Mr R’s mask and placed the mask in a mold. The anaplastologist painted the interior of the mask with a separation medium before he coated the entire impression with liquefied gypsum dental stone. After the stone hardened, the anaplastologist removed the impression mask, which revealed a three-dimensional stone moulage or cast of Mr R’s face. The moulage was used to shape and base the prosthesis. Wax sculpting. The anaplastologist took additional impressions from Mr R’s stone moulage to provide a smaller work surface for the next step in prosthesis construction, which was the wax sculpting of Mr R’s nose. Using preoperative photographs, the anaplastologist carved a wax model of Mr R’s nose. This wax nose was placed on Mr R and adjusted for fit and appearance. After achieving a satisfactory result with the wax prosthesis, the anaplastologist made a two-part dental stone mold of the wax nose. Prosthetic molding. Historically, a variety of materials have been used for final construction of nasal prostheses. In the past 16 years, the most acceptable material for use in fabrication of extraoral prostheses has been polydimethyl siloxane, a medical-grade elastomer silicone.I3 Polydimethyl silox-
ane is semiclear, so it must be tinted with dry pigments to obtain a tint that is close to the patient’s basic skin color. The anaplastologist mixed the tinted elastomer with a curing agent and poured the mixture into the two-part dental stone mold of Mr R’s nose. The anaplastologist placed the mold in a drying oven to cure for two to three hours. After curing, the anaplastologist removed Mr R’s mold from the drying oven, released the prosthesis, and trimmed the rough edges of the prosthesis. The anaplastologist also removed the excess silicone from behind the prosthesis and snipped off the inner ends of the nostrils to provide an opening for breathing. Permanent extrinsic tinting. After applying the prosthesis to Mr R’s face and verifying a satisfactory fit, the anaplastologist was ready to begin the third and final phase of prosthesis construction, the permanent extrinsic tinting. He removed the prosthesis from Mr R’s face and refined the nasal prosthesis with the application of additional tinted medicalgrade silicone and the inclusion of small red and purple fibers to simulate blood vessels. The anaplastologist sandblasted and painted skin pores into the prosthesis for a more realistic appearance. Prosthetic anchoring. Anaplastologists anchor nasal prostheses to patients’ faces by attaching them to eyeglasses, using medical-grade adhesives (ie, similar to the 173
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types used to secure ostomy appliances), or Future rehabilitation. Mr R has been followed carefully by the otorhinolaryngologist for recurrence using bone-anchored osseointegrated implants.14 Each method has advantages and drawbacks. of his tumor. At the present time, there is no evidence Eyeglass attachment, while convenient, may not pro- of tumor recurrence. Mr R successfully maintains his vide a satisfactory anchor because the eyeglass nasal prosthesis and is satisfied with his overall frames may slip and result in prosthetic gaps. appearance (Figures 11 and 12). Mr R has returned to Although retention with osseointegrated bone the hospital for further consultation with the surgeons anchors is excellent, optimum tissue recovery, in the division of oral maxillofacial surgery. The oral impeccable hygiene, and good manual dexterity are maxillofacial surgeons plan to rebuild Mr R’s resectcrucial to the success of this method, and these ed palate and maxillary ridge with an osseocutaneous anchors are still under investigation by the US Food vascular free flap taken from his radius. This proceand Drug Administration. Attachment with medical- dure, combined with a revision of Mr R’s recongrade adhesives, the most commonly used method, structed mouth to widen the opening, will result in may be associated with problems such as further improvement of Mr R’s appearance and allow for future denture fitting. skin irritation, lack of margin integrity, SUMMARY prosthetic misalignment, and inconsistent retention.15 The physical, emotional, and psychological conMedical-adhesive attachment method. The siderations associated with extensive surgical resecanaplastologist chose the medical-adhesive attach- tions for the treatment of intranasal SCC are numerment method for Mr R and instructed him on apply- ous. Familial support, competent and compassionate ing the adhesive to the inner side of his prosthesis. nursing care, and skilled surgeons, combined with Mr R learned to apply the medical adhesive with a successful prosthetic rehabilitation, can help restore cotton-tip applicator, allowing it to remain open to self-confidence and self-esteem for patients undergoair for two to three minutes before applying the pros- ing these radical surgical procedures. A thesis to his face. The anaplastologist told Mr R that the prosthesis, if properly cared for, would last six months to one year, and he taught Mr R how to Donna R. McEwen, RN, BSN, CNOR. CNRN, is a primaintain his prosthesis. Oil, dirt, perspiration, and mary neurosurgery nurse at South Texas Veterans extreme changes in temperatures can cause loosen- Health Care System, Audie L. Murphy Division, San ing of the prosthesis; therefore, Mr R was instructed Antonio. to carry extra adhesive and cleaning supplies for Susan A. Marenda, MD. is an otorhinolaryrigologist in mishaps. The cost of the first nasal prosthesis was private practice, San Antonio. $550, and additional prostheses will cost Mr R $230 each. It will take an anaplastologist one to two weeks The authors wish to thank Lani McEwen, San Antonio, to make and ship additional prostheses to Mr R. for preparing the original illustration used in this article. NOTES 1. R J Stanley, K D Olden,
“Rhinectomy for malignant disease,” Archives of 0tolaryngolog)LHead and Neck Surgery 114 (November
1988) 1307-1311. 2. S I Schwartz, G T Shires, F C Spencer, Principles of Surgery, sixth ed (New York: McGraw-Hill Book CO,1994) 595-658. 3. S E Otto, Oncology Nursing, second ed (St Louis: Mosby-Year Book, Inc, 1993) 221. 4. B E Jarrell, R A Carabasi, Surgery, second ed (Malvem, Pa: Harwal Publishing Co, 1991) 332-338. 5. Otto, Oncology Nursing, 222; Schwartz, Shires, Spencer, Principles of Surgery, 60 1-602.
6. R J Stanley et al, “Aggressive intranasal carcinoma mimicking infection or inflammation,” Cutis 42 (October 1988) 288-293; Jarrell, Carabasi, Surgepy, second ed, 332333. 7. American Joint Committee on Cancer Manual for Staging of Cancer (Philadelphia: J B Lippincott Co, 1983); Otto, Oncology Nursing, 50. 8. American Joint Committee on Cancer Manual for Staging of Cancer; Jarrell, Carabasi, Surgery, sec-
ond ed, 333. 9. Otto, Oncology Nursing, 250. 10. E H Rommerdale, “Maxillofacial technology, part 1: Introduction to facial impressions,” Trends and Technology in the Contemporary Dental
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Laboratory 7 (May 1990) 36-39. 11. Stanley, Olden, “Rhinectomy for malignant disease,” 1307-13I I . 12. J Teichgraeber, H Goepfert,
“Rhinectomy: Timing and reconstruction,” 0tolaryngolog)LHead and Neck Surgery 102 (April 1990) 362-369. 13. E H Rommerdale, “Maxillofacia1 reconstruction technique, part 2: Coloring and processing the prosthesis,” Trends and Technology in the Contemporary Dental Laboratory I
(July/August 1990) 24-28. 14. J J Gary, M Donovan, “Retention designs for bone-anchored facial prostheses,” Journal of Prosthetic Dentistry 70 (October 1993) 329-332. 15. h i d , 329.
Home Study Program SURGICAL TREATMENT FOR INTRANASAL SQUAMOUS CELL CARCINOMA
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he article “Surgical treatment for intranasal squamous cell carcinoma” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), professional education specialist, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn two contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is June 30, 1996. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-5711
BEHAVIORAL OBJECTIVES
After reading and studying the article on surgical treatment for intranasal squamous cell carcinoma (SCC), the nurse will be able to discussthe diagnosis and treatment of intranasal SCC, describe perioperative care for patients undergoing extensive surgical resections (eg, rhinectomy, palatectomy, maxillectomy) for intranasal SCC, discuss the treatment stages (eg, surgery, radiation therapy, rehabilitation) for patients diagnosed with intranasal SCC, and describe perioperative nurses’ roles when caring for patients undergoing extensive surgical resections for intranasal SCC.
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Surgical Treatment for Intranasal Squamous Cell Carcinoma Epidemiology. Carcinoma of the upper aerodigestive tract accounts for 5% of all human tumors, with 95% of these tumors having a squamous cell hi~tology.~ Fifty-nine percent of the tumors occur in the maxillary sinus, 24%are in the nasal cavity, 16% form in the ethmoid sinuses, and 1% develop in the frontal and sphenoid sinuses. Anterior tumors tend to be well differentiated, but tumors that arise from the posterior nasal cavity and ethmoids are poorly differentiated. Nasal and sinus carcinomas are characterized by local growth, and nodal metastases are unusual and tend to occur late in the disease process, GENERAL CONSIDERATIONS Squamous cell carcinoma of the upper aerodi- even with extensive local disease. Approximately gestive tract is not considered to be a major public one third of patients who develop SCC of the upper health problem in the United States. Incidence and aerodigestive tract die from their d i ~ e a s e . ~ Risk factors. Associated risk factors for the mortality rates have remained stable during the past 40 years in white males; however, mortality and development of malignancies of the upper aerodigesmorbidity rates have increased dramatically in non- tive tract include the concomitant, chronic use of white males and in white and nonwhite females. tobacco (eg, cigarette, cigar, pipe smoking; chewing This increased incidence of SCC in the upper tobacco; snuff) and alcohol (eg, distilled beverages, aerodigestive tracts of females is probably due to beer, wine, mouthwash with high alcohol content). the increase in cigarette smoking among women Although the chronic abuse of either tobacco or alcohol alone increases the likelihood of SCC of the during the past 30 years.2 upper aerodigestive tract, the cumulative effects of both habits greatly increase patients' risks. Chemical exposures to A B S T R A C T Surgical treatment for aggressive intranasal squamous cell car- chloroprene, isopropyl oil, and cinoma (SCC) requires a multidisciplinary team approach to ensure chloromethyl and work-related optimal patient outcomes. Surgical procedures for the removal of exposures to industrial contamiintranasal malignancies may include rhinectomy, palatectomy, and nants used in the manufacture of maxillectomy. These procedures leave patients with significant facial furniture, textiles, nickel, and radidefects that are corrected with staged surgical reconstructions or um-dial paints also have been applications of facial prostheses. This article describes the etiology implicated in the development of of intranasal SCC, discusses treatment options, and presents a case malignant tumors in the nose, study that chronicles the events from diagnosis through rehabilita- sinuses, and nasopharynx. Reverse tion of a patient undergoing rhinectomy, partial bilateral maxillecto- smoking (ie, smoking cigarettes and cigars with the lighted end my, and partial palatectomy. AORN J 63 (Jan 1996) 163-182.
eceiving a diagnosis of cancer, under any circumstances, is a devastating event. For the patient diagnosed with intranasal squamous cell carcinoma (SCC), the devastation may be coupled with concerns about his or her physical appearance after surgical treatment to eradicate the malignant tumor. As the nose is the most prominent feature of the face, surgical resection carries important aesthetic, physiologic, social, and psychologic implications.'
DONNA R. M v E W E N . R N : SUSAN A. M A R E N I I A , MI)
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Figure 1 Preoperative view of patient showing induration of maxilla and stenosis of nares.
inside the mouth) contributes to the high incidence of upper aerodigestive tract carcinomas seen in India and some parts of Central and South America: Diagnosis. Diagnosis of intranasal carcinoma may be difficult because the malignancy may mimic autoimmune diseases of the skin, inflammatory dermatosis, cutaneous infections, or trauma. These factors may contribute to the late diagnosis of SCC, allowing the cancer cells to spread and invade adjacent structures. Presenting patient symptoms may include reports of nasal obstruction, epistaxis, localized pain, and dental pain. The otorhinolaryngologist determines the extent of the disease through physical examination of the patient, x-rays, computed tomography (CT) scans, and biopsies that are performed under local anesthesia.6 Treatment options. Otorhinolaryngologists determine patients’ treatment options by classifying head and neck carcinomas according to criteria developed by the American Joint Committee on Cancer. This tumor classification method assesses three basic components: the size of the tumor (T), the absence or presence of regional lymph nodes (N), and the absence or presence of distant metastatic disease (M). Each component is followed by a letter or number that further defines the component (eg, stages T1 to T4 indicate increasing size or extent of tumor, NO indicates no lymph node involvement, MO indicates no distant spread of disease).’ The five-year survival rate for patients with T1 and T2 tumors is 70%, and the five-year survival rate for patients with T3 and T4 tumors is 15% to 20%. These tumors can be described based on tumor size and spread. Characteristics of the four stages of upper
aerodigestive tract carcinomas include the following. Stage T1: The tumor is confined to the inferior antrum without bone erosion. Stage T2: The tumor is confined to the superior antrum without bone erosion of the inferior or medial walls. Stage T3: The tumor is extensive and involves the skin of the cheek, the orbit, the anterior ethmoids, and/or the pterygoid muscles. Stage T4: The tumor is massive (ie, more than 4 cm in diameter) and involves the cribriform plate, posterior ethmoids, sphenoid, nasopharynx, pterygoid plates, and/or the base of the skull.8 Tumors less than 4 cm in diameter (ie, T1 and T2 tumors) are treated with surgical resections and radiation therapy if cancer cells are left at the surgical margins or if the carcinoma recurs. Aggressive intranasal SCCs (ie, T3, T4 tumors) must be treated with extensive surgical resections (eg, rhinectomy, palatectomy, maxillectomy) and radiation therapy followed by staged reconstructions or prosthetic rehabilitation. PATIENT PROFILE
Mr R was a 68-year-old, Latin-American male who came to the otorhinolaryngologist with a threemonth history of swelling and mild tenderness in his left nasal caudal septum. Mr R’s general practitioner previously had prescribed antibiotics; however, they did not resolve the facial swelling and tenderness. Patient findings. On physical examination of Mr R, the otorhinolaryngologist noted minimal tenderness and swelling of Mr R’s nasal septum and hardening of the surrounding upper lip and maxillary alveolar mucosa. The tip of the Mr R’s nose was prolapsed and fixed with some stenosis of the external nares (Figure 1). The otorhinolaryngologist also observed swelling and mild erythema of the premaxillary area. A radiographic sinus series demonstrated bilateral calcifications in Mr R’s maxillary sinuses. Mr R denied any personal history of diabetes mellitus, hypertension, liver disease, or cancer. He denied the use of prescribed or over-the-counter medications other than antibiotics. Mr R’s only previous surgery was for the removal of a mole from his back. He admitted to the concomitant use of cigarettes and alcohol. Using a local anesthetic agent, the otorhinolaryngologist performed a biopsy of the swollen area at the anterior margin of Mr R’s nasal septum to 165
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obtain a preliminary diagnosis. Mr R continued taking his antibiotics and returned to the otorhinolaryngologist’s office one week later, at which time the otorhinolaryngologist informed Mr R of the biopsy results, which demonstrated SCC. Hospitalization. The otorhinolaryngologist arranged for Mr R’s admission to the hospital to perform further diagnostic tests, to develop a treatment plan, and to determine the extent of the disease. Computed tomography - . . scans Figure 2 A computed tomography scan of the patient‘s paranasai sinuses. of Mr R’S maxillofacial sinuses revealed densities in the floors of both maxillary sinuses and fullness in the base of his increased risk for developing an infection during nares and upper lip (Figure 2). Other CT scans radiation therapy. The otorhinolaryngologist also informed Mr R revealed no disease or abnormalities in Mr R’s orbital or intracranial structures. Medical technicians per- that he would have to undergo radiation therapy to formed routine laboratory tests (ie, urinalysis, com- the head and neck region that could compromise plete blood count, prothrombin and partial thrombo- blood flow to the bone and soft tissues of the plastin times), and all laboratory results were within mandibular and maxillary regions. She explained that normal limits. Using the results of Mr R’s physical this compromise in blood flow could weaken the examination, CT scan results, radiographic reports, bone and tissue, decrease Mr R’s ability to respond to and pathology findings, the otorhinolaryngologist infection, and place him at risk for tissue t r a ~ m a . ~ classified Mr R’s tumor as a type “T4NOMO” (ie, 4cm or greater tumor without lymph node involvement PREOPERATIVE NURSING CONSIDERATIONS Given the nature of Mr R’s proposed initial suror distant spread of the disease). Treatment recommendations. The otorhino- gical procedure, the circulating nurse faced many laryngologist recommended that Mr R undergo sur- challenges in developing a perioperative patient care gical resection of the tumor and its margins, which plan to meet Mr R’s special needs. The circulating would include rhinectomy, partial palatectomy, and nurse arranged for extra time during the preoperative bilateral partial maxillectomy. The surgeon outlined interview for Mr R to verbalize his fears and anxiher plan to reconstruct Mr R’s upper lip, which eties about the procedure. would be resected with his nose. The reconstruction Day of surgery. The circulating nurse conwould occur at the time of the initial surgery using firmed Mr R’s identity and reviewed his chart to veran advancement technique known as a Gilles fan ify the presence of a signed and witnessed informed flap. She further recommended that Mr R undergo surgical consent, current laboratory reports, and prosthetic rehabilitation instead of facial reconstruc- other test results. She determined Mr R was not tion after surgery, because Mr R would need postop- allergic to medications or iodine and reinforced preerative radiation therapy to treat any residual disease. vious preoperative teaching that included informaThe surgeon informed Mr R that he would have tion about the surgical environment and experience. to undergo a total odontectomy and alveoloplasty (ie, The anesthesia care provider met with Mr R, inserted removal of the teeth, surgically smoothing the rough a peripheral IV line, and placed invasive monitoring surface of the tooth-bearing bone) before radiation lines (eg, radial arterial line, central venous pressure therapy would begin. A complete odontectomy and line). During this time, the circulating nurse returned alveoloplasty was performed 10 days after Mr R’s to the OR to collaborate with the scrub person and primary surgical procedure because his carious den- surgeon in preparing for the surgical procedure. Surgery preparations. The circulating nurse tition and early gingival disease placed him at 166 AORN JOURNAL
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knew the surgical procedure would be lengthy, so she took appropriate measures to protect Mr R from hypothermia and potential injury related to positioning. She obtained a circulating warm-air unit and a temperature regulating blanket and furnished the anesthesia care provider with two IV fluid warmers. The circulating nurse placed a full-length, table-sized gel pad over the OR bed and obtained egg crate foam to aid with patient positioning. The scrub person assembled the necessary nasal and plastic reconstruction instruments and supplies for the rhinectomy, maxillectomy, and palatectomy procedures. Central sterile supply personnel gas sterilized and aerated a custom-made, palatal prosthetic splint before surgery, according to hospital policy and procedures and the manufacturer’s guidelines. The scrub person gathered and tested a multifunction, air-powered handpiece with oscillating saw and rotating burr attachments so the surgeon could adapt the splint during surgery. The circulating nurse prepared a small table of supplies the otorhinolaryngologist would use to administer a preoperative application of 4% topical cocaine solution and injection of local anesthetic medication to Mr R’s surgical site. INTRAOPERATIVE NURSING CONSIDERATIONS
After the circulating nurse returned to the preoperative holding area, she and the anesthesia care provider transported Mr R to the OR and assisted him from the transport stretcher onto the OR bed. The circulating nurse secured Mr R to the OR bed by placing a safety strap two inches above his knees. She activated the temperature-regulating blanket and placed a warm blanket over Mr R to ensure his comfort and reduce heat loss. Patient preparation. The circulating nurse remained at the head of the OR bed during the induction of general anesthesia and the subsequent intubation to provide emotional support for Mr R and to assist the anesthesia care provider. After a successful orotracheal intubation, the circulating nurse inserted a Foley catheter into Mr R’s bladder and connected the catheter to a metered urine collection bag, which she placed by the anesthesia care provider. While the circulating nurse catheterized Mr R, the otorhinolaryngologist injected a 2% lidocaine solution into Mr R’s bilateral nasal vestibule, nasal ala regions, and gingivobuccal sulci. The surgeon then placed 4%topical cocaine-soaked neurosurgical patties into Mr R’s nasal passages. These preoperative measures were performed to promote venous
Figure 3 Line of surgical resection through the (A) nasal bone, (B) superior turbinate, (C) middle turbinate, (D) inferior turbinate, and (E) maxilla bone. (Court0sy of Lani McEwen, Sun Antonio)
constriction and reduce intraoperative bleeding. The surgical team members carefully positioned Mr R by padding all his bony prominences and pressure points with egg crate foam, and they placed a small pillow beneath his knees to prevent back strain. After confirming that Mr R was in correct anatomical alignment, the circulating nurse selected a site on Mr R’s anterior thigh for placement of the electrosurgical unit dispersive grounding pad, making sure the site was free of hair for adequate pad adhesion. The anesthesia care provider placed a circulating warm-air blanket on Mr R’s torso and lower body and activated the warming unit. The circulating nurse used two separate povidone-iodine prep trays to prep Mr R’s face and oral cavity. She placed sterile towels along each side of Mr R’s neck to prevent pooling of the prep solution. The scrub person assisted the surgeon and surgical assistant with gowning and gloving and facilitated placement of the sterile drapes on the patient. Surgical technique. The surgeon began the procedure by marking bilateral, lateral rhinotomy incision lines that would incorporate approximately 90% of Mr R’s upper lip (Figure 3). She carried these incisions laterally and intraorally over Mr R’s maxillary sinus antrums and created openings into the antrums to observe the interior of Mr R’s sinus cavities. The surgeon noted invasion of tumor in Mr R’s left sinus cavity. The surgeon continued the procedure by making medial and lateral alotomy incisions into Mr R’s nasal 168
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Figure 4 Initial incision lines for resection of tumor.
vestibule. She observed an extensive amount of tumor in Mr R’s nasal vestibule and anterior septum. Using Mayo scissors, the surgeon cut through the vomer at the level of the upper lateral cartilages and above the inferior turbinates. Next, she used a chisel to connect the antrostomies to the septa1 cuts, and she made additional chisel cuts to incorporate the anterior two thirds of the hard palate in the resection (Figure 4). After completing the osteotomies, the surgeon used a gentle rocking motion to remove the specimen in one piece (Figures 5 and 6 ) . The circulating nurse, acting on the surgeon’s orders, sent several samples of the tumor’s margins for frozen-section analysis. The pathologist verified that the tumor had been resected completely by noting that the tumor samples did not show evidence of further malignancy. Figure 7 shows the tissue defect after tumor removal.
The surgeon progressed to the next phase of the surgical procedure by placing the palatal splint inferior to the resection site in Mr R’s oral cavity, noting the fit and position. She removed the splint and refined it by using an oscillating saw and a cutting burr before securing it to the remainder of Mr R’s hard palate with three titanium screws. The surgeon made a circumferential incision from the remainder of Mr R’s upper lip down to the latter one third of his lower lip (ie, 2.5 cm lateral to the outer edge of the vermilion border) to reconstruct the upper lip. The surgeon carried these incisions to the level of the orbicularis oris muscle and subcutaneous tissue (Figure 8) and continued her blunt dissection of the area parallel to the neurovascular bundle. She made back cuts into each Gilles fan flap to release tension and began to reapproximate the flaps by
Figure 5 Anterior view of resected tumor showing the patienf‘s palate and the floor of maxillary sinus.
Figure 6 Posterior view of en bloc specimen. Ruler measures a massive tumor more than 4 cm in diameter. 169
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Figure 7 Facial defect after tumor removal for intranasai squamous cell carcinoma.
Figure 9 Gilles fan flap incision partially sutured with palatal splint visible below the tumor resection site.
Figure 8 Giiies fan flap incisions for upper lip reconstruction after intranasai tumor resection.
Figure 10 Reconstructed lip and open nasal defect with 8-Fr feeding tube inserted into left nasal cavity.
closing them in layers with absorbable suture. The surgeon made further modifications in the back cuts and closed the back cuts with nonabsorbable sutures using a Z-plasty technique. She reapproximated Mr R’s skin incision and vermilion border with silk and nonabsorbable nylon sutures (Figure 9). After the circulating nurse and scrub person verified that the sponge and sharp counts were correct, the surgeon lightly packed Mr R’s sinus and nasal cavities with one-half-inch iodoform gauze. The scrub person applied antibiotic ointment to the remaining incision sites and placed a large piece of petroleum gauze over the nasal defect. The surgeon placed an 8-Fr, pediatric-sized feeding tube through
Mr R’s left nasal cavity opening and sutured the feeding tube to Mr R’s face (Figure 10). The surgical team members moved Mr R onto a transport stretcher and transferred him to the postanesthesia care unit (PACU). Mr R remained intubated en route to the PACU, and the anesthesia care provider gave respiratory support to Mr R during the transfer. POIFMPWRATIW NURSING C0NSIDUIATH)NS
Mr R remained intubated while he was in the PACU and after he was transferred to the surgical intensive care unit (SICU) to avoid airway compromise from the nasal packing and postoperative 170
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edema in the oral cavity. Also, the small size of Mr R’s reconstructed mouth opening would make reintubation difficult. The anesthesia care provider successfully extubated Mr R on the first day after his surgery, and Mr R was transferred to the postoperative nursing unit after two days in the S K U . Postoperative nurses administered enteral nutrition through Mr R’s feeding tube after his transfer to the SICU. The surgeon removed Mr R’s nasal packing three days after the surgery and repacked Mr R’s nasal defect daily to promote granulation of his wound edges. Mr R’s recovery from surgery went smoothly, and he progressed to the point where he took responsibility for performing his own wound care and dressing changes. SUBSEQUENT TREATMENT
Mr R underwent a second surgical procedure, radiation therapy, and extensive rehabilitation after his initial surgery. Second surgical procedure. Oral maxillofacial surgeons performed odontectomy and alveoloplasty procedures under general endotracheal anesthesia 10 days after Mr R’s rhinectomy procedure. A root tip from one of Mr R’s teeth was retained after the odentectomy, which necessitated Mr R’s return to the OR for surgical removal of the tip. Mr R was discharged the day after the procedure to remove the retained root tip. Radiation therapy. Approximately one month after Mr R’s second surgical procedure, he returned to the hospital for radiation therapy. The radiation therapy focused on Mr R’s nasopharynx, lateral face, and lateral nares. Mr R tolerated the radiation therapy without complications, except for a mild case of conjunctival hyperemia (ie, blood located in the conjunctiva of the eye) that developed early in the treatment. An ophthalmologist successfully treated the conjunctival hyperemia with steroid ophthalmic drops. A CT scan was performed five days after the completion of radiation therapy, and it showed no evidence of tumor recurrence. Rehabilifation.Mr R kept his nasal defect covered with sterile gauze pads. He did not undergo speech therapy because a palatal prosthesis enabled him to be understood by others. Five months after completing his radiation therapy, Mr R traveled to St Louis to meet with the anaplastologist (ie, individual specially trained in the art of reconstructing body parts) who would create his facial prosthesis. Benefits of nasal prostheses. There are approxi-
mately 300 people who create various facets of maxillofacial prosthetics in the United States. This technology is associated closely with the dental laboratory industry (ie, prosthodontics), as the materials and construction methods parallel those used by dental prosthodontists. Anaplastologists, dentists, maxillofacial dental technicians, ocularists, and some medical sculptors are involved with this specialty.1° The use of a nasal prosthesis is the cornerstone of rehabilitation after a rhinectomy procedure because the nasal prosthesis offers the patient an immediate solution for the facial defect and can be used without further surgical intervention.Il Staged surgical reconstruction, using an advancement or free-flap tissue graft, may not produce the same superior result as a prosthesis sculpted by a skilled anaplastologist. The authors of one clinical study suggest that staged surgical reconstruction not begin until at least two years after a rhinectomy procedure to allow for the possibility of further surgery for the recurrence of the original lesion.’* Patient education. The anaplastologist discussed the step-by-step procedure for constructing Mr R’s nasal prosthesis with Mr R and his family members and told them that the prosthetic construction process would require three to five days. The anaplastologist worked closely with Mr R and his family members to achieve an aesthetically pleasing end product. Mr R brought photographs of himself before surgery to provide the anaplastologist with an idea of his preoperative appearance. Facial impression. The prosthetic construction process began with a facial impression. After reinforcing his previous explanation of the procedure, the anaplastologist positioned Mr R comfortably in a semireclining position in a chair. The anaplastologist placed towels around Mr R’s hairline and neck areas and coated Mr R’s eyebrows with petroleum jelly to prevent adhesion of the casting material in that area. The anaplastologist then placed petroleum-coated gauze into Mr R’s open nasal cavity and positioned small tubes in Mr R’s mouth to facilitate breathing. The anaplastologist mixed alginate, an irreversible hydrocolloidal impression material widely used for dental impressions, into a thin solution and poured it over Mr R’s face. While this mixture covered Mr R’s face, the anaplastologist placed a thicker mixture of the same material over the first layer. The anaplastologist then placed multiple loose strips of gauze into the exposed alginate to strengthen the 172
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Figure 1 1 Full frontal view of nasal prosthesis.
Figure 12 Semilateral view of nasal prosthesis.
mixture before he covered the mask with quick-set plaster of paris. Depending on the viscosity of the alginate mix, the impression mask requires 20 to 25 minutes to set. The anaplastologist carefully removed Mr R’s mask and placed the mask in a mold. The anaplastologist painted the interior of the mask with a separation medium before he coated the entire impression with liquefied gypsum dental stone. After the stone hardened, the anaplastologist removed the impression mask, which revealed a three-dimensional stone moulage or cast of Mr R’s face. The moulage was used to shape and base the prosthesis. Wax sculpting. The anaplastologist took additional impressions from Mr R’s stone moulage to provide a smaller work surface for the next step in prosthesis construction, which was the wax sculpting of Mr R’s nose. Using preoperative photographs, the anaplastologist carved a wax model of Mr R’s nose. This wax nose was placed on Mr R and adjusted for fit and appearance. After achieving a satisfactory result with the wax prosthesis, the anaplastologist made a two-part dental stone mold of the wax nose. Prosthetic molding. Historically, a variety of materials have been used for final construction of nasal prostheses. In the past 16 years, the most acceptable material for use in fabrication of extraoral prostheses has been polydimethyl siloxane, a medical-grade elastomer silicone.I3 Polydimethyl silox-
ane is semiclear, so it must be tinted with dry pigments to obtain a tint that is close to the patient’s basic skin color. The anaplastologist mixed the tinted elastomer with a curing agent and poured the mixture into the two-part dental stone mold of Mr R’s nose. The anaplastologist placed the mold in a drying oven to cure for two to three hours. After curing, the anaplastologist removed Mr R’s mold from the drying oven, released the prosthesis, and trimmed the rough edges of the prosthesis. The anaplastologist also removed the excess silicone from behind the prosthesis and snipped off the inner ends of the nostrils to provide an opening for breathing. Permanent extrinsic tinting. After applying the prosthesis to Mr R’s face and verifying a satisfactory fit, the anaplastologist was ready to begin the third and final phase of prosthesis construction, the permanent extrinsic tinting. He removed the prosthesis from Mr R’s face and refined the nasal prosthesis with the application of additional tinted medicalgrade silicone and the inclusion of small red and purple fibers to simulate blood vessels. The anaplastologist sandblasted and painted skin pores into the prosthesis for a more realistic appearance. Prosthetic anchoring. Anaplastologists anchor nasal prostheses to patients’ faces by attaching them to eyeglasses, using medical-grade adhesives (ie, similar to the 173
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types used to secure ostomy appliances), or Future rehabilitation. Mr R has been followed carefully by the otorhinolaryngologist for recurrence using bone-anchored osseointegrated implants.14 Each method has advantages and drawbacks. of his tumor. At the present time, there is no evidence Eyeglass attachment, while convenient, may not pro- of tumor recurrence. Mr R successfully maintains his vide a satisfactory anchor because the eyeglass nasal prosthesis and is satisfied with his overall frames may slip and result in prosthetic gaps. appearance (Figures 11 and 12). Mr R has returned to Although retention with osseointegrated bone the hospital for further consultation with the surgeons anchors is excellent, optimum tissue recovery, in the division of oral maxillofacial surgery. The oral impeccable hygiene, and good manual dexterity are maxillofacial surgeons plan to rebuild Mr R’s resectcrucial to the success of this method, and these ed palate and maxillary ridge with an osseocutaneous anchors are still under investigation by the US Food vascular free flap taken from his radius. This proceand Drug Administration. Attachment with medical- dure, combined with a revision of Mr R’s recongrade adhesives, the most commonly used method, structed mouth to widen the opening, will result in may be associated with problems such as further improvement of Mr R’s appearance and allow for future denture fitting. skin irritation, lack of margin integrity, SUMMARY prosthetic misalignment, and inconsistent retention.15 The physical, emotional, and psychological conMedical-adhesive attachment method. The siderations associated with extensive surgical resecanaplastologist chose the medical-adhesive attach- tions for the treatment of intranasal SCC are numerment method for Mr R and instructed him on apply- ous. Familial support, competent and compassionate ing the adhesive to the inner side of his prosthesis. nursing care, and skilled surgeons, combined with Mr R learned to apply the medical adhesive with a successful prosthetic rehabilitation, can help restore cotton-tip applicator, allowing it to remain open to self-confidence and self-esteem for patients undergoair for two to three minutes before applying the pros- ing these radical surgical procedures. A thesis to his face. The anaplastologist told Mr R that the prosthesis, if properly cared for, would last six months to one year, and he taught Mr R how to Donna R. McEwen, RN, BSN, CNOR. CNRN, is a primaintain his prosthesis. Oil, dirt, perspiration, and mary neurosurgery nurse at South Texas Veterans extreme changes in temperatures can cause loosen- Health Care System, Audie L. Murphy Division, San ing of the prosthesis; therefore, Mr R was instructed Antonio. to carry extra adhesive and cleaning supplies for Susan A. Marenda, MD. is an otorhinolaryrigologist in mishaps. The cost of the first nasal prosthesis was private practice, San Antonio. $550, and additional prostheses will cost Mr R $230 each. It will take an anaplastologist one to two weeks The authors wish to thank Lani McEwen, San Antonio, to make and ship additional prostheses to Mr R. for preparing the original illustration used in this article. NOTES 1. R J Stanley, K D Olden,
“Rhinectomy for malignant disease,” Archives of 0tolaryngolog)LHead and Neck Surgery 114 (November
1988) 1307-1311. 2. S I Schwartz, G T Shires, F C Spencer, Principles of Surgery, sixth ed (New York: McGraw-Hill Book CO,1994) 595-658. 3. S E Otto, Oncology Nursing, second ed (St Louis: Mosby-Year Book, Inc, 1993) 221. 4. B E Jarrell, R A Carabasi, Surgery, second ed (Malvem, Pa: Harwal Publishing Co, 1991) 332-338. 5. Otto, Oncology Nursing, 222; Schwartz, Shires, Spencer, Principles of Surgery, 60 1-602.
6. R J Stanley et al, “Aggressive intranasal carcinoma mimicking infection or inflammation,” Cutis 42 (October 1988) 288-293; Jarrell, Carabasi, Surgepy, second ed, 332333. 7. American Joint Committee on Cancer Manual for Staging of Cancer (Philadelphia: J B Lippincott Co, 1983); Otto, Oncology Nursing, 50. 8. American Joint Committee on Cancer Manual for Staging of Cancer; Jarrell, Carabasi, Surgery, sec-
ond ed, 333. 9. Otto, Oncology Nursing, 250. 10. E H Rommerdale, “Maxillofacial technology, part 1: Introduction to facial impressions,” Trends and Technology in the Contemporary Dental
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Laboratory 7 (May 1990) 36-39. 11. Stanley, Olden, “Rhinectomy for malignant disease,” 1307-13I I . 12. J Teichgraeber, H Goepfert,
“Rhinectomy: Timing and reconstruction,” 0tolaryngolog)LHead and Neck Surgery 102 (April 1990) 362-369. 13. E H Rommerdale, “Maxillofacia1 reconstruction technique, part 2: Coloring and processing the prosthesis,” Trends and Technology in the Contemporary Dental Laboratory I
(July/August 1990) 24-28. 14. J J Gary, M Donovan, “Retention designs for bone-anchored facial prostheses,” Journal of Prosthetic Dentistry 70 (October 1993) 329-332. 15. h i d , 329.