neoplasms of nose & para nasal sinuses
DESCRIPTION
pptTRANSCRIPT
Moderator- Dr. Baldev Singh (Professor & Head) Presenter- Dr. Gaurav Kataria
NEOPLASIA Means Process of new growth
Defined as an abnoramal mass of
tissue, the growth of which exceeds & is uncoordinated with that of normal tissues and persist in the same excessive manner after cessation of the stimuli which evoked the change.
TypesBenign Usually smooth, localised and covered with mucous membrane Malignant Usually friable, having granular surface & have bleeding tendency
Features Characterized by Pleomorphism Abnormal nuclear morphology Mitoses Loss of polarity Hyperchromatism Other changes like tumor giant cells and polymorphism
SINONASAL NEOPLASM 3% of aerodigestive malignancies 1% of all malignancies male : female 2:1
Sixth to seventh decade Predominately of older males Exposure: Wood, nickel-refining processes Industrial fumes, leather tanning Cigarette and Alcohol consumption
CLASSIFICATION EPITHELIALBenign
Squamous papilloma Inverted papilloma Columnar papilloma Adenoma Nasal dermoid
Malignant
Squamous cell carcinoma Transitional cell carcinoma Adenocarcinoma Adenoid cystic carcinoma Melanoma Olfactory neuroblastoma Undifferentiated carcinoma Basal cell carcinoma
NonepithelialBenign Fibroma Chondroma Osteoma Neurilemmoma Neurofibroma Hemangioma leiomyoma
Malignant
Soft-tissue sarcoma Rhabdomyosarcoma Leiomyosarcoma Fibrosarcoma Liposarcoma Angiosarcoma Myxosarcoma Hemangiopericytoma Connective tissue sarcoma Chondrosarcoma Osteosarcoma Malignant histiocytoma Osteogenic sarcoma Neurogenic tumors
Lymphoreticular tumors Lymphoma Plasmacytoma
Giant cell tumor
Metastatic tumours
Tumors of the nasal cavity proper are
approximately evenly divided between benign and malignant neoplasia, with inverted papilloma predominating in the benign group& squamous cell carcinoma in the malignant. On the other hand, most sinus tumors are malignant with squamous cell carcinoma being the most prevalent.
The maxillary sinus is most commonly involved with tumor, followed by the nasal cavity, the ethmoids and then the frontal & sphenoid sinuses.
Maxillary sinus most common (55 %) Nasal cavity 35 %
Ethmoid sinuses 9 % Frontal and sphenoid sinuses (1 %)
Benign Sinonasal TumorsEPITHELIAL Squamous papilloma Inverted papilloma Columnar papilloma Salivary Adenoma Nasal dermoid
NON EPITHELIAL
Ossifying Fibroma Chondroma lipoma Osteoma Ameloblastoma (adamantinoma) Fibrous dysplasia Neurilemmoma Neurofibroma Hemangioma meningioencephalocoele Schwanoma,meningioma, glioma Angiofibroma leiomyoma
Squamous Papilloma Mainly occurs in skin of the nasal vestibule & septum (
lower part ) Usually solitary, pedunculated or sessile warty lesions Also k/a everted papilloma Sometimes causes nasal obstruction Treatment local excision with cauterisation of base to prevent recurrence Cryosurgery or laser can also be used
Papilloma Nasal papillomas are true neoplasms and, while their etiology is unclear, they are known to arise from the nasal respiratory epithelium, which undergoes metaplastic change and proliferation. Papillomas differ from inflammatory polyps, which are more common, in that inflammatory polyps are associated with allergic rhinitis and are actually reactive lesions, not a tumor.
Three types: Fungiform papillomas 50 % of all arises from nasal septum, cylindrical papillomas 3% of total from lateral wall or sinus inverted papillomas 47 % of total from lateral wall
Inverted Papilloma Also k/a transitional cell papilloma & ringertz tumor 4 % of all nasal neoplasms 4 / million population, rare in blacks
Male > female, 3: 1 to 10: 1 Age affected 40- 70 years Most common site lateral wall of nose Presents as unilateral, friable, pale , pink mass arising
from middle meatus Diagnosis made by punch biopsy
Their etiology is unclear. They are known to have high recurrence rates. They are associated with malignancy and also
have locally aggressive growth patterns, which makes them technically difficult to remove. There is also controversy over the appropriate surgical approach for tumor removal. There is a role for radiation therapy
Inverted papillomas arise from the Schneiderian membrane, which is an invagination of the olfactory ectoderm that occurs during the fourth week of embryonic development. The mucosa creates a transitional zone between the endodermally-derived respiratory epithelium of the nasopharynx and keratinizing squamous epithelium with the nasal vestibule.
Grossly, inverted papillomas appear more opaque than inflammatory polyps, and this is because they have a thick epithelial layer.
Inverting papilloma traces its name to the
histologic appearance with squamous epithelium inverted in the polyps
They are commonly located in the
nasal cavity and they typically involve an adjacent sinus. The most common location is the lateral wall of nose, but other common locations include the ethmoid sinus and maxillary sinus. They have even been found in the nasopharynx.
Clinical featuresSymptoms Nasal obstruction Facial swelling
Hyponasal speech Epistaxis & blood stained discharge Rhinorrhoea
Pressure & pain Orbital symptoms- proptosis,diplopia, epiphora Hyposmia, anosmia
Most common symptoms are unilateral and include
can be an incidental finding on examination. These tumors are rare. They occur about 0.6 cases per 100,000 per year and they occur approximately 1/25th as often as inflammatory polyps. The recurrence rates cited in the literature varies anywhere from 11% to 78%, and this depends a lot on the treatment modality used.
nasal obstruction, nosebleed and nasal discharge. It
They are associated with malignancy, 5% to 15% malignancy rates are most generally accepted. Inverted papillomas are more commonly associated with squamous cell carcinomas. There are four types of association: Metachronous squamous cell carcinoma. Carcinoma in situ within the IP Synchronous lesions Malignant transformation
Differential diagnosis A.C. polyp Allergic fungal sinusitis Sq. cell ca
Adenocarcinoma esthesioblastoma
Treatment Traditionally procedures have been either a transnasal procedure with polypectomy or confined transnasal polypectomy with additional sinus procedure, such as Caldwell-
Luc. The gold standard was lateral rhinotomy with medial maxillectomy. Radiation therapy can be used as the sole therapy for inverted papilloma or it can be used postoperatively. The absolute indication for radiation therapy is when an inverted papilloma is associated with squamous cell carcinoma
The patients who should get radiation therapy are those who had advanced incompletely resected or unresectable lesions that are biologically aggressive, or patients where morbidity in resection would be more pronounced that morbidity of tumor radiation Enbloc ethmoidectomy , medial maxillectomy & mid facial degloving also used
Haemangioma M.C site nasal septum Nasal tip commonest site in external nose Other sites turbinates,nasopharynx, external nose, upper jaws,
frontal bone, nasal bone & maxilla Age group mainly 20-50, with F > M M.C presenting feature.nasal obstruction and recurrent epistaxis. Delayed treatment causes broadening of nose and deformity
Types Capillary haemangioma ( bleeding polypus of septum)- soft, dark
red, pedunculated or sessile arising from anterior part of nasal septum, local excision done .Laser excision is TOC
Cavernous haemangioma Arises from turbinates & lateral wall of nose Surgical excision with cryotherapy is TOC
In extensive lesions radiotherapy along with surgical
excision used
Osteoma Benign osteogenic tumor of slow growth containing
mature bone Most commonly seen in frontal sinus followed by ethmoid & maxillary 15-40 yrs age group m.c. affected
TypesLocalized Ivory osteoma of compact bone frontal sinus Cancellous bone - maxillary/ ethmoid sinus
Mainly asymptomatic, becomes symptomatic when
they block the sinus drainage & mucocele forms Clinical features asymptomatic sinusitis mucocele Being discovered incidentally on X- rays Complete removal of the tumor with its base attachment is done by bicoronal osteoplastic flap technique
Ethmoid osteomas cause proptosis & always invaded
the orbit If they extend posteriorly they can be contiguous with sphenoid bone & are close to optic nerve So simple excision not sufficient they require frontoethmoidectomy Gardners syndrome is an autosomal dominant syndrome of osteomas with other soft tissue tumors and intestinal polyposis. Treatment of osteomas is excision by osteoplastic flap technique or through Lynch-Howarth external frontoethmoidectomy approach
AETIOLOGY
Fibrous dysplasia
Normal bone replaced by collagen, fibroblasts, and osteoid material Most commonly involves maxillary but some times ethmoid & frontal sinuses F> M Usually diagnosed in infancy or childhood & growth may cease after puberty Presents as painless, slow growing swelling, nasal obstruction & progression to deformity Common site in maxilla is canine fossa area or zygomatic area, alveolus is frquently involved
3 histological forms Active form rich in cellular connective tissue with numerous mitotic figures Quiescent more mature connective tissue with fewer mitosis
Inactive form degeneration of connective tissue & matrix
Functional disabilities Orbital - proptosis, impaired vision if o.n.
compressed, epiphora Oral dysarthria, malocclusion, difficulty in chewing Polystotic form with cutaneous pigmentation & endocrine abnormality called Albrights syndrome
Radiography X ray shows ground glass appearance of tumors ( fine
orange peel texture ) CT shows obliteration of sinuses with obliteration of infraorbital margin Treatment Surgical resculptring of the involved bone to achieve a good cosmetic & functional result
Ossifying Fibroma Encapsulated, slow growing benign fibro-osseus
tumors composed of fibrous tissue mixed with varying account of mature bone F>M 3 rd to 4 th decade Most common site is maxilla Lesions occuring in sinuses & cranial bones are more aggressive Diagnosed accidentally on radiographs
Clinical features Facial swelling Deformity Proptosis Malocclusion Treatment surgical excision Prognosis excellent after surgical excision
CT Picture
Chondroma Can arise from ethmoid, nasal cavity or nasal septum Smooth, firm & lobulated tumors Other types mixed fibro, osteo & angiochondromas
Treatment is wide surgical excision because of their
tendency of malignant transformation
Schwannoma Sinonasal schwannoma accounts for 4% of peripheral
benign nerve tumors Arises from surface of nerve fibre Age group 1 st decade to 8 th decade Positive S-100 protein staining Usually lacks the capsule Can present as massive lesions with bony erosions in nasal cavity No malignant degeneration Usually involves trigeminal & ANS Surgical excision by lateral rhinotomy
Meningioma Extracranial meningioma arises from ectopic
arachnoid tissue Can also spread to frontal sinus Can also present intranasally Locally recurrent & difficult to operate Surgical excision Radiotherapy can also be used for inoperable tumors
Glioma 30 % are intranasal 10 % both intra & extra nasal Seen mainly in infants & children
Presents as firm polypoidal mass sometimes
protruding at the anterior nares Surgical excision is TOC
Neurofibroma Arises within nerve fibres Associated with Von Recklinghausens disease Malignant transformation in 15 % cases
Complete surgical excision TOC 5 yrs survival rate 30%
Leiomyoma Sinonasal leiomyoma very rare Presnt as purplish mass causing nasal obstruction Treatment complete excision
No recurrence after complete excision
Intranasal meningoencephalocele Herniation of brain tissues & meninges through
foramen caecum or cribriform plate Presents as smooth polyp in the upper part of nose between the septum & m.t. Usually seen in infants & young children Mass increases in size on crying or straining CT scan essential to demonstrate defect in skull base If it is misdiagnosed & avulsed, it results in meningitis or CSF rhinorrhoea
Treatment is frontal crainotomy severing the stalk
from the brain & repair of dural or bony defect Intranasal mass can be removed as secondary procedure after cranial defect is sealed
Angiofibroma Uncommon, benign, slow growing tumors Most commonly arise from sphenopalatine foramen or
the posterolateral wall of roof of the nose Locally destructive tumors causing invasion into the nasal cavity, maxillary sinuses, orbit & some times in cranium
Extensions Nasal cavity Paranasal sinuses Pterygomaxillary fossa
Infratemporal fossa Cheek Orbit Cranial cavity
Features
M> F Profuse & recurrenty epistaxis Progressive nasal obstruction Denasal speech Facial swelling Conductive hearing loss Serous otitis media Mass in nasopharynx Proptosis Broadening of nasal bridge Involvement of 2,3,4,6 cranial nerves
On CT scan antral sign or holman miller sign which is
pathognomic Surgical excision is TOC Transpalatine approach Transpalatine + sublabial Extended lateral rhinotomy Transmaxillary Maxillary swing approach Infratemporal approach
Salivary adenoma Rare tumors Usually arises from nasal septum Presents with nasal obstruction
Wide surgical excision TOC
Adamantinoma Also c/a ameloblastoma Locally aggressive tumor Arises from odontogenic tssue
M.C involves maxillary sinus Surgical excision is TOC
Nasal dermoid Lined by squamous epithelium Male = female Contain skin appendages like hair follicles, sebaceous
& sweat glands Solid or cystic painless mass Present as widening of upper part of nasal septum with splaying of nasal bones & hypertelorism Pit or sinus may be seen in the midline of nasal dorsum with hair protruding out of it. Complete local excision TOC
Malignant sinonasal tumorsEpithelial
Squamous cell carcinoma Transitional cell carcinoma Adenocarcinoma Adenoid cystic carcinoma Melanoma Olfactory neuroblastoma Undifferentiated carcinoma Basal cell carcinoma Soft-tissue sarcoma Rhabdomyosarcoma Leiomyosarcoma Fibrosarcoma Liposarcoma Angiosarcoma
Nonepithelial
Myxosarcoma Hemangiopericytoma Connective tissue sarcoma Chondrosarcoma Osteosarcoma Malignant histiocytoma Neurogenic tumors
Lymphoreticular tumors Lymphoma Plasmacytoma Giant cell tumor
Malignant Sinonasal TumorsEPIDEMIOLOGY < 1 % of all neoplasms 3% of tumors of upper aero digestive tract 0.44% of all body cancers in India Incidence 0.5-1 / 100,000/ yr 5th -6th decade M:F 2:1 Avg delay between the first symptom and diagnosis six mths
Origin (Scott Brown) Maxillary sinus most common (55 %) Nasal cavity 35 % Ethmoid sinuses 9 % Frontal and sphenoid sinuses (1 %) Despite their infrequence, they represent both a diagnostic and therapeutic challenge because the presenting signs and symptoms may be indistinguishable from benign or inflammatory disorders.
AETIOLOGY Wood workers 70 times increased incidence particularly in ethmoid African mahogany most dangerous Biologically active compounds in wood dust impair mucociliary clearance and predispose to carcinogenesis Hardwood exposure - adenocarcinoma Soft wood exposure - squamous cell carcinoma
Nickel
Relative risk >250 Interval between exposure to nickel and tumor 18 to 36 years Chromium Leather industry Polycyclic hydrocarbons Smoking synergistic with wood dust Aflatoxin (found in certain foods and dust) Mustard gas Thorotrast (thorium dioxide used in paints for watch dials) Radiation Viral EBV, HPV Use of snuff (cocaine) Genetic role suggested but not proven
Sinus anatomyMaxillary antrum Significance Superior orbit, ethmoids Posterior pterygoids, infratemporal fossa
Ethmoid sinus Significance Superior fovea, cribiform Medial lamina papyracea
Sphenoid sinus Significance Superior optic nerve, pituitary Lateral ICA, cavernous sinus Lateral wall < 0.5mm Inferior vidian nerve
Frontal sinus Significance Inferior orbit Posterior anterior cranial fossa
Lymphatic drainage The anterior nose has the same lymphatic
drainage as the external nose. These tend to spread to the submental or level I area. The posterior nose tends to drain to the retropharyngeal nodes as well as the lateral pharyngeal nodes, which eventually drain into the level II.
Squamous cell carcinoma Most common malignant tumor (80%)
Location: Maxillary sinus (70%) Nasal cavity (20%) 90% have local invasion by presentation Commonly associated with bone erosion of lateral nasal wall, palate, alveolus & sometimes pterygoid plates, orbit, cribriform plate & posterior ethmoids & have poor prognosis. Spread Antral to- nasal cavity, ethmoid, orbit via IOF, Infratemporal fossa, buccal sulcus,palate or alveolar ridge through dental foramina, & soft tissues of cheek by erosion of anterior wall
From ethmoid to maxillary antrum, orbit, nose, sphenoid by direct spread & anterior fossa through fovea or cribriform plate Lymphatic drainage: From maxillary sinus to retropharyngeal nodes then to submandibular nodes from ethmoid sinus to jugulodiagstric & subdigastric nodes Surgical resection with postoperative radiation
Squamous cell carcinoma In nose it may arise from vestibule, anterior part of nasal
septum or lateral nasal wall Male > female Age group 50-70 Types Vestibular arises from lateral wall of nasal vestibule & may extend in to columella, nasal floor & upper lip with metastases to parotid nodes Septal arises from mucocutaneous junction & causes burning & soreness in nose.also k/a nose pickers cancer Lateral wall it is the m.c. site. Extends in to ethmoid or maxillary sinuses.presents as polypoidal mass. Metstases rare & treatment is combination of radiotherapy & surgery
Adenocarcinoma
2nd most common malignant tumor 9 % of total sinonasal malignancies Male > female , 5th to 7 th decade Present most often in the superior portions Strong association with occupational exposures like nickel & wood dust Common in ethmoid sinuses
GRADES High grade
Solid growth pattern with poorly defined margins 30% present with metastasis . Pain & deformity also present. Bad prognosis Low grade Uniform and glandular with less incidence of perineural invasion/metastasis
Adenoid Cystic Carcinoma 3rd most common malignancy Around 5 % of total sinonasal malignancies Arises from minor salivary glands with in nasal cavity &
maxillary antrum M.c. affected site maxillary sinus Perineural spread & Vascular spread also present istologically 3 types tubular, cribriform & solid Perineural spread occurs through infraorbital nerve, maxillary nerve, greater palatine nerve & sphenopalatine foramen.
Adenoid Cystic Carcinoma Despite aggressive surgical resection and radiotherapy,
most grow insidiously Neck metastasis is rare and usually a sign of local failure Postoperative RT is very important Prognosis worst
Olfactory Neuroblastoma (Esthesioneuroblastoma)
Tumor of olfactory placode Originate from basal stem cells of neural crest origin. Around 5 % of all sinonasal malignancies Peak at 20 and 50 yrs. With bimodal distribution If peak at 20 yrs, less local recurrence & more metastasis If peak at 50 yrs, more local recurrece & less metastasis Both sex equally affected Presents as cherry red, polypoidal mass in upper third of nasal cavity. Vascular tumor & bleeds profusely on biopsy Kadish Classification A: Confined to nasal cavity B: Involving the paranasal cavity C: Extending beyond these limits D: With mets to neck or distant sites
UCLA Staging system T1: Tumor involving nasal cavity and/or paranasal sinus,
excluding the sphenoid and superior most ethmoids T2: Tumor involving the nasal cavity and/or paranasal sinus including sphenoid/cribriform plate T3: Tumor extending into the orbit or anterior cranial fossa T4: Tumor involving the brain Aggressive behavior Local failure: 50-75% Metastatic disease develops in 20-30% Treatment: En bloc surgical resection with postoperative RT
Chondrosarcoma Rare septal lesion Divided in 1-3 grades histologically Low grade are difficult to distinguish from chondroma
Ring form calcification seen on CT Prognosis poor if present in posterior part of nose &
PNS & often associated with skull base erosion & destruction
Osteogenic sarcoma Rare tumor of nose & PNS but most common bone
tumor Usually affects maxilla Can also involve sphenoid bone Presents as an enlarging, firm mass which is rock hard on palpation Surgical excision difficult due to involvement of skull base 5 yrs survival rate 10 30 %
Rhabdomyosarcoma Common in children M.c. sinus malignancy in children Embryonal variety m.c. which have good prognosis
It presents in nose & PNS as polypoidal outgrowth Positive for desmin immunological marker Treatment is triple therapy with radio, chemo &
surgery.
Vascular tumor arise from pericyte of capillaries Low grade malignant potential Painless grey to tan coloured polypoidal, spongy,
Haemangiopericytoma
haemorrhagic mass Age 5-80 yrs, male = female Presents with epistaxis, nasal obstruction, facial swelling & proptosis Positive for vimentin, CD34, & clotting factor X111 a Occisionally causes paraneoplastic syndrome Wide local excision is TOC, RT used in inoperable cases Recurrence rate 18 %, 2.5% metastatize
Malignant Melanoma 1 % of
nose & PNS cancers M.C. site septum & lateral nasal wall ( in nasal cavity m.c. site septum followed by middle & inferior turbinates) Origin from sinus mucosa rare Peak age 5th to 8th decade, M >F Present as polypoidal slaty grey or bluish black mass Tumor spreads by lymphatics & blood stream Less than 40% have neck nodes Wide surgical excision is TOC Prognosis poor, with 5 yr survival rate 30% Melanoma is positive for S-100, vimentin & HMB -45 immunological markers.
Malignant fibrous histiocytoma Arises in previous bone diseases like fibrous dysplasis Associated with irradiation in that area Presents as gradually expanding mass which is hard on
palpation If it invades skull base it is difficult to resect it
Plasmacytoma Solitary plasmacytoma may be seen without
generalised osseous disease in nasal cavity Males > females Age around 40 yrs Tumors of well differentiated B lymphocytes Treatment is RT later followed by surgery 20 % develop multiple myleomatosis
Lymphoma
Non-Hodgkins type Median age 50 Male > Female Common site nasal septum Most have no other evidence of lymphoma Express T cell markers like CD2, CD43, CD 45RO Ass. With EBV Treatment is by radiation, with or without chemotherapy Survival drops to 10% for recurrent lesions Adverse prognostic factors are asian patients, age > 60, advanced Ann Arbor stage
Basal cell carcinoma External nose is m.c. site for BCC in head & neck 6 th to 8 th decade Male = female
Presentation vary from small nodular growth to
chronic ulcer or ulceronodular lesions Border of ulcer may be rolled out or flat Wide & aggressive surgical excision is TOC as recurrence is common Distant metastasis rare
Picture showing B.C.C. of nose
Metastatic tumors Renal cell carcinoma m.c. lungs
breasts urogenital tract gastrointestinal tract Palliation necessary
Carcinoma of Maxillary sinus & Ethmoid sinus Arises from sinus lining & may present as sinusitis Then it spreads to destroy the bony confines of the
maxillary sinus & invade surrounding structures
Ohngrens classification
Ohngren line Running from the medial canthus of orbit to angle of
mandible Separates tumours into two groups Those that developed above the line Those that developed below it Ohngren suggested Superiorly based cancers more aggressive and poorly differentiated Tumours arising from below line more amenable to treatment With newer imaging & surgical techniques, no longer used now
Lymphatic drainage Lymphatic drainage of nose and paranasal sinuses
relatively scanty Two lymphatic pathways Anterior Anteroinferior part of nasal cavity and skin of vestibule Drain to facial, parotid and submandibular lymph nodes the first echelon nodes These drain into the upper deep cervical chain Posterior Remainder of nose and the paranasal sinuses Pathway which runs anterior to the Eustachian tube to first echelon nodes - the retropharyngeal lymph nodes Further drain to upper deep cervical chain
PATTERNS OF TUMOUR SPREAD Local spread Tend to fill sinus cavity before eroding bony walls Periosteum, perichondrium and dura seem to act as a temporary barriers Bone of the antronasal wall, canine fossa and orbital floor very thin easily destroyed Only 25 percent of maxillary sinus carcinomas are contained within the antrum at time of presentation Regional spread Lymphatic spread apparent in 25-35 % of patients at some time during the course of their disease Only 10 % have nodal disease at time of presentation Submandibular and jugulodigastric nodes most commonly involved
Bilateral lymph node involvement likely when tumor
near midline Distant spread Adenocarcinomas 18% Squamous cell carcinomas 10% Common sites bone, brain, liver, lung, skin
Clinical features
SYMPTOMS Nasal: 50% Obstruction, epistaxis, rhinorrhea Oral symptoms: 25-35% Pain, trismus, alveolar ridge fullness, malocclusion, erosion Ocular: 25% Epiphora, diplopia, proptosis Facial Paresthesias, asymmetry Neck mass Ears Hearing loss, serous otitis media
PHYSICAL FINDINGS Nasal, facial, or intraoral mass Intranasal mass Often necrotic, but polypoid mucosa may obscure Facial swelling antral tumor erodes into cheek Widening of the upper alveolar ridge Loose teeth Palatal mass and ulceration
Proptosis Cranial nerve deficits
CN II, III, IV, VI CN V ( V1 and V2) Complete H&N exam and Endoscopy
Diagnostic Assessment CT scan Three-dimensional image of the lesion Bone destruction, orbital & intracranial involvement MRI Better soft tissue delineation Ability to differentiate between tumor bulk and retained secretions Combined with CT for planning surgery for sinus neoplasms Angiography If the lesion demonstrates enhancement during initial CT study If it approximates carotid system In evaluation of unusual tumors involving the sphenoid sinus and skull base In vascular tumors for assessment of tumor extent, feeding vessels and in combination with embolization
Ultrasound
B-mode scanning orbital masses PET Follow-up after concomitant chemoradiation Assessing presence of metastatic disease Endoscopy and Biopsy Punch biopsy Chances of bleeding Tumors contained within the sinus cavities should be biopsied transnasally Dental / prosthetic consultation
Workup for distant metastasis
CXR PA view USG abdomen
Workup for surgery Hb, TLC, DLC INR, Platelet count Bld Grouping Urine RE,ME BS F/PP LFT, RFT, Electrolytes ECG Lipid profile
Staging of Maxillary sinus cancer (AJCC )
Staging of nasal cavity & ethmoid sinus T1 tumor restricted to any one subsite, with or without bony
invasion T2 Tumor invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion T3 Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate T4a moderately advanced local disease Tumor invades any of the following : anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinus T4b- very advanced disease tumor invades any of the following : orbital apex, dura, brain, middle cranial fossa, cranial nerves other than V 2, nasopharynx or clivus
TREATMENTGeneral principles Most patients have very advanced disease at presentation All investigations & accurate staging Choice between treatment for cure and palliation Options for patients potentially curable Surgery Radiotherpy Chemoradiotherapy Combinations Infusion & perfusion techniques
Surgical options External Ethmoidectomy Inferior Medial Maxillectomy Medial Maxillectomy
Radical Maxillectomy Craniofacial Resections Extended Craniofacial Resection Minimally Invasive Approaches
Surgical approaches Endoscopic Lateral rhinotomy Transoral/transpalatal
Midfacial degloving Weber-Fergusson Combined craniofacial approach
External EthmoidectomyIndications Removal of benign tumors of the ethmoidal region Approach to biopsy and drainage for tumors of sphenoethmoidal region and medial orbit Bony Excision - medial orbital wall and the ethmoidal labyrinth Surgical Approach - incision on the lateral wall of the nose Benefits allows excellent cosmesis and preservation of functional tissue Limitations For limited tumors (middle turbinate) Tendency to form a fistula to nasal cavity on irradiation
Inferior Medial MaxillectomyIndications Resection of medial wall of the antrum and inferior turbinate Most often used for inverted papilloma
Bony Excision margins
Laterally - vertical line dropped from the infraorbital foramen Inferiorly - floor of the nose Superiorly - lacrimal fossa and the middle meatus Posteriorly - dorsal end of the inferior turbinate Surgical Approach - Lateral rhinotomy Benefits Adequate exposure and resection for limited tumors Preserve functional tissue Provide a very acceptable cosmetic result Limitations - provides en bloc removal of limited area
Indication - larger benign or intermediate tumors involving the entire lateral nasal wall but without extension to the orbit, anterior cranial fossa, lateral maxilla, or alveolus Bony Excision - lateral nasal wall, including all turbinate tissue, and the contents of the ethmoid and maxillary sinuses Surgical Approach - Weber Fergusson with Lynch extension and lip split Bony cuts Removal of ant maxillary wall medial to infra orbital foramen Orbital cut from inferior rim carried medially to lamina papyracea Nasomaxillary suture line cut extending from cut 2 into pyriform aperture Cut in lateral nasal wall near floor upto post wall of maxillary sinus Vertical cut from post. nasal floor to post end of sup turbinate & post ethmoidal cells Benefit - en bloc resection with little cosmetic deformity Limitations - Removal of all turbinate tissue results in an abnormal nasal cavity, often requiring chronic management of crusting
Medial Maxillectomy
Medial maxillectomy
Total Maxillectomy Indications - advanced carcinoma of maxilla Bony Excision - removal of maxilla along with nasal bone,
the ethmoid sinus, and in some instances, the pterygoid plates Surgical Approach - Weber Fergusson with a Defenbach (subciliary) extension Bony cuts Zygomatico maxillary suture line Orbital floor & medial orbital wall Naso maxillary suture line Hard palate Pterygoid process
Can be combined with orbital exentration Preformed obturator - support for packing Benefits - When supplemented by irradiation, cure
rate 30% Limitations - Even when orbital exenteration is included - inadequate resection if ethmoidal roof, orbital apex or pterygoid region involved Therefore, careful evaluation & planning required before surgery
Craniofacial Frontoethmoidectomy Indications - en bloc resection for tumors of the
ethmoidal and frontal regions Bony Excision Anterior cranium (including the frontal sinus) Floor of anterior cranial fossa Ethmoid +/- Eye Nasal septum
Benefits Provides direct visualization of the cribriform plate and fovea ethmoidalis Potential for en bloc removal Provides wide exposure to allow effective repair of dural tears Allows intraoperative irradiation or placement of a radioactive implant Limitations - If tumor extends to sphenoid sinus, cavernous or transdurally, en bloc resection cannot be achieved
Extended Craniofacial ResectionIndications - Extensive tumors involving the anterior skull base including pterygoid plates Bony Margins Posterior limits Foramen ovale Foramen rotundum ICA Remaining margins - as for craniofacial frontoethmoidectomy and total maxillectomy Surgical Approach Bicoronal and anterior or lateral facial incisions Closure - split-galea flap to cover dura Benefits - Thorough exposure and complete excision of otherwise unresectable tumors Contrindications - clear-cut pterygoid plate erosion and cranial nerve invasion.
Supplemental Management in Extended Craniofacial Resection Intraoperative iodine seed implantation
Adenoid cystic carcinoma - more beneficial Undifferentiated carcinoma and squamous cell carcinoma - less optimistic Reconstruction Radial forearm Rectus abdominis musculocutaneous flaps Latissimus dorsi flap
Radiotherapy Conventional
66-70 Gy (2.0 Gy/fraction; daily Monday-Friday) in 7 weeks Neck - Uninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction) Concurrent chemoradiotherapy Primary and gross adenopathy: 70 Gy (2.0 Gy/fraction) Neck - Univolved nodal stations: 44-64-Gy (1.6-2.0 Gy/fraction) Postoperative RT Primary 60 66 Gy (2.0 Gy / fraction
Neck
Involved nodal stations: 60-66 Gy (2.0 Gy/fraction) Uninvolved nodal station: 44-64 Gy (1.6-2.0 Gy/fraction) Preferred interval between resection and postoperative RT is