Sino-nasal Tumours Dr. Vishal Sharma. Classification Benign Simple papilloma Ossifying Fibroma...

Sino-nasal Tumours

Dr. Vishal Sharma

ClassificationBenign

Simple papilloma

Ossifying Fibroma

Osteoma

Haemangioma

Neurofibroma

Intermediate

Inverted papilloma

Malignant

Squamous cell

carcinoma

Adenocarcinoma

Anaplastic carcinoma

Transitional cell

carcinoma

Malignant melanoma

Salivary gland tumours

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 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: complete surgical excision

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 from the lateral wall of nose

Presents as unilateral, friable, pale, pink mass

arising from middle meatus

Diagnosis made by punch biopsy

Inverted papilloma

Treatment: 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 10 15% 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

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

.

Late Clinical featuresInferior 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 featuresPosterior 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, bone

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 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 Options1. 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

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

periorbita into retrobulbar fat

Orbital exenteration

Cranio-facial resection

Thank You