Ca maxilla

Carcinoma maxillary sinus,vivekanand,bmcri,bengaluru

1. Malignant tumours of maxillary sinus Dr vivekanand A,BMCRI 1

2. contents INTRODUCTION EPIDEMIOLOGY ETIOLOGY CLASSIFICATION CLINICAL PRESENTATION SPREAD OF TUMOUR STAGING EVALUATION TREATMENT PROGNOSIS 2

3. INTRODUCTION One of the most challenging problems in head and neck cancer Rare Area of greatest histological diversity Initialy develops as innocuous symptoms Often present with significant invasion of adjacent vital structures High morbidity and poor prognosis 3

4. EPIDEMIOLOGY 0.2-0.8% of all malignancies Incidence of 0.5-1 per 100,000 per year 3% of all tumours of head and neck 3% of upper aerodigestive tract neoplasms Fifth and sixth decades Male predominance 4

5. Site of origin SITE ACC TO COMPREHENSIVE MANAGMNT OF SKULL BASE TUMOURS(IN %) CUMMINGS(IN %) MAXILLARY SINUS 60 50-70 NASAL CAVITY 22 15-30 ETHMOID 15 10-20 FRONTAL AND SPHENOID 3 LESS THAN 5 PREVALENCE 5

6. MOST COMMON LESIONS IN DESCENDING ORDER Squamous cell carcinoma Adenocarcinoma Sarcoma Esthesioneuroblastoma Adenoid cystic carcinoma Melanoma Undifferentiated Mucoepidermoid lymphoma 6

7. etiology Occupational-mainly due to inhalation of carcinogens Hard wood exposure increases the relative risk by 70 fold particularly ethmoids Soft wood exposure increases the risk of squamous cell carcinoma Nickel exposure increases the risk for SCC by 250 times 0ther factors-smoking,aflatoxins,formaldehyde,chromium,mustard gas,polycyclic hydrocarbons,thorotrast 7

8. occupation Suspected carcinogen histology Wood workers Dust >5 micromtr, tar,aldehydes,chromium Adeno-hardwood SCC-softwood leather Dust,tar,tannins,aldehydes adeno Chrome pigment Calcium chromate Zinc potassium chromate adeno Isopropyl alcohol Isopropyl oil adeno textile Dyes and wood dust Melanoma and adeno 8

9. classification WHO CLASSIFICATION HISTOLOGICAL CLASSIFICATIONS Most common epithelial subtypes-SCC,Adenoid cystic and Adeno carcinoma Most common non epithelial includes-lymphoma,esthesioneuroblastoma and undifferentiated 9

10. Wh0 10

11. Histological classification 1. EPITHELIAL EPIDERMOID-SCC (spindle cell,verrucous,transitional) NON EPIDERMOID-adenoid cystic,adeno,mucoepidermoid,acinic cell 2. Neuroectodermal-malignant melanoma,olfactory neuroblastoma,neuroendocrine carcinoma,SNUC,ewing’s 3.Odontogenic-ameloblastoma 4.Mesenchymal-fibrosarcoma,liposarcoma,malignant fibrous histiocytoma,alveolar soft part sarcoma 5.Vascular-angiosarcoma,kaposi’s sarcoma,glomangiopericytoma 6.Muscular-leiomyosarcoma,rhabdomyosarcoma 7.Cartilagenous-chondrosarcoma 8.Osseous-osteosarcoma 9.lymhoreticular-NHL,burkitts,NK cell lymphoma,plasmocytoma 10.Metastasis 11

12. Squamous cell carcinoma Most common-58-73% M/C -maxillary sinus >ethmoid >fronto sphenoid Risk factors-inverted papilloma,thorotrast,nickel Presents at advanced stage-80% with stage III or IV Tumours from nasal cavity are keratinizing usually and from PNS non keratinizng Most are poorly differentiated 70%,un differentiated 10-20% Undifferentiated may mimick SNUC and melanoma 12

13. Macroscopocally - exophytic,fungating or papillary ,friable ,haemorrhagic ,necrotic or indurated and demarcative or infiltrative Microscopically -keratinizng can be well,moderately or poorly differntiated -shows squamous differentiation as extra or intracellular keratin Cells are opposed to one another in a ‘mosaic tile’ arrangement Tumour cells may be in nests, masses or small groups of individual cells Desmoplastic stromal reaction is often evident Non keratinizing SCC -cylinfrical cell carcinoma Characterized by plexiform or ribbon like growth pattern Maturation is lacking with evident atypia Invades underlying tissues with smooth well delineated smooth border 13

14. 14

15. Scc from inverted papilloma SCC in IP frequently occur concomitantly or as metachronous SCC Regional or distant metastasis is uncommon Radiotion with or without surgery resulted in a survival rate of 85% Surgery with post operative radiation has improved local control rate and cure rates from less than 50% to 60% Ref:-treatment outcomes in the management of IP,Lawson et al,laryngoscope 2003;113:1548-1545 15

16. adenocarcinoma Epidemiological association with wood working Latency period of approx 40 years Two types- intestinal and seromucinous INTESTINAL SEROMUCINOUS Identical to Colonic adenocarcinoma respiratory site Ethmoidal sinus and nasal cavity Ethmoid and maxillary sinus histology Resembles intestine,may show signet ring or mucinous Back to back cuboidal lined glands and cords 16

17. Macroscopically -necrotic friable some times gelatinous. Microscopically -Barne classification-papillary,colonic,solid,mucinous,mixed -kleinasser-papillary tubular cylinder,alveolar goblet,signet,transitional HISTOLOGICAL TYPES Papillary- papillary architecture with occasional tubular glands,minimal atypia Colonic-tubulo glandular,nuclear pleomorphism and atypia Solid-loss of differentiation,solid or trabecular growth with isolated tubule formation 17

18. 18

19. Adenoid cystic carcinoma Incidence peak in 5th and 6th decade Equal incidence in men and women Histological types-tubular,cribriform and solid Tends to infiltrate perineuraly and adjacent structures Hemategenous spread is common-high rate of lung metastasis Baseline CT chest High rate of local recurrence in spite of appropriate surgery and irradiation 19

20. 20

21. snuc Rare tumour,5th -6th decade,M=F, Highly aggressive Macroscopicaly -large >3cm,infiltrate adjacent areas with bone erosion Microscopically - No glandular or squamous differentiation,3 types Western type-cells with pink cytoplasm Undifferentiated NPC type-cells with large round water clear nuclei and lymphocyte infiltrates Large cell type-identical to lung type,cells with pleomorphic nucleiand prominent eosinophilic with or without giant cell formation 21

22. 22

23. chondrosarcoma 3rd to 4th decade,M=F Maignant tumour of hyaline cartilage Macroscopically -lobulated pale glistening masses with cystic changes -chalky white calcification foci Microscopicaly -lobulated,round to oval shaped cells with blue chondroid matrix with myxoid changes Frequently immunoreactive for CD99 23

24. 24

25. chordoma Derived from remnants of notochord Frequently in sacral areas Rarely from spheno occipital or vertebral regions Three variants- Conventional Chondroid Dedifferentiated Piecemeal surgical resection 25

26. esthesioneuroblastoma Arises from olfactory epithelium Neither occupational or other aetiology nor genetic factors identified Slight male predominant with bimodal peak 2nd-3rd and 6th -7th decade Most common location-at the level of cribriform plate Diagnosis is often delayed Macroscopically-polypoid reddish grey mass that bleeds easily Microscopicaly-limited to submucosa,growing in circumscribed lobules or nests separated by richly vascularised fibrous stroma -surrounded by neurofibrillary matrix Rosettes-Homer Wright type(pseudorosette) <30% Flexner Wintersteiner type (true rosette) <5% 26

27. 27

28. melanoma 3.6%,female predominance,elderly Nasal cavity and septum High hematogenous spread-lungs and brain Macroscopicaly-bulky polypoidal lesions that tends to ulcerate Microscopicaly-may have different characteristics such as small spindle cells,epithelioid or pleomorphic cells -melanin pigment in two third of cases High recurrence rate 28

29. 29

30. lymphomas <10%,more in males,6th to 8th decade Most are primary NHL most common variety 53% limited to nasal cavity,M/c sinus involved-maxillary Other varities-NK cell -anaplastic large cell -burkitt(m/c in children) - follicular lymphoma -extra nodal marginal zone B lymphoma -MALT 30

31. 31

32. HAEMANGIOPERICYTOMA Rare,develop from pericytes with in outer capillary wall Associated with steroid therapy,coincidental trauma,hypertension and malignancy Macroscopicaly-red grey firm polypoid lesions Rarely metastasize Relatively radioresistant Recurrence rate upto 60% 32

33. 33

34. Ohngren’s line Suprastructure: poor Prognosis Infrastructure: good prognosis 34

35. Lederman’s classification Ethmoid, sphenoid, frontal sinuses & olfactory area of nose. Maxillary & respiratory part of nose. Alveolar process 35

36. Clinical presentation MAXILLARY SINUS TUMOURS Naasal blockage,bleeding,hyposmia Mass,ulceration Middle ear effusion Glabellar mass Paraesthesia Loosening of teeth or dentures Malignant oroantral fistula Proptosis diplopia 36

37. ETHMOID SINUSES TUMOURS Same as of maxillary sinuses tumours Can cross to contralateral side Mucous retention Proptosis Chemosis Visual loss,diplopia Personality changes 37

38. Spread of tumours MAXILLARY SINUS 38

39. ETHMOIDAL SINUS 39

40. FRONTAL SINUSES 40

41. SPHENOID SINUSES 41

42. SITE ANTERIORLY POSTERIORLY MEDIALY LATERALY SUPERIORLY INFERIORLY FRONTAL skin Anterior cranial fossa,frontal lobe ethmoid ETHMOID skin Spenoid,nasopharynx,clivus,pituitary Cribriform plate orbit Anterior cranial fossa,frontal lobe Nasal cavity MAXILLARY Cheek,skin Pterygopalatine and infra temporal fossa,temporal lobe,middle cranial fossa Nasal cavity Cheek,skin orbit palate SPHENOID Ethmoidal sinus Clivus,pituitary gland,posterior fossa Cavernous sinus,middle cranial fossa Pituitary,hypothalamus nasopharynx NASAL CAVITY skin Spenoid sinus,nasopharynx Maxillary sinus Anterior cranial fossa,frontal lobes palate 42

43. Lymphatic spread Lymphatic spread is seen in 25-30% of cases If tumor extension into skin of face, nasal cavity, NPX > ↑ed incidence of LN Submandibular and subdigastric nodes Contralateral metastasis extremely rare 43

44. Distant metastasis More common with adenocarcinoma (18%)> SCC(10%) COMMON SITES-bone,brain,liver,lung and skin 44

45. staging AJCC TNM SYSTEM Only for maxillary and ethmoid sinuses and nasal cavity 45

46. MAXILLARY SINUS T X- Primary tumour cannot be assessed T0-no evidence of primary tumour T is -carcinoma in situ T1-tumour limited to antral mucosa with no bone erosion or destruction T2-tumour with erosion or destruction of infrastructure including hard Palate and / or the middle nasal meatus T3-tumour invades any of the following:-skin of the cheek,posterior wall Of maxillary sinus,floor or medial wall of orbit,ant ethmoid sinus T4-tumour invades orbital contents and/or any of the following Cribriform plate,posterior ethmoid or sphenoidal sinuses,nasopharynx,palate Pterygomaxillary or temporal fossa or base of the skull 46

47. Nasal cavity & Ethmoid Sinus Tx - Primary tm cannot be assessed To - no evidence of primary tm Tis - carcinoma in situ T1 - Tm restricted to any one subsite with or without bony invasion T2 - invading two subsite in a single region or extending to involve an adjacent region within the nasoethmoidal complex T3 - invade medial wall/ floor of orbit, maxillary sinus,palate/ cribiform plate T4a - invade ant orbital contents, skin of nose /cheek, ant cranial fossa, pterygoid plates,sphenoid/ frontal sinus T4b - orbital apex, dura, brain,mid cranial fossa, cr nerves, nasopharynx/ clivus 47

48. Nx - regional nodal status cannot be assessed, No - No regional lymph node metastasis N1 - single I/L clinically +ve lymph node ≤ 3cm N2 - metastasis in ipsilateral, bilateral, contralateral node N2a - single I/L +ve LN >3cm <6cm N2b - multiple, I/L +ve LN <6cm N2c - B/L or C/L LN <6cm N3 - any LN > 6cm 48

49. Mx - distant metastasis cannot be assessed Mo - No distant metastasis M1 -distant metastasis multiple, ipsilateral clinically positive node <6cm 49

50. stage I - T1N0M0 stage II – T2N0M0 stage III – T3N0M0 OR T1-T3N1M0 stage IV : IVA -T4N0-1M0 any TN2M0 IVB any TN3M0 IVC any T any N, M1 50

51. Kadish staging for esthesioneuroblastoma GROUP DEFNITION KADISH A CONFINED TO NASAL CAVITY KADISH B EXTENDS TO PARANASAL SINUSES KADISH C EXTENDS BEYOND NASAL CAVITY AND PARANASL SINUSES KADISH D LYMPHNODE OR DISTANT METASTASIS 51

52. DULGUEROV STAGING FOR ESTHESIONEUROBLASTOMA T1-tumour involving the nasal cavity and/or paranasal sinuses (except sphenoid),sparing the most superior ethmoidal cells T2-tumour involving the nasal cavity and/or paranasal sinuses (including sphenoid),with extension to or erosion of cribriform plate T3-tumour extending into the orbit or protruding into the anterior cranial Fossa,without dural invasion T4-tumour involving the brain No- no cervical lymph node metastasis N1-any form of cervical lymph node metastasis M0-no metastasis M1-distant metastasis present 52

53. 53

54. 54

55. Clinical evaluation Endoscopy Imaging Biopsy immunohistochemistry 55

56. Ct scan Advantages Bony detail Detects calcification,cartilage or bone with in the tumour Planning reconstruction Preliminary detail about intra cranial and intra orbital spread 85% accuracy 56

57. Key areas include the bony orbital walls, cribriform plate, fovea ethmoidalis, posterior wall of the maxillary sinus, pterygopalatine fossa, the sphenoid sinus, and the posterior table of the frontal sinus 57

58. Limitations Periorbital involvement Difficult to differentiate between: Tumor vs. Inflammation vs. secretions 58

59. mri 94% accuracy • Inflammatory tissue & secretions: intense T2 • Tumor: Intermediate T1 & T2, Enhancement with Gadolinium • MRI is excellent for determining perineural spread, involvement of the dura, or involvement intracranially. 59

60. Pet ct Increased 18FDG by sinonasal inflammation limits its use To detect distant metastasis 60

61. biopsy For confirmation of diagnosis Can be tran nasal,endoscopic maxillary antrostomy or sphenoidotomy,CT guided needle biopsy Biopsy via Caldwell-Luc approach is not recommended because of the potential to seed the gingivobuccal sulcus and cheek skin with tumor Rule out encephalocele or vascular tumour before biopsy Tissues for IHC 61

62. ihc Pathological diagnosis sometimes difficult To know the cells of origin or kind of tumour 62

63. tumour CK LCA NSE ACTIN SNP S100 VIMENTIN HMB45 CD99 SCC + ADENO + ESTHESIONEUROBLASTOMA + + + MELANOMA +/- +/- + + + SNUC + +/- FIBROSARCOMA + HAEMANGIO +/- + LYMPHOMA + PNET +/- +/- +/- + + 63

64. TREATMENT FOR CURE- surgical resection followed by adjuvant radiation or chemoradiation For palliative-local debulking with adjuvant radiation 64

65. Multidisciplinary expertise Surgical planning -evaluate bony and soft tissue structures to be resected -designing the optimal approach for better exposure -reconstruction and rehabilitation 65

66. Maxillary sinus-treatment options Surgery • Radiotherapy - definitive - pre op RT - post op RT • Combined modality ( Sx + RT) • Chemotherapy - Neo adjuvant - Concomitant 66

67. Surgical approaches Aim-to achieve complete tumour resction with negative margin Open and endoscopic approaches 67

68. UNRESECTABILITY • Superior extension: Frontal lobes or gross brain invasion • Lateral extension: Cavernous sinus,invovment of carotid arteries • Posterior extension: Prevertebral fascia,gross involvement of pterygoid • Bilateral optic nerve involvement • Distant Metastasis Treated by primary chemoradiation 68

69. Open procedures Caldwell luc Maxillectomy-medial/subtotal/total with or without orbital exenteration Lateral rhinotomy Mid facial degloving Anterior craniofacial resection 69

70. anaesthesia Under GA, reversed trendelenburg position with 15-20 head elevation Nasal mucosal vasoconstriction with 2-4ml,of Moffat’s solution Incision site infiltrated with 2%lignocaine and adrenaline 1;80,000 Incase of craniofacial resection,patient should be started with antiepileptics 48hrs prior Broad spectrum antibiotic 70

71. Midfacial degloving Popularized by cassen et al in 1970s and price in 1980s Excellent access to middle third of the face Used alone or combined with coronal scalp incision for craniofacial resection 71

72. INDICATIONS Nasal cavity,maxillary tumors with bilateral involvement,pterygopalatine and infratemporal fossa Most suited for inferiorly located tumors with minimal ethmoidal involvement CONTRAINDICATION Limits of resection Posteriorly-posterior wall of sphenoid,pterygoid plate and muscles Superiorly skull base Lateraly-coronoid process of mdible 72

73. INCISION A bilateral sublabial incision from maxillary Tuberosity to tuberosity down to bone Routine rhinoplasty intercartilagenous incision 73

74. TECHNIQUE The procedure is started with complete transfixion incision, which is connected to bilateral intercartilagenous incisions. Elevation of soft tissue from the nasal dorsum is performed through the intercartilagenous space. The soft tissue elevation over dorsum of nose is continued over the anterior wall of maxilla on both sides. Elevation of soft tissue should also continue over the glabella and frontal bone. 74

75. Supero laterally the elevation should extend up to the medial canthal region. The intercartilagenous incision is extended laterally and caudally across the floor of the vestibule to be connected with the transfixation incision. This results in a full circumvestibular incision on both sides. At the pyriform aperture region sublabial incision is connected to intranasal incisions. 75

76. § periosteal elevators are used to elevate the soft tissue over the anterior walls of both maxilla up to the level of the orbital rim taking care to protect the infraorbital vessels and nerve. § The entire midfacial skin is stripped from the dorsum of the nose and anterior wall of maxilla. § This flap includes the lower lateral cartilages, columella with its medial crura. 76

77. The elevation is continued till the level of glabella superiorly and medial canthus laterally. The bony nasal pyramid and the attached upper lateral cartilages are exposed completely. Two rubber drains are passed through the nose and upper lip and are used to retract the midfacial flap along with the upper lip. Once in every 15 minutes one of the drain should be released to allow blood supply to the middle portion of the upper lip . 77

78. 78

79. COMPLICATIONS Immediate-hemorrhage -facial bruising -infraorbital paraesthesia Late -vestibular stenosis -oro antral fistula -epiphora -septal perforation 79

80. Medial maxillectomy INDICATION Lesions that involve upto the entire lateral nasal wall but do not extent into orbit,anterior cranial fossa,lateral maxilla or alveolus A complete medial maxillectomy-encompasses middle and inferior turbinates,contents with in ethmoid and maxillary sinuses 80

81. The operation may be considered in 3 stages: soft tissue dissection/bone exposure bone resection closure/reconstruction. It is important to complete the soft tissue dissection and bone exposure before doing any bone work so as to avoid excessive blood loss. 81

82. SOFT TISSUE DISSECTION Done via midfacial degloving or lateral rhinotomy approach midfacial degloving approach avoids facial scars and is suited to resections that do not extend above the orbital floor when the resection requires removal of the medial wall of the orbit and the ethmoids, lateral rhinotomy provides better access. Soft tissue of the face are elevated off the maxilla,till lateraly upto infraorbital foramen Identify medial palpebral ligament,anterior lacrimal crest,lacrimal sac in lacrimal foss,posterior lacrimal crest Elevate lacrimal sac from the fossa 82

83. Expose medial and inferior orbit Frontoethmoidal suture line is identified-anterior and posterior ethmoid artery ligated,clipped or bipolar cauterised Strip along the floor of the orbit in extra periosteal plane Free soft tissue from bone up to anterior free margin of nasal apertures 83

84. 84

85. BONE RESECTION An antrostomy in the anterior face of maxilla uptpo orbital rim Inspect the antrum and plan subsequent bone cuts 85

86. Through infraorbital rim Connecting antrostomy with nasal vestibuli Across frontal process of maxilla Along orbital floor Along floor of nose Through lacrimal bone,lamina papyracea and anterior ethmoids Vertical posterior osteotome through posterior ethmoids,antrum along posterior wall and pterygopalatine plate 86

87. 87

88. 88

89. The medial maxillectomy specimen is then removed by gently levering it inferiorly and laterally with the Mayo scissors while completing the posterior osteotomy, in the process fracturing through the apex of the orbital floor and the posterior ethmoids cells, and remaining lateral to and preserving the middle turbinate. 89

90. • The specimen is inspected to determine the adequacy of the tumour resection. • An external ethmoidectomy may safely be completed up to the cribriform plate. • The ethmoids are carefully inspected to determine whether an external frontoethmoidectomy +/- sphenoidectomy is required, and for evidence of a CSF leak 90

91. RECONSTRUCTION Haemostasis is achieved with cautery, bone wax and or topical haemostatics. The objectives of closure are to minimise enophthalmos, diplopia, epiphora and an unsightly scar. Suture any tears in the periorbita to avoid herniation of orbital fat. The lacrimal sac is slit open along its longitudinal axis and the edges are sutured to the surrounding tissues to avoid epiphora. If an extensive resection of the orbital floor has been done, then consideration should be given to reconstructing the floor with fascia / bone / titanium mesh. The skin is carefully repaired to optimise the cosmetic results. Patients are instructed about nasal douching and are recalled for nasal toilette. 91

92. SUB TOTAL AND TOTAL MAXILLECTOMY Infrastructural maxillectomy-medial maxillectomy with removal of dentition,alveolar ridge and hard palate Subtotal-entire maxilla is removed Total-subtotal +orbital floor Approach is modified weber ferguson with subciliary extension 92

93. 93

94. 94

95. When tumour invoves bony orbital wall not contents-maxillectomy that removes orbital rim en bloc with rest of maxilla Orbital exenteration-invasion through orbital periosteum into the periorbita 95

96. Lateral rhinotomy Gives excellent access to nasal cavity through which medial maxillectomy can be done Can extend superiorly or inferiorly if required Ascribed to moure in 1902 96

97. INDICATION - Any malignant tumour affecting the nasal septum,lateral wall and extending into sphenoid,ethmoid and maxillary sinuses and up to anterior skull base CONTRAINDICATION- Tumours extended beyond these areas 97

98. INCISION Runs from level of medial canthus,midway between the medial canthus and the nasal bridge in the nasomaxillary groove curving around the lower ala into nasal cavity 98

99. Through the incision orbital periosteum dissected from lamina and nasolacrimal duct mobilized Anterior and posterio ethmoidal artery En bloc or piecemeal removal of lateral nasal wall including pyriform aperture,nasal bones,frontal process of maxilla,anterior maxillary wall,the medial orbital floor and rim, ethmoids lamina papyrracea and lacrimal fossa If extended superiorly-sphenoids and frontals Orbital periosteum resected if required 99

100. Whitehead varnish packing if necessary Incision closed Care must be exercised at alar margin to get good approximation 100

101. COMPLICATIONS Early-haemorrhage,orbital edema,CSF leak,meningitis Late-epiphora,diplopia,cosmetic(alar lift vestibular stenosis), frontal paraesthesia,Sinus obstruction,infection,mucocele 101

102. CRANIOFACIAL RESECTION Gold standard for tumours affecting the anterior skull base CONTRAINDICATIONS Extensive frontal lobe or middle cranial fossa involvement Certain histologies where extent of surgery does not influence outcome Distant metastasis 102

103. INCISION Extended lateral rhinotomy In young patients coronal flap with a midfacial degloving variation 103

104. Bicoronal scalp skin incision a few centimeters post hairline. The supraorbital, supratrochlear and superficial temporal vessels are well identified and preserved in the base of the flap. Adequate elevation of posterior scalp flap deep to galeal plane to allow generous-length pericranial flap for skull base repair; Anterior scalp flap pericranial flap elevated up to supraorbital ridges to maintain blood supply of flap. Minimum osteotomy may be needed to release supraorbital vessels providing extrapericranial flap length and bone exposure; 104

105. Anteriorly based U-shaped pericranial flap elevated; • Small frontal craniotomy; • Frontal bone plate is preserved; • The tumor can be approached from the inferior aspect via one of many transfacial approaches; • Management of the orbit as appropriate; • The nasolacrimal drainage needs to be dealt with to avoid any afterward epiphora; • Skull base and dural defect should be repaired • The entire nasal cavity is then packed snugly with Whitehead’s varnish to provide a support to the galeal flap superiorly and the medial orbital periosteum laterally. Nasal packs are to be kept for 2 weeks or more as needed 105

106. 106

107. COMPLICATIONS Immediate-convulsion,hemorrhage,air embolism Intermediate-CVA,pulm embolism,meningitis,aerocele Late- hemorrhage,frontal abscess,bonenecrosis/fistula,epilepsy,epiphora,diplopia Cellulitis,pituitary deficeincy 107

108. Endoscopic resection ANATOMIC LIMITS Soft tissue involvement or skin of the face and forehead Frontal sinus/bone involvement Dural involvement lateral to orbit Significant brain invasion >2cm Internal carotid artery encasement Involvement of mandible Invasion to extraocular muscles or optic nerve,cavernous sinus 108

109. TYPES 1. Endoscopic partial or medail maxillectomy 2. Transcribriform cranial resection 3. Coronal plane resection to pterygopalatine or infratemporal fossa 4. Orbital extensions 5. Endoscopic nasopharyngectomy 109

110. EBRT Supine position • Immobilisation • Mouthbite • Planning - maxilla - adj. nasal cavity - ethmoid sinuses - NPx - pterygopalatine fossa - portion of orbit • Techniques - Anterolateral wedge pair tech - 3 field tech 110

111. Dose prescribed at depth of 5 cm • EBRT dose - Pre operative : 45-50 Gy over 5 wks - Post operative : 55-60 Gy over 5.5 – 6 wks 111

112. chemotherapy ROLE For palliation Induction approach to reduce tumour burden Certain histological types-SNUC,lymphoma,rhabdomyosarcoma DRUGS-Cisplatin -5 Flurouracil -Carboplatin -Docetaxel -Gemcitabine 112

113. KNEGT’S REGIMEN For adenocarcinoma of ethmoid Surgical debulking Tumour bed packed with 5 FU Necrotomy 5 year survival 87% 113

114. Management of orbit BIOPSY/IMAGING CRANIOFACIAL RESECTION LAMINA PAPYRACEA ERODED INTACT ADJACENT TO PERIOSTEUM TUMOUR THROUGH PERIOSTEUM RESECTION/FROZEN SEC CLEAR ORBITAL CLEARANCE RECURRENCE PRESERVATION 114

115. STAGEWISE TREATMENT 115

116. 116

117. RECONSTRUCTION Optimizing functional rehabilitation in terms of speech,swallow and sight Maxillectomy and orbital defects with facial and dental prostheses Microvascular free flap reconstruction 117

118. Brown and shaw midface and maxillary classification Consists of Vertical component Horizontal component 118

119. 1. Not causing oroantral fistula 2.not involving orbit 3.involving orbital adnexa with orbir retension 4.orbital enucleation or extenteration 5.Orbitomaxillary defect 6.Nasomaxillary defect 119

120. A.palatal defect only,not involving dental alveolus B. Less than or equal to half unilateral C.less than or equal to half bilateral transverse anterior D.greater than half maxillectomy 120

121. Class I to IIB defects-obturation,reconstruction,faciocutaneous radial forearm flap Class III- soft tissue rectus abdominis reconstruction with neovascularised bone(iliac crest),Deep circumflex iliac artery flaps,Thoracodorsal angular arterty flaps Class IV- DCIA flaps,TDAA flaps Class V- temperoparietal or temporalis flap with orbital prosthesis Class VI-0steocutaneous radial forearm flap and vascularised bone 121

122. Skull base defects Region 1-arises from sinuses and orbitand extend into anterior cranial fossa Region II-originate in the lateral skull base and involve the infratemporal and pterygopalatine fossa and extend to middle cranial fossa Region III-originate at the ear,parotid or temporal bone and extend intracranialy to posterior fossa 122

123. 123

124. prognosis Factors affecting Anatomical Histological Tumour stage 124

125. Anatomical factors 5 year survival in % Nasal cavity 77 Maxillary sinus 62 Ethmoid sinus 48 Above Ohngren’s line worse 125

126. histology 5 year survival in % OAN 88 Adenocarcinoma 68 SCC 51 SNUC 44 Melanoma 18 126

127. TUMOUR STAGE 5 year survival in % T1 91 T2 64 T3 72 T4 49 127

128. TO SEE WHAT IS INFRONT OF ONE’S NOSE,NEEDS A CONSTANT STRUGGLE GEORGE ORWELL THANK YOU 128