Sino-nasal Malignancies PRESENTATION ENT

ENT PRESENTATION

1. Sino-nasal
Malignancy

2. tumours of nasal cavity
Benign
squamous
papilloma
inverted papilloma
pleomorphic
adenoma
schwannoma
meningioma
hemangioma
chondroma
angiofibroma
encephalocele
glioma
dermoid
Malignant
Carcinoma (Squamous cell
Ca.,
Adenocarcinoma)
malignant melanoma
olfactory neuroblastoma
haemangiopericytoma
lymphoma
solitary plasmacytoma
various type of sarcoma

3. tumours of paranasal sinuses
Benign
-osteomas
-fibrous dysplasia
-ossifying fibromas
-ameloblastoma
Malignant
-Carcinoma of maxillary sinus,
ethmoid sinus,
frontal sinus,
sphenoid sinus.
*80% SCC,
rest adenocarcinoma, adenoid
cystic carcinoma,melanoma,
various type sarcomas

4. Tumors of the nasal cavity
proper are approximately
evenly divided between
benign and malignant
neoplasia, with inverting
papilloma predominating in
the benign group and
squamous cell carcinoma in
the malignant.

5. On the other hand, most
sinus tumors are
malignant with
squamous cell
carcinoma being the
most prevalent.
The maxillary sinus is most
commonly involved with
tumor, followed by the
nasal cavity, the ethmoids,
and then the frontal and
sphenoid sinuses.
 

6. Papillomas
1.vestibular papillomas
2.schneiderian papillomas- derived from
schneiderian mucosa (squamous)
•fungiform- 50% nasal septum
•cylindrical- 3% lateral wall/sinuses
•inverted- 47% lateral wall

7. Inverted papillomas
Etiology is unclear.
High recurrence rates.
Associated with malignancy
Male predominance
Locally aggressive growth patterns,( technically
difficult to remove )
There is also controversy over the appropriate
surgical approach for tumor removal.
There is a role for radiation therapy.

8. Inverted papillomas
Papillomas differ from
inflammatory polyps, which
are more common, in that
inflammatory polyps are
associated with allergic rhinitis
and are actually reactive
lesions, not a tumor.
Nasal papillomas are true
neoplasms and, while their
etiology is unclear, they are
known to arise from the nasal
respiratory epithelium, which
undergoes metaplastic
change and proliferation.

9. They are commonly
located in the nasal
cavity and they typically
involve an adjacent
sinus.
The most common
location is the middle
turbinate, but other
common locations
include the ethmoid
sinus and maxillary
sinus.
They have even been
found in the
nasopharynx.

10. Most common symptoms are unilateral and
include nasal obstruction, nosebleed and
nasal discharge. It can be an incidental finding
on examination.
 They are associated with malignancy, 5% to
15%. Inverted papillomas are more commonly
associated with squamous cell carcinomas.

11. Cannady (2007) further recommended a modification of the
Krause staging for IP as follows:
Modified Krause staging
A – Inverted papilloma (IP) confined to the nasal cavity,
ethmoid sinus, or medial maxillary wall
B – Inverted papilloma (IP) with involvement of any
maxillary wall (other than the medial wall) or frontal sinus
or sphenoid sinus
C – Inverted papilloma (IP) with extension beyond the
paranasal sinuses

12. •Tumors in group A were amenable to complete
endoscopic resection and low recurrence rates (RR) of
(3%).
•Tumors in group B could be resected endoscopically but
often required adjunctive procedures (Caldwell-Luc
approaches or osteoplastic frontal sinusotomy,
respectively) for removal and RR of 20%.
•Tumors in group C always required open approaches,
and RR were closer to 35%.
•Risk factors for the recurrence of inverted papillomas of
the sphenoid sinus include the presence of dysplasia or
carcinoma in situ (CIS) and attachment of the tumor over
the optic nerve or carotid artery

13. The mainstay of treatment is surgery,
although radiation therapy can be involved.
Surgery either a transnasal procedure with polypectomy
or confined transnasal polypectomy with additional
sinus procedure, such as Caldwell-Luc.
The gold standard was medial maxillectomy via
lateral rhinotomy or en bloc ethmoidectomy
Radiation therapy - absolute indication for radiation
therapy is when an inverted papilloma is associated with
squamous cell carcinoma. Those
-advanced incompletely resected or unresectable lesions
that are biologically aggressive
-patients where morbidity in resection would be more
pronounced than morbidity of tumor radiation.

14. Sinonasal neoplasms
These are rare, comprising less than 3% of all
malignant aerodigestive tumors and less than
1% of all malignancies.
typically affect Caucasion males in the fifth to
seventh decades of life ,2:1 male
preponderance.

15. Sinus Anatomy:
Maxillary antrum
Significance
Superior – orbit,
ethmoids
Posterior – pterygoids,
infratemporal fossa
Ethmoid sinus
Significance
Superior – fovea,
cribiform
Medial – lamina
papyracea

16. Sinus Anatomy:
Sphenoid sinus
Significance
Superior – optic nerve,
pituitary
Lateral – ICA,
cavernous sinus
Inferior – vidian nerve

17. Frontal sinus
Significance
Inferior – orbit
Posterior –
anterior cranial
fossa

18. Lymphatic Drainage
The anterior nose has the
same lymphatic drainage
as the external nose. 
These
tend to spread to the
submental or level I area, and
also to level II and III
The posterior nasal
cavity,posterior ethmoids
and sphenoids tends to
drain to the
retropharyngeal nodes as
well as the lateral pharyngeal
nodes, which eventually drain
into the level II.
 

19. Etiology
Up to 44% are attributed to occupational
exposures, including nickel, chromium, isopropyl
oils, volatile hydrocarbons, and organic fibers
that are found in the wood, shoe, and textile
industries.
In addition, human papilloma virus can be a
cofactor
Specific asssociations found include squamous
cell carcinoma in nickel workers and
adenocarcinoma in workers exposed to
hardwood dusts and leather tanning.

20. The most common entities are squamous
cell carcinoma. The lateral nasal wall is the
most common site of involvement, but SCC
can also present in the sinuses(most common
maxillary followed by ethmoid, frontal and
sphenoid).
Adenocarcinoma is the second most
common malignancy in this area. It is most
often in the ethmoids, has a male
predominance, and is often seen in industrial
workers.

21. Squamous cell carcinoma
-most common tumor (80%)
-Location -maxillary sinus 70%
-nasal cavity 20%
-90% have local invasion by presentation
-88% present in advanced stage (T3/T4)
-Tx -surgical resection with postoperative
radiation

22. Adenocarcinoma
-2nd most common malignant tumor in in maxillary
and ethmoid sinuses
-present most often in the superior portion (strong
asso. with occupational exposure)
-High grade- solid growth pattern with poorly
defined margin (30% present with metastasis)
-Low grade- uniform and glandular with less
incidence of perineural invasion/metastasis.

23. Adenoid cystic carcinoma
-3rd most common site is the nose/paranasal
sinuses
-perineural spread - anterograde & retrograde
-despite aggressive surgical recection and
radiotherapy,most grow insidously
-neck metastasis is rare and usually a sign of local
failure
-postoperative RT is very important

24. Mucoepidermoid carcinoma
-extremely rare
-widespread local invasion makes resection
difficult, therefore radiation is often
indicated

25. Hemangiopericytoma
-pericytes of Zimmerman
-present as pale, rubbery, well
circumscribed lesion resembling nasal
polyp
-Tx- surgical resection with postoperative RT
for positive margin

26. Melanoma
-0.5-1.5% of melanoma originates from
nasal cavity and paranasal sinuses
-anterior septum- most common site
-treatment is wide excision with/without
postoperative radiation therapy

27. Olfactory neuroblastoma
Esthesioneuroblastoma
-originates from stem cells of neural crest
origin that differentiate into olfactory
sensory cells
-aggressive behaviour
-local failure 50-75%
-metastatic disease develop in 20-30%
-treatment is en-bloc surgical resectionwith
postoperative RT

28. Sarcomas
-osteogenic sarcomas
•most common primary malignancy of bone
•mandible > maxilla
•sunray radigraphic appearance
-fibrosarcoma
-chondrosarcoma

29. Rhabdomyosarcoma
-most common paranasal sinus malignancy
in children
-non-orbital, parameningeal
-triple therapy often necessary
-agressive chemo/RT has improved survival
from 51% to 81% in patients with cranial
nerve deficits/skull/intracranial involvement

30. Lymphoma
-Non-Hodgkins type
-strong asso. with EBV
-tumor is a destructive sinonasal lesion
associated with obstructive symptoms,
bone and soft-tissue destruction, and
hemorrhage
-Tx - radiation with/without chemotherapy
-survival drops to 10% of recurrent lesion

31. Sinonasal Undifferentiated
Carcinoma
-aggressive locally destructive lesion
-dependent on pathological differentiation
from melanoma, lymphoma, and olfactory
neuroblastoma
-preoperative radiation and chemotherapy
offer improved survival

32. Metastatic tumors
-Tumors that most frequently metastasize to
this bony region are those that are well
known to metastasize to other bones
which include prostate, breast, kidney,
lung, and thyroid.
-RCC is the most common
-palliative treatment only

33. Carcinoma of Maxillary Sinus
Clinical features
•common in 40 - 60 age group, preponderance in
males.
•Early feature- epistaxis, nasal obstruction,
recurrent sinusitis, cranial neuropathy, sinus
pain, facial paresthesia, proptosis, diplopia, or
an asymptomatic neck mass
•Ominous signs and symptoms (eg, severe
intractable headache, visual disturbances)

34. Signs and symptoms of maxillary sinus
carcinoma fall into several major categories
Oral
Nasal
Ocular, facial
Auditory

35. Oral presentations occur in
25-35% and include pain
involving the maxillary
dentition,loosening of
teeth, trismus, palatal and
alveolar ridge fullness, and
frank erosion into the oral
cavity.
Nasal findings are seen in
up to 50% of patients and
include obstruction,
discharge, stuffiness,
congestion, epistaxis, and
extension into the nasal
cavity.

36. Ocular findings
occur in
approximately 25%
and arise from
upward extension
into the orbit,
where unilateral
tearing, diplopia,
fullness of lids,
pain, and
exophthalmos are
seen

37. Facial signs include infra-orbital nerve
hypoesthesia, cheek swelling, pain, and
facial asymmetry.
Auditory complaints include hearing loss
secondary to serous otitis media due to
nasopharyngeal extension.
With advanced disease , the classic triad
of findings for carcinoma of the nasal
cavity and paranasal sinuses may be
present: These include
Facial asymmetry
A visible or palpable tumor bulge in the oral
cavity
Tumor visible in the nose with anterior
rhinoscopy.

38. Classification
Ohngren line, a line that
is drawn from the angle of
mandible to the medial
canthus. Ohngren's
classification indicates
that tumors presented
above this line, both
superiorly and posteriorly
(suprastructural), have a
poorer prognosis than
infrastructural.

39. American Joint Committee on Cancer (AJCC) Staging System is the
gold standard used for reporting, only for SCC.Histopathologically
further divided into 3 (well, moderate and poorly differentiated,
alsoto note on vascular and perineural invasion.)
 
T1 tumors restricted to any one sub-site, with or without bony
invasion.
 
T2 tumors invading two sub-sites in single region or extending to
involve adjacent regions of the nasoethmoidal complex,with or
without bony invasion
 
T3 tumors begin to have bony involvement, invade the medial wall
or floor of the orbit,maxillary sinus, cribriform plate or palate.
 
T4-A tumors involve any of the following; anterior orbital contents,
skin of nose or cheek, minimal extension to anterior cranial fossa,
pterygoid plates, sphenoid or frontal sinuses.
 
T4-B tumors involve any of the following; orbital apex, dura, brain,
middle cranial nerves other than V2, nasopharynx or clivus.

40. •Lederman's classification. Uses 2 horizontal
lines of Sebileau ; one passing through the floor
of orbits and the other passing through floors of
antra; thus dividing the area into;
•a)suprastrucure - ethmoid, sphenoid, and frontal
sinuses and olfactory area of the nose
•b)mesostructure - maxillary sinus and respiratory
part of nose
•c)infrastructure - contain alveolar process
•*further uses vertical lines, extending down the
medial walls of orbit to separate ethmoid sinuses
and nasal fossa from maxillary sinuses.

43. Investigations
CT scans are excellent for determining
bony erosion and extent of invasion.

44. MRI is excellent for
determining perineural
spread, involvement of
the dura, or involvement
intracranially.

45. confirm diagnosis via biopsy (often biopsy
is performed after imaging rule out
encephaloceles or other vascular issues)
PET scan has been used to evaluate for
residual tumor, recurrent tumor, and
radiated treated fields.
Angiography is not initially used, but can
be used for vascular tumors to determine
extent and vascularity as well as to allow
for embolization prior to any surgical
interventions.

46. Management (depend on histology, location and extend
of the disease)
Adenocarcinoma:
Treatment is
controversial, but the
literature indicates
that craniofacial
resection is the key.

47. Management
SCC: For the treatment of
early lesions, surgery, if
the tumor is excised en
bloc with good margins,
and, if there is no evidence
of perineural spread, then
surgery is usually
sufficient. If there are any
questions about the
margins or perineural
invasion, the addition of
radiation is indicated
External Inferior medial
Medial Radical

48. Management

Combined modality generally tends to be the
gold standard: surgery with postoperative
radiation therapy.

49. Management
Also, the use of chemotherapy is now being
added with the goal of better local control and
improvement in survival.
Chemotherapy does have a role in palliation for
large tumors that are nonresectable.
If there is nodal disease of the neck with
squamous cell carcinoma, a neck dissection is
generally indicated

50. •Maxillary sinus ca
- surgical excision of the growth by total or
extended maxillectomy (weber-fugerson's
incision used in maxillectomy).radiotherapy can
be given before or after the surgery
•Ethmoid sinus ca
-CF nasal obstruction, blood stained nasal
discharge and retro-orbital pain
-late features- broadening nasal root, lateral
displacement of eyeball, diplopia. Extension
through cribriform plate- cause meningitis

51. -early cases- preoperative radiation, then lateral rhinotomy
and total ethmoidectomy
-cribriform plate involved-craniofacial resection (ant cranial
fossa exposed)
•Frontal sinus ca
•uncommon, age 40-50,male
•CF-pain and swelling of frontal region, may extend into
orbit through ethmoid. Dura of ant cranial fossa involved
if growth penetrates post wall of sinus
•Tx- preop radiation then surgery (frontal sinusectomy
with ethmoid and orbital exentration).
•Sphenoid sinus ca
• rare, radiotherapy is mainstay of tx

52. Unresectable tumors
-superior extension : frontal lobes
-lateral extension : cavernous sinus
-posterior extension :prevertebral fascia
-bilateral optic nerve involvement

53. THANK YOU