3OeteomaOsteomas are common incidental finding in frontal sinus CT scanMajority are asymptomatic & do not growSurgery is done for symptomatic osteomas or those that rapidly increase in sizeComplete removal of tumor with its base attachment is done by FESS, bicoronal osteoplastic flap technique
8Ossifying fibroma Synonym: Fibrous dysplasia Normal medullary bone is replaced by abnormal proliferation of fibrous tissue, resulting in distortion & expansion of boneC.T. scan: ground - glass appearance with regions of osteolysis & calcificationTreatment: surgical excision for symptomatic Pt
11Inverted papilloma Locally aggressive sino-nasal tumour Synonyms: Ringertz or Schneiderian papillomaCommon in males between yearsIt arises commonly from the lateral wall of nosePresents as unilateral, Bilatral, friable, pale, pink mass arising from middle meatusDiagnosis made by punch biopsy
12Inverted papillomaTreatment: Endscopic 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 5 – 10 % cases.
21Epidemiology Uncommon tumors - >1% of all neoplasms Produces very little symptomsCommonly mistaken for rhinosinusitisAverage delay from first symptom to diagnosis is about 6 monthsAccurate staging is still not possible – Current staging system is only for maxillary & ethmoid sinuses
22Epidemiology Incidence – 1% per 100,000 / year Commonly develop during 5th – 6th decades of lifeTwice as common in men than womenCommon sino-nasal malignancy – Primary epithelial tumors followed by non-epithelial malignant tumorsTumors arising from nose 25% and tumors arising from sinuses 75%60% of squamous carcinomas arise from maxillary sinus, 20% from nasal cavity rest from ethmoids. 1% arise from sphenoid
30Late Clinical features Medial spread:Unilateral nasal obstructionUnilateral purulent nasal dischargeEpistaxisUnilateral, friable, nasal massAnterior spread:Cheek swellingInvasion of facial skin
31Late Clinical features Inferior spread:Expansion of alveolus with dental painLoosening of teeth, poor fitting of denturesSwelling in hard palate or alveolusSuperior spread:ProptosisDiplopiaOcular pain.
32Late Clinical features Posterior spread:Pterygoid muscle involvement trismusIntracranial spread via:Ethmoids, cribriform plateLymphatic spread:Neck node metastases in late stagesSystemic spread: Lungs, bone
40Ohngren's Classification Ohngren's line: An imaginary plane extending between medial canthus of eye & angle of mandibleSupra structural growths situated above this plane have a poorer prognosisIntra structural growths situated below this plane have better prognosis
42Lederman’s Classification 2 horizontal lines of Sebileau pass through floors of orbits & maxillary sinus, producing:Suprastructure: ethmoid, sphenoid & frontalsinuses; olfactory area of noseMesostructure: maxillary sinus & respiratorypart of noseInfrastructure: alveolar process
43T.N.M. Staging T1 = tumor confined to antral mucosa T2 = bone destruction of hard palate / middle meatusT3 = involvement of skin of cheek, floor or medialwall of orbit, ethmoid sinus, posterior antral wall,pterygoid plates, infratemporal fossaT4 = involvement of orbital contents, cribriform plate,frontal or sphenoid sinus, skull base, nasopharynx
44Treatment T1 & T2 = Surgery or Radiotherapy T3 = Surgery + RadiotherapyT4 = Surgery + Radiotherapy + ChemotherapyEuropeans: pre-operative Radiotherapy ( cGy) surgery after 4-6 weeksAmericans: Surgery post-operative Radiotherapy after 4-6 weeks
45Surgical Options Total maxillectomy malignancy limited to maxilla 2. Radical maxillectomy with orbital exenterationinvolvement of orbital fat3. Anterior Cranio Facial Resection (extendedlateral rhinotomy incision) = involvement of cribriform plate, frontal sinus
47Orbital exenteration indications Involvement of orbital apexInvolvement of extra-ocular musclesInvolvement of bulbar conjunctiva or scleraNon-resectable full thickness invasion through periorbita into retrobulbar fat