Transcript TUMORS OF THE NOSE AND PARANASAL SINUS
Sino-nasal Tumours
Dr.Mohammad
aloulah
Benign Classification Malignant
Simple papilloma Ossifying Fibroma Osteoma Haemangioma Neurofibroma
Intermediate
Squamous cell carcinoma Adenocarcinoma Anaplastic carcinoma Transitional cell carcinoma Malignant melanoma Salivary gland tumours Rhabdomyosarcoma Inverted papilloma
Oeteoma
Osteomas are common incidental finding in frontal sinus CT scan
Majority are asymptomatic & do not grow
Surgery is done for symptomatic osteomas or those that rapidly increase in size
Complete removal of tumor with its base attachment is done by FESS, bicoronal osteoplastic flap technique
Frontal sinus osteoma
Bicoronal osteoplastic flap
Osteoma exposed
Tumor removal + closing of bone flap
Ossifying fibroma
Synonym: Fibrous dysplasia
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
Treatment: surgical excision for symptomatic Pt
Ossifying fibroma
Ossifying fibroma
Inverted papilloma
Locally aggressive sino-nasal tumour
Synonyms: Ringertz or Schneiderian papilloma
Common in males between 50-70 years
It arises commonly from the lateral wall of nose
Presents as unilateral, Bilatral, friable, pale, pink mass arising from middle meatus
Diagnosis made by punch biopsy
Inverted papilloma
Treatment: Endscopic medial maxillectomy and en bloc ethmoidectomy by lateral rhinotomy or midfacial degloving.
Inverted papilloma has a marked tendency to recur after surgical removal.
Squamous cell ca is present in 5 – 10 % cases.
Anterior rhinoscopy
Contrast C.T. scan P.N.S.
Left intra-nasal mass with opacification of maxillary and ethmoid sinus
Punch Biopsy & H.P.E.
Inward invasion of hyperplastic epithelium into underlying stroma. No evidence of malignancy.
lateral rhinotomy
Bone removed & tumor exposed
Tumour removed & inicision closed
Midfacial degloving approach
Sino-nasal Malignancy
Epidemiology
·Uncommon tumors - >1% of all neoplasms ·Produces very little symptoms ·Commonly mistaken for rhinosinusitis ·Average delay from first symptom to diagnosis is about 6 months ·Accurate staging is still not possible – Current staging system is only for maxillary & ethmoid sinuses
Epidemiology
·Incidence – 1% per 100,000 / year ·Commonly develop during 5 th – 6 th decades of life ·Twice as common in men than women ·Common sino-nasal malignancy – Primary epithelial tumors followed by non-epithelial malignant tumors ·Tumors arising from nose 25% and tumors arising from sinuses 75% ·60% of squamous carcinomas arise from maxillary sinus, 20% from nasal cavity rest from ethmoids. 1% arise from sphenoid
Common sinonasal malignancy
·Squamous cell carcinoma – commonest ·Adenocarcinomas ·Adenocystic carcinomas ·Undifferentiated carcinomas ·Non Hodgkin's lymphoma ·Melanomas
Adenocarcinoma
Risk factors
Hardwood dust (adenocarcinoma)
Softwood dust (squamous carcinoma)
Nickel refining; chromium workers
Boot, shoe and textile workers
Mustard gas exposure
Human papilloma virus
Maxillary sinus malignancy
Early Clinical features Mimic maxillary sinusitis
Nasal stuffiness
Blood-stained nasal discharge
Facial paraesthesias or pain
Epiphora
Spread
Late Clinical features Medial spread:
Unilateral nasal obstruction
Unilateral purulent nasal discharge
Epistaxis
Unilateral, friable, nasal mass Anterior spread:
Cheek swelling
Invasion of facial skin
Late Clinical features Inferior spread:
Expansion of alveolus with dental pain
Loosening of teeth, poor fitting of dentures
Swelling in hard palate or alveolus Superior spread:
.
Proptosis
Diplopia
Ocular pain
Late Clinical features Posterior spread:
Pterygoid muscle involvement
trismus Intracranial spread via:
Ethmoids, cribriform plate
Lymphatic spread:
Neck node metastases in late stages Systemic spread: Lungs, bone
Cheek swelling
Cheek skin involvement
Alveolar & Palatal swelling
Nasal mass
Diagnosis
Diagnostic nasal endoscopy
X-ray paranasal sinus: expansion & destruction of bony wall
C.T. Scan: axial & coronal cuts with contrast
Biopsy
C.T. Scan
Ohngren ’s Classification
Ohngren's Classification
Ohngren's line: An imaginary plane extending between medial canthus of eye & angle of mandible
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:
Suprastructure: ethmoid, sphenoid & frontal sinuses; olfactory area of nose
Mesostructure: maxillary sinus & respiratory part of nose
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
T1 & T2 = Surgery or Radiotherapy
T3 = Surgery + Radiotherapy
T4 = Surgery + Radiotherapy + Chemotherapy
Europeans: pre-operative Radiotherapy (5000 6500 cGy)
surgery after 4-6 weeks
Americans: Surgery
post-operative Radiotherapy after 4-6 weeks
Surgical Options 1.
Total maxillectomy malignancy limited to maxilla 2. Radical maxillectomy with orbital exenteration involvement of orbital fat 3. Anterior Cranio Facial Resection (extended lateral rhinotomy incision) = involvement of cribriform plate, frontal sinus
Palatal defect & prosthesis
Orbital exenteration indications
Involvement of orbital apex
Involvement of extra-ocular muscles
Involvement of bulbar conjunctiva or sclera
Non-resectable full thickness invasion through periorbita into retrobulbar fat