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Tumors ofnasal cavity & paranasal        sinuses         ByDr, Ibrahim Habib (M.D)   ENT consultant
‫بسم هللا الرحمن الرحيم‬
‫{ أقم الصالة لدلوك الشمس إلى غسق الليل وقرآن الفجر إن قرآن الفجر كان مشهودا }‬                                 ‫اإلسراء :...
IntroductionCancers of nose & PNS : 3% of Head & Neck cancers .Age : 5th up to 7th decade .Predominately of older males .E...
location       3%1%            20%            70%
• Floor : palatine process of maxilla• Roof : cribriform plate .
Anatomy of maxillary antrumAnterior : soft tissue of face .Posterolateral : ITF , pterygopalatine FSuperior : Inferior orb...
Anatomy of ethmoid sinusesAnterior : lacrimal bone .Medialy : lateral nasal wall.Superior : Fovea ethmoidalis .
Anatomy of sphenoid sinus      Anteriorly : nasal cavity , ethmoid .      Posteriorly : clivus , brainstem .      Superior...
Anatomy of frontal sinusAnteriorly :soft tissue of forehead .Inferiorly :orbit .Posteriorly :anterior cranial fossa .
1- frontal sinus2- ant. Ethmoid sinus3- infundibulum4- middle. Ethmoidsinus5- post. Ethmoid sinus6- middle concha7- spheno...
Drainage of PNSMaxillary sinus : middle meatusEthmoid sinuses “ anterior “ : middle meatus .Ethmoid sinuses “ posterior “ ...
Classification of sinonasal tumors
Benign ( epithelial )        Benign ( non             Malignant                  Malignant (nonsinonasal tumors           ...
Squamous Cell Carcinoma• Most common sinonasalmalignancy• 70% arise in antrum• 30% arise in nasal cavity• 15% with synchro...
Adenocarcinoma• 13-19% of SNmalignancies• Arise from surfaceepithelium andseromucinous glands• Intestinal, salivary,neuroe...
Adenoid Cystic Ca• <10% of SN malignancies• 25% of adenocarcinomas• Glandular origin• Perineural growth pattern (60%)• Neu...
Sinonasal Melanoma• < 4% of SN neoplasms• Melanocytes in mucosa• Prefers nasal cavity• Epistaxis• Worse prognosis thancuta...
Esthesioneuroblastoma• Originate from olfactoryepithelium• Two incidence peaks• Adolescence• 50 - 60 years• Epistaxis• Hig...
Sinonasal Undifferentiated Ca (SNUC)• Separate entity from SCCa,ENB, and others• Rare, high-grade malignancy• 2-3:1 male p...
Sinonasal Lymphoma• 44% of extranodallymphomas arise in SN• Prefers nasal cavity• Types• T-cell (Asian)• B-cell (US, Europ...
Sarcomas and Other Malignancies• Sarcomas• Rhabdomyosarcoma• Liposarcoma• Leiomyosarcoma• Fibrosarcoma• Chondrosarcoma• Os...
symptomsEarly : asymptomatic .Oral symptoms: 25-35%, Toothache , trismus, alveolar ridge fullness, erosion ,malocclosion ....
Physical examinationNasal mass or polyposis .Mass in the check or medical canthus .Broadening of nasal dorsum .Maxillary s...
Nasal endoscopy that shows a tumor in the left nasal wall
InvestigationsAim : detect the disease & its extention .Extention : orbit , skull base , dura , Intracranial , greatvessel...
Presentation of tumours of nose & PNS  Nasal mass or polyposis   )mass in check )
Broadening of nasal dorsum , proptosis , restricted occular mobility
C T scan- Ideal- surrounding bone erosion or destruction .Tum : -     ourCalification .Soft tissue denistyNecrosis or hgeV...
Coronal section of nose & PNS shows soft tissue mass in region of Rt ethmoid air cellpushing septum to other side with bon...
CT Scan, of paranasal sinus, that shows the tumor( angiosarcoma ) in the left                                  nasal cavity
MRIAdvantages :- excellent delineation of tumour fromsurrounding inflammatory soft tissue andretained secretions.- obtaine...
Figures 1 and 2: MR shows a 3.0 x 4.0-cm mass arising from the mucosa of the rightethmoid region with some areas of necros...
Tumour                  secretion            inflammationT1                      Intermediate signal     No enhancement   ...
AngiographyIndications :1- Evaluations of vascular tumours extention , vascular anatomy ,selective embolization .2- Skull ...
P.E.T.- Agent : 18 – F flurodeoxy glucose .            C – 11 methionine .- Principle : image metabolic activity of head &...
BiopsyAim : confirm diagnosis & plan appropriate ttt.Route : 1- transnasl .           2- transoral .           3- direct a...
Staging of sinonasal tumours
Ohngern 1933 staged maxillary            Ohngern 1933 staged maxillary                  sinus cancers (Infrastructure )   ...
Staging of non maxillary sinonasal malignanciesStage I : tumor confined to site of origin .Stage II : spread to adjacent s...
Staging system for olfactory neuroblastomaStage I : confined to primary site .Stage II : presence of nodal metastasis .Sta...
AJCC staging for PNS       primary tumor ( T ) of maxillary sinus- Tx primary T can’t be assessed .- To : no evidence of p...
AJCC staging for PNS primary tumor ( T ) of maxillary sinus- T3 Tumour invade any of the following : bone of posterior wal...
Staging of ethmoid sinus- T1 tumour confined to the ethmoid with or without boneerosion .- T2 Tumour extends into nasal ca...
Nodal involvement in sinonasal tumours. Nodal involvement infrequent despite advanced stage• Depends on primary site, exte...
staging- stage o         Tis         No         Mo- stage I          T1         No         Mo- stage II         T2        ...
TNM Staging of Maxillary Carcinomas• Stage I: Limited to mucosa• Stage II: Bone involvement(NOT posterior wall)• Stage III...
Management of sinonasal tumours
Surgical management         Indication        Surgical management           Indication  of early primary                  ...
Midfacial degloving approach.. Surgical Treatment of Squamous Cell                    Carcinoma of the Sinuses.
Combined bicoronal approach and Dieffenbach-Weber-Fergusson incision. Surgical            Treatment of Squamous Cell Carci...
Management of orbit          Indication          Orbital complications             N.B.in sinonasal tumors                ...
Reconstruction and Prosthetic Rehabilitation- Aim : - prevent contracture of the check , to separateoral & nasal cavities ...
. Algorithm to depict tissue options for midface reconstruction
Treatment of maxillary sinus carcinoma(A) 66-year-old woman with total maxillectomy defectand orocutaneous fistula status ...
Management of tumours of nose &                          PNS                     (1) The NeckNo :T1 – T2 :electve ND is no...
Management of tumours of nose &                          PNS          (1) The Neck )late node metastasis)- 5 – 45% occure ...
Radiotherapy as an adjuvant therapy in       management of sinonasal tumours- 1- combined with surgery in advanced resecta...
chemotherapy as an adjuvant therapy in      management of sinonasal tumours- Combination chemotherapy with pre. Or post.Op...
- Knegt ‘s regimen in using topical chemotherapy as an adjuvant Therapy in management of sinonasal tumours.The regimen1-an...
prognosisThe advancement of skull base surgery , cure rates forpatients with sinonasal tumours ,form 39-76% have been achi...
Tumours have good chance of cure :1- early maxillary tumours .2- patients with nasal cavity tumours .3- well differentiate...
Tumours with bad prognosis1- Advanced maxillary cancer .2- lesions involving pterygoid plates orpterygopalatine fossa .3- ...
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses
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Tumours of nasal cavity & paranasal sinuses

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classification, diagnosis , staging & management of sinonasal tumors

Tumours of nasal cavity & paranasal sinuses

  1. 1. Tumors ofnasal cavity & paranasal sinuses ByDr, Ibrahim Habib (M.D) ENT consultant
  2. 2. ‫بسم هللا الرحمن الرحيم‬
  3. 3. ‫{ أقم الصالة لدلوك الشمس إلى غسق الليل وقرآن الفجر إن قرآن الفجر كان مشهودا }‬ ‫اإلسراء : 87‬
  4. 4. IntroductionCancers of nose & PNS : 3% of Head & Neck cancers .Age : 5th up to 7th decade .Predominately of older males .Exposure:Wood, nickel-refining processesIndustrial fumes, leather tanningCigarette and Alcohol consumption:No significant association has been shown
  5. 5. location 3%1% 20% 70%
  6. 6. • Floor : palatine process of maxilla• Roof : cribriform plate .
  7. 7. Anatomy of maxillary antrumAnterior : soft tissue of face .Posterolateral : ITF , pterygopalatine FSuperior : Inferior orbital plate .Inferiorly : hard palate , superior alveolar ridge
  8. 8. Anatomy of ethmoid sinusesAnterior : lacrimal bone .Medialy : lateral nasal wall.Superior : Fovea ethmoidalis .
  9. 9. Anatomy of sphenoid sinus Anteriorly : nasal cavity , ethmoid . Posteriorly : clivus , brainstem . Superiorly : pituitary fossa . Laterally : cavernous sinuses & optic N .
  10. 10. Anatomy of frontal sinusAnteriorly :soft tissue of forehead .Inferiorly :orbit .Posteriorly :anterior cranial fossa .
  11. 11. 1- frontal sinus2- ant. Ethmoid sinus3- infundibulum4- middle. Ethmoidsinus5- post. Ethmoid sinus6- middle concha7- sphenoid sinus8- inf. concha9- hard palate
  12. 12. Drainage of PNSMaxillary sinus : middle meatusEthmoid sinuses “ anterior “ : middle meatus .Ethmoid sinuses “ posterior “ : sphenoethmoid recess .Sphenoid sinus : sphenoethmoid recess .Frontal sinus : frontonasal duct .
  13. 13. Classification of sinonasal tumors
  14. 14. Benign ( epithelial ) Benign ( non Malignant Malignant (nonsinonasal tumors epithelial ) sinonasal (epithelial ) epithelial ) sinonasal tumours sinonasal tumours tumours- Schneiderian papilloma : Leiomyoma - squamous cell - chondrosarcoma .inverted . chondromyxoid fibroma carcinoma : - Rabdomyosarcoma Papillary ( septal ). Differentiated . .Cylinderical Basaloid squamous . - Squamous papilloma ( Adeosquamousnasal vestibule )- Adenoma . Adenocarcinoma . - lymphoproliferative- Dermoid Adenoid cystic . Lymphoma Mucoepidermoid Midline malignant reticulosis Plasmacytoma - Terato carcinosarcoma- Lobular capillary Neuroendocrine Hemangiopercytomahemangioma . carcinoma . Angiosarcoma- Hemangiopericytoma . Hyallinizing clear cell kaposi’sarcoma- peripheral nerve sheath carcinomatumors- Fibrous histocytoma . myxoma , fibromyxoma. - Melanoma . Fibrosarcoma- fibroma . ameloblastoma - olfactory neuroblstoma Osteogenic sarcoma- osteoma . . Malignant fibrous- fibrosseus lesios . - sinonasal Histocytoma undifferentiated carcinoma (SNUC)N.B. Secondary malignancy – Melanoma ,Thyroid , lung , kidney and G I T
  15. 15. Squamous Cell Carcinoma• Most common sinonasalmalignancy• 70% arise in antrum• 30% arise in nasal cavity• 15% with synchronus ormetachronus lesion• Pre or co-existing papilloma isrisk factor• 4-9%• Look for necrosis on imagingN.B. Squamous Cell Carcinoma in Inverted Papilloma
  16. 16. Adenocarcinoma• 13-19% of SNmalignancies• Arise from surfaceepithelium andseromucinous glands• Intestinal, salivary,neuroendocrine types• Non-specific imagingfeatures• Predilection forethmoid sinuses
  17. 17. Adenoid Cystic Ca• <10% of SN malignancies• 25% of adenocarcinomas• Glandular origin• Perineural growth pattern (60%)• Neural cell adhesion molecule(NCAM) in 93%• Small lesions extend beyondwhat is apparent• Difficult to entirely remove• Late recurrences and mets
  18. 18. Sinonasal Melanoma• < 4% of SN neoplasms• Melanocytes in mucosa• Prefers nasal cavity• Epistaxis• Worse prognosis thancutaneous types• High recurrence andmortality rates
  19. 19. Esthesioneuroblastoma• Originate from olfactoryepithelium• Two incidence peaks• Adolescence• 50 - 60 years• Epistaxis• High survival withmultimodality therapy• Ca++ and peripheral cysts
  20. 20. Sinonasal Undifferentiated Ca (SNUC)• Separate entity from SCCa,ENB, and others• Rare, high-grade malignancy• 2-3:1 male predominance• Broad age range from 3rd to9th decades• Characterized by aggressivelocal growth, regional anddistant mets, and poorsurvival
  21. 21. Sinonasal Lymphoma• 44% of extranodallymphomas arise in SN• Prefers nasal cavity• Types• T-cell (Asian)• B-cell (US, Europe)• T/NK-cell (LMG)• Remodeling or erosion• Homogeneous enhancement
  22. 22. Sarcomas and Other Malignancies• Sarcomas• Rhabdomyosarcoma• Liposarcoma• Leiomyosarcoma• Fibrosarcoma• Chondrosarcoma• Osteosarcoma• Plasmacytoma• Metastases
  23. 23. symptomsEarly : asymptomatic .Oral symptoms: 25-35%, Toothache , trismus, alveolar ridge fullness, erosion ,malocclosion .Nasal findings: 50%Obstruction, epistaxis, rhinorrhea , post nasal discharge , anosmia .Ocular findings: 25%Epiphora, diplopia, proptosisFacial signsParesthesias, asymmetry
  24. 24. Physical examinationNasal mass or polyposis .Mass in the check or medical canthus .Broadening of nasal dorsum .Maxillary sinus involvement : Mass in palate or upper alveolus . Mass in upper gingivobuccal sulcus . Malocclusion or loose teeth .Advanced : Trismus .Orbital :Periorbital swelling , proptosis .Epiphora , impaired occular mobilityUncommon : Neck mass
  25. 25. Nasal endoscopy that shows a tumor in the left nasal wall
  26. 26. InvestigationsAim : detect the disease & its extention .Extention : orbit , skull base , dura , Intracranial , greatvessels .Presence of regional or distant metastasis
  27. 27. Presentation of tumours of nose & PNS Nasal mass or polyposis )mass in check )
  28. 28. Broadening of nasal dorsum , proptosis , restricted occular mobility
  29. 29. C T scan- Ideal- surrounding bone erosion or destruction .Tum : - ourCalification .Soft tissue denistyNecrosis or hgeVascular tum : enhancem ors ent increase with contrastEntrapped secretion : with low density Lym node : regional L.N. , ( retropharyngeal ) L.N. ph. Staging• Guide biopsy and surgery• Treatm responseDistant m ent etastasis .
  30. 30. Coronal section of nose & PNS shows soft tissue mass in region of Rt ethmoid air cellpushing septum to other side with bony erosion of septum and fovea ethmoidalis )B)
  31. 31. CT Scan, of paranasal sinus, that shows the tumor( angiosarcoma ) in the left nasal cavity
  32. 32. MRIAdvantages :- excellent delineation of tumour fromsurrounding inflammatory soft tissue andretained secretions.- obtained in multiple planes .- no exposure to ionizing radiation .- no artifact in the presence of dental filling .
  33. 33. Figures 1 and 2: MR shows a 3.0 x 4.0-cm mass arising from the mucosa of the rightethmoid region with some areas of necrosis; the surrounding bony structure is intact but its growth expands nasal septum and lamina papiracea -
  34. 34. Tumour secretion inflammationT1 Intermediate signal No enhancement Low signalT1 with contrast Diffuse enhancement No enhancement Low signalT2 Intermediate signal High signal High signalN.B. flow void --- vascular lesion .With contrast -- perineural invasion, dural or intracranial involvementsL.N. -- Heterogenous on T2 , > 1 cm , peripheral enhancement with contrast using fatsuppresion
  35. 35. AngiographyIndications :1- Evaluations of vascular tumours extention , vascular anatomy ,selective embolization .2- Skull base surgery with brain retraction , delineate intracranialarterial and venous anatomy .3- tumour encroaching on carotid a. , assess collaterals , may beused with balloon occlusion testing .
  36. 36. P.E.T.- Agent : 18 – F flurodeoxy glucose . C – 11 methionine .- Principle : image metabolic activity of head & neck . Tumors including nose& PNSAssess : Local , regional or systemic metastasis . -. Direct biopsy -• Therapy response• Recurrence vs.treatment change• Re-staging- Result : inferior to C.T. & MRI .
  37. 37. BiopsyAim : confirm diagnosis & plan appropriate ttt.Route : 1- transnasl . 2- transoral . 3- direct access to the sinus :Maxillary sinus : Transnasal , medial wall ofmaxillary sinus . Caldwell – Luc . Procedure .Ethmoid sinuses : Endoscopic ethmoidectomy - External ethmoidectomy .Sphenoid sinus : endoscopically Trans – septallyFrontal sinus : its floor .
  38. 38. Staging of sinonasal tumours
  39. 39. Ohngern 1933 staged maxillary Ohngern 1933 staged maxillary sinus cancers (Infrastructure ) sinus cancers(Suprastructure)Site Infrastructure to Ohngern line Suprastructure to Ohngern lineSymptoms Early LateSpread Oral , nasal , I.T.F Pterygomaxillary fossa , middle & anterior cranial fossaTreatment More amenable to surgical resection Less amenable to surgical resectionprognosis Good BadOhngern line : an imaginary line drawn from maxillary tuberosity to inner canthus .Ohngern 1933 staged maxillary sinus cancers
  40. 40. Staging of non maxillary sinonasal malignanciesStage I : tumor confined to site of origin .Stage II : spread to adjacent sinuses , skin , nasopharynx ,ptergomaxillary fossa , and or orbit .Stage III : involvement of skull base , pterygoid plate andor intracranial extension .
  41. 41. Staging system for olfactory neuroblastomaStage I : confined to primary site .Stage II : presence of nodal metastasis .Stage III : presence of distant metastasis .
  42. 42. AJCC staging for PNS primary tumor ( T ) of maxillary sinus- Tx primary T can’t be assessed .- To : no evidence of primary T.- Tis : carcinoma in situ .- T1 : T limited to antral mucosa with no erosion nordestruction of bone .- T2 Tumour causing erosion or destruction except forposterior antral wall , including extention into m.m. ofhard palate and / or middle nasal meatus .
  43. 43. AJCC staging for PNS primary tumor ( T ) of maxillary sinus- T3 Tumour invade any of the following : bone of posterior wall ofmaxillary sinus , subcutaneous tissue , skin of check , floor ormedial wall of orbit , I.T.F. , pterygoid plates , ethmoid sinuses .- T4a (resectable): anterior orbit,skin, infratemporal fossa, pterygoidplates, cribriform plate, frontal orsphenoid sinuses- T4b (unresectable): orbital apex,dura, brain, middle fossa, clivus,nasopharynx, CNs (other than V2)-
  44. 44. Staging of ethmoid sinus- T1 tumour confined to the ethmoid with or without boneerosion .- T2 Tumour extends into nasal cavity .- T3 Tumour extends into ant. Orbit and / or maxillarysinus .- T4 Tumour with intracranial extension , orbitalextension including apex , involving sphenoid and / orfrontal sinus and / or skin of external nose .
  45. 45. Nodal involvement in sinonasal tumours. Nodal involvement infrequent despite advanced stage• Depends on primary site, extent, and histology• 8-18% with nodes at presentaion. Nodal stage based on: N1: Single ipsilat ≤ 3cm • N2:• Number • a: Single ipsilat 3 – 6cm• Uni- or bilateral • b: Multiple ipsilat ≤• Size 6cm-Nodal drainage • c: Bilat or contralat ≤• Facial, parotid, submandibular 6cm• Retropharyngeal • N3: ≥ 6cm node• Then L II
  46. 46. staging- stage o Tis No Mo- stage I T1 No Mo- stage II T2 No Mo- stage III T3 No Mo- T1-T3 N1 Mo- stage IV A T4 No Mo T4 N1 Mo- stage IV B any T N2 Mo any T N2 Mo- stage IV c any T any N M1( N ) lymph node . ( M ) distant metastasis .
  47. 47. TNM Staging of Maxillary Carcinomas• Stage I: Limited to mucosa• Stage II: Bone involvement(NOT posterior wall)• Stage III:• T3 lesion• TI or T2 lesions with N1• Stage IV• T4 lesion• Any T with N2/N3 or M1
  48. 48. Management of sinonasal tumours
  49. 49. Surgical management Indication Surgical management Indication of early primary of lesion Advanced primary lesionInfrastructure lesions confined to Radical maxillectomy advanced lesionsmaxillectomy floor of maxillary sinus confined to maxillary . sinus advanced lesions confined to maxillary sinusMedial maxillectomy lesions confined to Craniofacial resection extension of disease medial wall of into the frontal maxillary sinus sinuses and / or cribriform platePartial or complete lesions confined to Palliative disease is extendedseptectomy septum radiotherapy into brain , sphenoid rostrum , cavernous sinus & internal carotid a
  50. 50. Midfacial degloving approach.. Surgical Treatment of Squamous Cell Carcinoma of the Sinuses.
  51. 51. Combined bicoronal approach and Dieffenbach-Weber-Fergusson incision. Surgical Treatment of Squamous Cell Carcinoma of the Sinuses..
  52. 52. Management of orbit Indication Orbital complications N.B.in sinonasal tumors where R.T.Resection of a small cases with minimal epiphora , keratitis , complications withportion of the periorbital diplopia , pain , pre-operative R.T. areperiorbita & involvement without exophthalmos , and mostly minor andreconstruct with full penetration into loss of vision . transient .fascial graft the orbital fat .Resection of orbit with invasion of the complications are periorbita , the more frequent when infraorbital nerve , or post operative R.T. is the orbital apex used
  53. 53. Reconstruction and Prosthetic Rehabilitation- Aim : - prevent contracture of the check , to separateoral & nasal cavities , and to provide support for theglobe .- An obturator should be made preoperatively from animpression of the hard palate .
  54. 54. . Algorithm to depict tissue options for midface reconstruction
  55. 55. Treatment of maxillary sinus carcinoma(A) 66-year-old woman with total maxillectomy defectand orocutaneous fistula status after surgery and radiotherapy. (B) Cranial bone grafts used to reconstruct orbitozygomatic structure surrounded by rectus abdominus free flap. (C) 3-year postoperative result. (D) Intraoral view of 3-year postoperative result.
  56. 56. Management of tumours of nose & PNS (1) The NeckNo :T1 – T2 :electve ND is not generally performed.T3 – T4 :R.T. post. Operative . Upper neck & retro-ph. L.Ns .N+ve with resectable 1ry :MRND . Or dissect 1-V & retropharyngeal chain .
  57. 57. Management of tumours of nose & PNS (1) The Neck )late node metastasis)- 5 – 45% occure after 2-3 yrs .- rarely occurs in absence of synchronous local or distantrecurrence you should search for .- TTT aggressively : R.N.D.- 5 yr survival rate was 39% after ttt of delayed metastasis.- N.B. None with nodes at presentation survived 3 years .
  58. 58. Radiotherapy as an adjuvant therapy in management of sinonasal tumours- 1- combined with surgery in advanced resectablelesions . Pre. Or post. Operative .- 2- Single modality for :- advanced unresectable lesions .- patients unwilling or unable to undergo surgery .- Average 5 yrs survival rates 10 – 15 % ( total doses up to 79 Gy ) .
  59. 59. chemotherapy as an adjuvant therapy in management of sinonasal tumours- Combination chemotherapy with pre. Or post.Operative R.T. in :- Olfactory neuroblastoma & SN undifferentiated ca.- Japanese researchers use combination of R.T. , intra-arterial 5 – fluorouracil ( 5 FU ) and local debridementor cryosurgery for maxillary sinus cancer .
  60. 60. - Knegt ‘s regimen in using topical chemotherapy as an adjuvant Therapy in management of sinonasal tumours.The regimen1-antrostomy and debulking of the tumour . 2-The tumour bed is then packed with topical 5FUemulsion .3- The pack are removed and any residual necroticmaterial is debrided as often as necessary . He reported 5-yr survival of 71% .
  61. 61. prognosisThe advancement of skull base surgery , cure rates forpatients with sinonasal tumours ,form 39-76% have been achieved
  62. 62. Tumours have good chance of cure :1- early maxillary tumours .2- patients with nasal cavity tumours .3- well differentiated adenocarcinoma 90% .4- low grade minor salivary gland tumour .5- olfactory neuroblastoma : 100% stage A & 75% stage B & 60% stage C . Survival .6- sq. cell ca. arising in inverted papilloma .
  63. 63. Tumours with bad prognosis1- Advanced maxillary cancer .2- lesions involving pterygoid plates orpterygopalatine fossa .3- lesions involving brain , dura , nasopharynx ,sphenoid .4- lesions involving orbital contents .
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