Transcript TUMORS OF THE NOSE AND PARANASAL SINUS

Sino-nasal
Tumours
Dr. Vishal Sharma
Classification
Malignant
Benign
Simple papilloma

Squamous cell carcinoma
Ossifying Fibroma
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Adenocarcinoma
Osteoma
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Anaplastic carcinoma
Haemangioma
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Transitional cell carcinoma
Neurofibroma
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Malignant melanoma
Intermediate
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Salivary gland tumours
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Rhabdomyosarcoma
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Inverted papilloma
Oeteoma
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Osteomas are common incidental finding in
frontal sinus x-ray
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Majority are asymptomatic & do not grow
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Surgery is done for symptomatic osteomas or
those that rapidly increase in size

Complete removal of tumor with its base
attachment is done by bicoronal osteoplastic
flap technique
Frontal sinus osteoma
Bicoronal osteoplastic flap
Osteoma exposed
Tumor removal + closing of
bone flap
Ossifying fibroma

Synonym: Fibrous dysplasia
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Normal medullary bone is replaced by abnormal
proliferation of fibrous tissue, resulting in
distortion & expansion of bone

C.T. scan: ground - glass appearance with
regions of osteolysis & calcification
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Treatment: complete surgical excision
Ossifying fibroma
Ossifying fibroma
Inverted papilloma
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Locally aggressive sino-nasal tumour
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Synonyms: Ringertz or Schneiderian papilloma
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Common in males between 50-70 years
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It arises from the lateral wall of nose
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Presents as unilateral, friable, pale, pink mass
arising from middle meatus
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Diagnosis made by punch biopsy
Inverted papilloma
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Treatment: medial maxillectomy and en bloc
ethmoidectomy by lateral rhinotomy or midfacial
degloving.
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Inverted papilloma has a marked tendency to
recur after surgical removal.
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Squamous cell ca is present in 1015% cases.

Radiotherapy is avoided.
Anterior rhinoscopy
Contrast C.T. scan P.N.S.

Left intra-nasal mass
with opacification of
maxillary and ethmoid
sinuses (African
continent sign).

Bone destruction of
lateral nasal wall.
Punch Biopsy & H.P.E.
Inward invasion of hyperplastic epithelium into
underlying stroma. No evidence of malignancy.
Moure’s lateral rhinotomy
Osteotomy cuts
Bone removed & tumor exposed
Tumour removed & inicision closed
Midfacial degloving approach
Sino-nasal
Malignancy
Epidemiology
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O.5% of all body cancers
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15% of all upper respiratory neoplasm
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Maxillary sinus is most common
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80-85% are squamous cell carcinoma
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Male : female = 2:1
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Commonly seen in 45-60 years
Risk factors
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Hardwood dust (adenocarcinoma)
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Softwood dust (squamous carcinoma)
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Nickel refining; chromium workers
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Boot, shoe and textile workers
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Mustard gas exposure
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Human papilloma virus
Maxillary sinus
malignancy
Early Clinical features
Mimic maxillary sinusitis
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Nasal stuffiness
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Blood-stained nasal discharge
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Facial paraesthesias or pain
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Epiphora
Spread
Late Clinical features
Medial spread:
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Unilateral nasal obstruction
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Unilateral purulent nasal discharge
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Epistaxis
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Unilateral, friable, nasal mass
Anterior spread:
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Cheek swelling
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Invasion of facial skin
Late Clinical features
Inferior spread:
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Expansion of alveolus with dental pain
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Loosening of teeth, poor fitting of dentures
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Swelling in hard palate or alveolus
Superior
spread:
.
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Proptosis
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Diplopia
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Ocular pain
Late Clinical features
Posterior spread:
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Pterygoid muscle involvement  trismus
Intracranial spread via:
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Ethmoids, cribriform plate or foramen lacerum
Lymphatic spread:
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Neck node metastases in late stages
Systemic spread: Lungs, bone
Cheek swelling
Cheek skin involvement
Alveolar & Palatal swelling
Nasal mass
Diagnosis
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Diagnostic nasal endoscopy
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X-ray paranasal sinus: expansion & destruction
of bony wall
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C.T. Scan: axial & coronal cuts with contrast
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Biopsy
X-ray paranasal sinus
C.T. Scan
Ohngren’s Classification
Ohngren's Classification
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Ohngren's line: An imaginary plane extending
between medial canthus of eye & angle of
mandible
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Supra structural growths situated above this
plane have a poorer prognosis

Intra structural growths situated below this
plane have better prognosis
Lederman’s Classification
Lederman’s Classification
2 horizontal lines of Sebileau pass through
floors of orbits & maxillary sinus, producing:
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Suprastructure: ethmoid, sphenoid & frontal
sinuses; olfactory area of nose
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Mesostructure: maxillary sinus & respiratory
part of nose
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Infrastructure: alveolar process
T.N.M. Staging
T1 = tumor confined to antral mucosa
T2 = bone destruction of hard palate / middle meatus
T3 = involvement of skin of cheek, floor or medial
wall of orbit, ethmoid sinus, posterior antral wall,
pterygoid plates, infratemporal fossa
T4 = involvement of orbital contents, cribriform plate,
frontal or sphenoid sinus, skull base, nasopharynx
Treatment
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T1 & T2 = Surgery or Radiotherapy
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T3 = Surgery + Radiotherapy
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T4 = Surgery + Radiotherapy + Chemotherapy
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Europeans: pre-operative Radiotherapy (50006500 cGy)  surgery after 4-6 weeks

Americans: Surgery  post-operative
Radiotherapy after 4-6 weeks
Surgical Options
1. Total maxillectomy (Weber Fergusson incision)
= malignancy limited to maxilla
2. Radical maxillectomy with orbital exenteration
(Weber Fergusson Diffenbach incision)
= involvement of orbital fat
3. Anterior Cranio Facial Resection (extended
lateral rhinotomy incision)
= involvement of cribriform plate, frontal sinus
Total Maxillectomy
Tarsorrhaphy
Weber Fergusson incision
Osteotomy cuts
Total maxillectomy done &
incision closed
Palatal defect & prosthesis
Orbital exenteration indications
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Involvement of orbital apex
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Involvement of extra-ocular muscles
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Involvement of bulbar conjunctiva or sclera
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Lid involvement beyond a reasonable hope for
reconstruction
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Non-resectable full thickness invasion through
periorbita into retrobulbar fat
Orbital exenteration
Cranio-facial resection
Thank You