Neoplasms of nose and paranasal sinuses

Neoplasms of Nose and Paranasal
Sinuses
DR GURCHAND SINGH
Ent department
5/23/2020 1NEOPLASMS OF NASAL CAVITY & PNS

Neoplasms of Nose and PNS
 Very rare 3%
 Delay in diagnosis due to similarity to benign
conditions
 Nasal cavity
 ½ benign
 ½ malignant
 Paranasal Sinuses
 Malignant
2
5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS

Classification
Benign
Simple papilloma
Osteoma
Fibrous dysplasia
Neurogenic tumors
Haemangioma
Chondroma
Angiofibroma
Meningoencephalocele
Gliomas
Intermediate
Inverted papilloma
Malignant
 Squamous cell carcinoma
 Adenocarcinoma
 Haemangiopericytoma
 Adenoid cystic carcinoma
 Malignant melanoma
 Esthesioneuroblastoma
 Lymphoma
 Rhabdomyosarcoma

Oeteoma
 Osteomas are common incidental finding in
frontal sinus x-ray
 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 bicoronal osteoplastic
flap technique5/23/2020 4NEOPLASMS OF NASAL CAVITY & PNS

Frontal sinus osteoma

Bicoronal osteoplastic flap

Osteoma exposed

Tumor removal + closing of
bone flap

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: complete surgical excision5/23/2020 9NEOPLASMS OF NASAL CAVITY & PNS

Mccune Albright Sternberg Syndrome
POLYOSTOTIC FIBROUS DYSPLASIA
CUTANEOUS PIGMENTATION
HORMONAL HYPERFUNCTION
MOST COMMON SITE
MAXILLA
FRONTAL
ETHMOSPHENOID
AGE YOUNG AGE GROUP
CF
ASYMPTOMATIC MASS
PATHOLOGICAL
FRACTURES
FACIAL DEFORMITY
EYE DISPLACEMENT

Neurogenic
tumors
 4% are found within the paranasal sinuses
 Schwannomas
 Neurofibromas
 Treatment via surgical resection
 Neurogenic Sarcomas are very aggressive and
require surgical excision with post op
chemo/XRT for residual disease.
 When associated with Von Recklinghausen’s
syndrome: more aggressive (30% 5yr survival).
13

Chondroma
 Arise from ethmoid,nasal cavity,septum.
 Pure are Smooth,firm,lobulated
 Others may be mixed type
[fibro,osteo,angio]
 Treatment –surgical excision
5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS 14

Meningoencephalocele
 Brain tissue & meninges –foramen
caecum or cribriform plate
 Smooth polyp ,upper part of nose
 Mass increases in size on crying
 If avulsed,CSF rhinorrhoea
 CT SCAN
 T/t—frontal craniotomy,repair of bony
defect

Gliomas
 Rare congential lesion
 60% extranasal,30%intranasal,10% both
 Infants & children
 Firm polyp,incompressible
 sometimes protuding outside
 T/t ..surgery alone.

Papilloma
 Vestibular papilloma- verrucous lesions like skin
warts. Single/ multiple, pedunculated/ sessile.
Tt- local excision with base cauterization.
 Schneiderian papillomas derived from
schneiderian mucosa (squamous)
 Fungiform: 50%, nasal septum
 Cylindrical: 3%, lateral wall/sinuses
 Inverted: 47%, lateral wall
17

Inverted papilloma
 Locally aggressive sino-nasal tumour
 Synonyms: Ringertz //Transitional cell
papilloma // Schneiderian papilloma
 Common in males between 50-70 years
 It arises from the lateral wall of nose
 Presents as unilateral, friable, pale, pink mass
arising from middle meatus
 Diagnosis made by punch biopsy5/23/2020 18NEOPLASMS OF NASAL CAVITY & PNS

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.

Inverted Papilloma Resection
 Initially via transnasal resection:
 50-80% recurrence
 Medial Maxillectomy via lateral rhinotomy:
 Gold Standard
 10-20% recurrence
 Endoscopic medial maxillectomy:
 Key concepts:
 Identify the origin of the papilloma
 Bony removal of this region
 Midfacial Degloving.
22

 Inverted papilloma has a marked tendency to
recur after surgical removal.
 Squamous cell ca is present in 1015% cases.
 Radiotherapy is avoided,chances of conversion
into malgnancy.

Moure’s lateral rhinotomy

Osteotomy cuts

MEDIAL MAXILLECTOMY
REMOVE MEDIAL WALLOF MAXILLAFROM THE FLOOR
OF ORBIT TO FLOOR OF NOSE
CAN BE EXTENDED TO INCLUDE LOWER ETHMOID
SINUSES & LAMINA PAPYRACEA
26

Bone removed & tumor exposed

Tumour removed & inicision closed

Sino-nasal
Malignancy

Epidemiology
 O.5% of all body cancers
 15% of all upper respiratory neoplasm
 Maxillary sinus is most common
 80-85% are squamous cell carcinoma
 Male : female = 2:1
 Commonly seen in 45-60 years

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

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

Posterior spread:
 Pterygoid muscle involvement  trismus
Intracranial spread via:
 Ethmoids, cribriform plate or foramen lacerum
Lymphatic spread:
 Neck node metastases in late stages
Systemic spread: Lungs, bone5/23/2020 37NEOPLASMS OF NASAL CAVITY & PNS

Cheek swelling

Cheek skin involvement

Alveolar & Palatal swelling

Nasal mass

 Diagnostic nasal endoscopy
 X-ray paranasal sinus: expansion & destruction
of bony wall
 C.T. Scan: axial & coronal cuts with contrast
 Biopsy
Diagnosis

X-ray paranasal sinus

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 process5/23/2020 48NEOPLASMS OF NASAL CAVITY & PNS

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, nasopharynx5/23/2020 49NEOPLASMS OF NASAL CAVITY & PNS

Treatment
 T1 & T2 = Surgery or Radiotherapy
 T3 = Surgery + Radiotherapy
 T4 = Surgery + Radiotherapy + Chemotherapy
 Europeans: pre-operative Radiotherapy (5000-
6500 cGy (centiGray)  surgery after 4-6 weeks
 Americans: Surgery  post-operative
Radiotherapy after 4-6 weeks5/23/2020 50NEOPLASMS OF NASAL CAVITY & PNS

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 sinus5/23/2020 51NEOPLASMS OF NASAL CAVITY & PNS

Ethmoid sinus
malignancy

Ethmoid sinus
Primary tumor
(T):
 T1: Tumor confined to the ethmoid with or
without bone erosion
T2: Tumor extends into the nasal cavity
T3: Tumor extends to the anterior orbit, and/or
maxillary sinus
T4: Tumor with intracranial extension, orbital
extension including apex, involving sphenoid,
and/or frontal sinus and/or skin of external
nose
53

Regional lymph nodes (N)
NX: Regional lymph nodes cannot be assesse
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in
greatest dimension
N2: Metastasis in a single ipsilateral lymph node, more than 3 cm
but not more than 6 cm in greatest dimension, or in multiple
ipsilateral lymph nodes, none more than 6 cm in greatest
dimension, or in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
N2a: Metastasis in a single ipsilateral lymph node more than 3
cm but not more than 6 cm in greatest dimension
N2b: Metastasis in multiple ipsilateral lymph nodes, none more
than 6 cm in greatest dimension
N2c: Metastasis in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
N3: Metastasis in a lymph node more than 6 cm in greatest
dimension
54

 Distant metastasis (M)
 MX: Distant metastasis cannot be assessed
M0:No distant metastasis
M1:Distant metastasis
55

AJCC stage groupings
 Stage 0------Tis, N0, M0
 Stage I------T1, N0, M0
 Stage II------T2, N0, M0
 Stage III------T3, N0, M0 T1, N1, M0 T2, N1, M0 T3, N1, M0
 Stage IVA-------T4, N0, M0 T4, N1, M0
 Stage IVB-----Any T, N2, M0 AnyT, N3, M0
 Stage IVC------AnyT, Any N, M1
56

Adenoid Cystic
Carcinoma
 3rd most common site is the nose/paranasal
sinuses
 Perineural spread
 Anterograde and retrograde
 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
57

Mucoepidermoid
Carcinoma
 Extremely rare
 Widespread local invasion makes resection
difficult, therefore radiation is often indicated
58

Adenocarcinoma
 2nd most common malignant tumor in the
maxillary and ethmoid sinuses
 Present most often in the superior portions
 Strong association with occupational exposures
(hard wood workers)
 High grade: solid growth pattern with poorly
defined margins. 30% present with metastasis
 Low grade: uniform and glandular with less
incidence of perineural invasion/metastasis.
59

Haemangiopericytoma
 Age 60—70 presents with epistaxis
 Pericytes of Zimmerman surrounding the capillaries
 Present as rubbery, pale/gray, well circumscribed lesions
resembling nasal polyps with nasal bleed in elderly
 Treatment is surgical resection with postoperative RT for
positive margins
60

30
Melanoma
 0.5- 1.5% of melanoma originates from the nasal
 Nasal cavity and paranasal sinus.
 Anterior Septum: most common
site, bluish- black polypoid mass
 Tumor spreads by both lymphatics and
blood stream.
 Treatment is wide local excision with/without
postoperative radiation therapy

Olfactory Neuroblastoma
Esthesioneuroblastoma
 Originate from stem cells of neural crest origin
that differentiate into olfactory sensory cells.
 Cherry red polypoidal mass in the upper third of
nasal cavity.
 Kadish Classification
 A:confined to nasal cavity
 B:involving the paranasal cavity
 C: extending beyond these limits
62

Olfactory Neuroblastoma
Esthesioneuroblastoma
 Aggressive behavior
 Bimodal incidence at 10-20 & 50-60 years
 Unilateral nasal obst with epistaxix
 Biopsy only after imaging
 Local failure: 50-75%
 Metastatic disease develops in 20-30%
 Treatment:
 En bloc surgical resection with postoperative RT
63

Sarcomas
 Osteogenic Sarcoma
 Most common primary malignancy of bone.
 Mandible > Maxilla
 Sunray radiographic appearance
 Fibrosarcoma
 Chondrosarcoma
 Rare tumor of nose
64

Rhabdomyosarcoma
 Most common paranasal sinus malignancy in
children
 Non-orbital, parameningeal
 Triple therapy is often necessary
 Aggressive chemo/RT has improved survival
from 51% to 81% in patients with cranial nerve
deficits/skull/intracranial involvement.
 Adults, Surgical resection with postoperative RT
for positive margins.
65

Lymphoma
 Non-Hodgkins type on septum
 Treatment is by radiation, with or without
chemotherapy
 Survival drops to 10% for recurrent lesions
66

Sinonasal Undifferentiated
Carcinoma
 Aggressive locally destructive lesion
 Dependent on pathological differentiation from
melanoma, lymphoma, and olfactory
neuroblastoma
 Preoperative chemotherapy and radiation may
offer improved survival
67

Surgery
 Surgical approaches:
 Endoscopic
 Lateral rhinotomy
 Transoral/transpalatal
 Midfacial degloving
 Weber-Fergusson
 Combined craniofacial approach
 Extent of resection
 Medial maxillectomy
 Inferior maxillectomy
 Total maxillectomy
68

ENDOSCOPIC
SURGERY
 ENDOSCOPIC MEDIAL MAXILLECTOMY
INDICATIONS
1. SMALLINVERTED PAPILLOMA
2. SMALLBENIGN TUMORS
3. OSTEOMAS
69

Lateral
Rhinotomy
70

Weber Fergusson incision

72

MIDFACIAL DEGLOVING
 Described by Rouge.
 Rediscovered by Casson et al.
 Cosmetically better
 Completely avoid facial incisions, allows bilateral exposure
 Combines a b/l sublabial approach to the anterior wall of
the maxilla with a midline mobilisation of the cartilaginous
nose using rhinoplasty techniques.
 Excellent exposure of nasal cavity, post nasal space, antra,
pterygopalatine fossae,
73

Midfacial degloving approach

LIMITATION
POOR ACCESS TO ORBIT, LATERAL
ASPECT OF MAXILLA, ETHMOID SINUS
INDICATED FOR
MEDIAL MAXILLECTOMY ,
UNCOMPLICATED CRANIOFACIAL
RESECTION
CONTRAINDICATION
ORBITAL EXENTRATION
SIGNIFICANT SKIN INVOLVEMENT
75

STEPS
1) COMPLETE TRANSFIXION INCISION
2) NASAL STRUCTURE MOBILISATION
3) SUBLABIAL INCISION
4) ELEVATE PERIOSTEUM OF MAXILLAUPTO
INFRAORBITAL NERVE
5) MAXILLECTOMY ,UNCOMPLICATED CRANIOFACIAL
RESECTION IS PERFORMED
 COMPLICATIONS
HEMATOMA
NASALVESTIBULAR STENOSIS
INFECTIONS
76

Orbital exenteration indications
 Involvement of orbital apex
 Involvement of extra-ocular muscles
 Involvement of bulbar conjunctiva or sclera
 Lid involvement beyond a reasonable hope for
reconstruction
 Non-resectable full thickness invasion through
periorbital into retrobulbar fat5/23/2020 77NEOPLASMS OF NASAL CAVITY & PNS

Orbital exenteration

Tarsorrhaphy

MEDIAL MAXILLECTOMY
REMOVE MEDIAL WALLOF MAXILLAFROM THE FLOOR
OF ORBIT TO FLOOR OF NOSE
CAN BE EXTENDED TO INCLUDE LOWER ETHMOID
SINUSES & LAMINA PAPYRACEA
80

INDICATIONS
 INVERTED PAPILLOMA
 ANY BENIGN / MALIGNANT TUMOR
LIMITED TO MEDIAL WALLOF MAXILLA
OR LOWER PART OF ETHMOID
COMPLICATIONS-
 ORBIT INJURY
 NASALVESTIBULAR STENOSIS
 NASAL CRUSTING
81

TOTAL MAXILLECTOMY
 COMPLETE REMOVAL OF ALLELEMENTS OF
MAXILLA
 INDICATIONS
TUMORS CONFINED TO MAXILLARY SINUS
MUCORMYCOSIS
 CONTRAINDICATONS- INVOLVEMENT OF
OPTIC CANAL
ORBITAL FISSURES
NASOPHARYNX
SPHENOID SINUS
CAVERNOUS SINUS
MIDDLE CRANIAL FOSSA
82

STEPS
1 INCISION& EXPOSURE
2 ELEVATE MUCOSAL FLAP TO EXPOSE BONE OF HARD
PALATE
3 DISSECT PERIORBITAL FROM FLOOR OF ORBIT
4 OSTEOTOMIES
PALATAL OSTEOTOMY
THROUGH THE FRONTAL PROCESS OF MAXILLA
THROUGH THE BODY OF ZYGOMA
THROUGH THE PTERYGOID PLATES
83

Osteotomy cuts

TOTAL MAXILLECTOMY WITH ORBITAL
EXENTRATION
 INDICATION
MAXILLARYSINUS CANCER
EXTENDING INTO SOFT TISSUE OF
ORBIT
(INVOLVEMENT OF PERIOSTEUM ITSELF
IS NOT AN INDICATION)
MUCORMYCOSIS
85

STEPS
1Extended weber fergusson incision
2 Orbital content dissected from orbital walls
preserving the attachment to floor
3Ant & post ethmoidal arteries ligated
4Lacrimal sac & gland elevated
5Optic canal reached
6Optic nerve clamped,transfixed,cut
7 Contents of superior orbital fissure removed
8Maxillectomy performed
86

Total maxillectomy done &
incision closed

Palatal defect & prosthesis

89

90

MAXILLARY SWING APPROACH
 INDICATIONS
Tumors of nasopharynx & middle cranial base &
infratemporal fossa
 Displace the maxilla by rotating lat on greater palatine
vessels or completely removing maxilla asa free graft
 CONTRAINDICATIONS
Tumors Extending Post To Carotid, AntCranial Fossa,
Contralateral Skull Base
91

CRANIOFACIAL RESECTION
 DESCRIBED BYDANDY IN 1941
 DEVELOPED BYKetcham et al,Clifford
 PRESENT 3APPROACHES DESCRIBED BYCheesman
& Reddy
 3 TYPES
 1 CRANIOFACIAL (TRANSORBITAL) RESECTION
An extended medial maxillectomy using lateral
rhinotomy incision and allows wide exposure of ethmoid
roof and orbital periosteum.
92

Type 2 CRANIOFACIAL (WINDOW
CRANIOTOMY) RESECTION
Alateral rhinotomy for anterior access and extended
superiorly in a frown line to the frontal bone.
Asmall midline ‘window’ craniotomy made to access
floor of ant. Cranial fossa.
This gives exposure of both ant &post ethmoids, dura
, adjacent brain &also into sphenoid , the orbit, the
pterygopalatine fossae and the skull base centrally.
93

Type 3 CRANIOFACIAL RESECTION
 PERFORMED IN CONJUNCTION WITH
NEUROSURGERY TEAM
 COMBINES TRANSFACIALAPPROACH &
CRANIOTOMY LIKE FRONTOLATERAL
CRANIOTOMY
LATERAL CRANIOFACIAL RESECTION
suitable to clear infratemporal fossa
94

Cranio-facial resection

Surgical Options - CFR
Craniofacial resection
96
• Introduced by Smith et al., 1953
Frontoethmoidectomy

INDICATIONS
 RESECTION OF TUMORS INVOLVING CRIBRIFORM
PLATE, ETHMOID SINUS, INTRACRANIAL EXTENSION
 ESTHESIONEUROBLASTOMA
 ADENOCARCINOMA & SCC
 SARCOMAS
 SINONASAL UNDIFFERENTIATED CARCINOMA
 ADENOID CYSTIC CARCINOMA
 MELANOMA
 BENIGN TUMORS WITH LOCAL SPREAD
 DESTRUCTIVE GRANULOMA
 SKULL BASE OSTEOMYELITIS
 INVASIVE FUNGAL INECTION
97

STEPS
DONE BYCOMBINED BICORONAL &TRANSFACIAL
INCISION
1 PERICRANIAL FLAP ELEVATED (IN ADDITION A
TEMPORAL GALEAL FLAP CAN BE EMPLOYED)
2 FRONTAL CRANIOTOMY
3 DURA ELEVATED
4 INTRACRANIAL BONE CUTS EXTENDED ASPER
REQUIREMENTS
5 TANSFACIAL SURGERY PERFORMED
6 TOTAL ETHMOIDECTOMY &REMOVAL OF DISEASE
DONE
98

COMPLICATIONS
 PERIOPERATIVE MORTALITY 1.3-7.7%
 COMPLICATIONS
INTRACRANIALrisk of CSF leak, meningitis, brain abscess,
brain injury-mental status changes, stroke, coma
EXTRACRANIAL
 Loss of sense of smell (lifelong) ,
 Blood loss (transfusion)
 Damage to adjacent structures leading to Nasal crusting, nasal
distortion, nasal obstruction, facial pain, facial numbness, epiphora,
septal perforation, anosmia, blindness, diplopia
99

100

Neoplasms of nose and paranasal sinuses

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