1. Neoplasms of the Paranasal Sinus
University of Esfahan Medical
June 22, 2009
cummings,51

2. are uncommon in the general population.
most common are squamous cell carcinomas, frequency of <1:200,000 per year
diagnosis usually becomes evident only after an advanced stage has been reached, thus explaining the relatively poor prognosis.

3. ANATOMY Maxillary Antrum
The most significant structures prognostically are above and behind the maxillary antrum.
Superiorly, orbit and the ethmoid sinus.
Posterior, pterygoid plates, the pterygoid space, and the infratemporal fossa.
Anteriorly is the canine fossa,
inferiorly the alveolus,
and medially the nasal cavity.

4. Ethmoid Sinus
greater concern is spread superiorly, where the fovea ethmoidalis and the cribriform plate provide little barrier to intracranial spread.
The lateral wall consists of the thin bone of the lamina papyracea, which also provides little resistance to neoplastic invasion.

5. Sphenoid Sinus
Located the sphenoid sinus relates to very complex and vital structures.
superior, The optic nerve and the pituitary gland
Laterally,the internal carotid artery and the cavernous
Anterior to the sinus are posterior ethmoidal cells,
and inferiorly are the vidian nerve and the nasopharynx.

6. Frontal Sinus
The least frequently involved by malignant tumor
anteriorly by the soft tissues of the scalp, inferiorly by the ethmoidal cells and the orbit
posteriorly by the anterior cranial fossa.
It is important to realize that all of the sinuses have venous communications with intracranial veins, which provide yet another avenue for lethal spread of neoplasm.

7. Lymphatics
they do metastasize but that clinical evidence of early metastasis is absent, because the primary drainage is to the lateral and retropharyngeal nodes

8. SYMPTOMS early symptoms : facial or dental pain, nasal obstruction,
and epistaxis.
These early signs represent the impact of a necrotic infected mass situated within the paranasal sinus or nose.

9. additional symptoms as follows:
    Diplopia or vision loss    2.    Epiphora    3.    Facial swelling and malocclusion
   4.    Trismus signals    5.    Neck mass, palpable metastatic adenopathy in the jugular chain
first nodes are located in the parapharyngeal region.    6.    Hearing loss
   7.    Facial numbness

10. nasopharyngeal extension of disease
Hearing loss usually results from nasopharyngeal extension of the tumor causing serous otitis.
contraindication to surgery:
nasopharyngeal extension of disease   

11. PHYSICAL FINDINGS
  1.    Nasal, facial, or intraoral mass. The widening of the upper alveolar ridge or development of loose, nonvital teeth may be the earliest sign of inferior bony invasion.
A palatal mass and ulceration are evidence of more advanced disease.    2.    Proptosis.    3.    Cranial nerve deficits. The commonly involved cranial nerves are the CN II, CN III, CN IV, two branches of CN V (CN V1 and CN V2), and CN VI.
Involvement of cranial nerves is a manifestation of advanced disease and indicates a poor prognosis.

12. DIAGNOSTIC ASSESSMENT
Computed Tomography Scan
CT is equal to tomography for assessment of bony involvement.
CT scanning may also be misleading in evaluation of the orbital floor.
helpfull involvement of the retroorbital and orbital apex region.
assessing infiltration of the nasopharynx
evaluation of intracranial extension is necessary, contrast-enhanced CT scanning

13. Angiography
the lesion demonstrates enhancement during initial CT study
it approximates the carotid system.
evaluation of unusual tumors involving the sphenoid sinus and skull base
essential for assessment of tumor extent and delineation of feeding vessels and as an approach for embolization

14. Ultrasound B-mode scanning: is helpful in assessing orbital masses
Positron Emission Tomography (PET):
PET scanning is of little use in assessing tumor extent;
play some role in assessing the presence of metastatic disease before oncologic surgery
follow-up after concomitant chemoradiation.
pretreatment PET provides the optimal baseline for posttreatment decision making.

15. Magnetic Resonance Imaging (MRI)
The impact of MRI on the preoperative assessment of tumor extent has been dramatic.
The particular benefit of MRI is its ability to differentiate tissue density and the difference between tumor bulk and retained secretions in the sinuses.

16. Biopsy
Tumors contained within the sinus cavities should be biopsied transnasally,
possibility of a vascular tumor or an encephalocele when biopsying unilateral nasal masses.

17. Aspiration cytology for diagnosis deep tumors of the antrum.
useful for tumors that cause proptosis and present along the medial aspect of the orbit. Because the diagnosis in this setting includes benign lesions such as an orbital pseudotumor, histologic evaluation before surgical invasion is most appropriate.

18. SURGICAL OPTIONS External Ethmoidectomy Indications :
removal of benign tumors of the ethmoidal region
approach to biopsy and drainage for tumors of the sphenoethmoidal region and the medial orbit.
Benefits
allows excellent cosmesis and preservation of functional tissue.
Limitations: will not provide en bloc excision for any but the most limited tumors (middle turbinate).
there is a tendency to form a fistula to the nasal cavity when this area is irradiated.

19. Inferior Medial Maxillectomy
Indications
Inferior medial maxillectomy is designed for resection of the medial wall of the antrum and the inferior turbinate.
It is most often used for management of an inverted papilloma.

20. Medial Maxillectomy Indications
for larger benign or intermediate tumors involving the entire lateral nasal wall but without extension to the orbit, anterior cranial fossa, lateral maxilla, or alveolus.
Limitations
Removal of all turbinate tissue results in an abnormal nasal cavity, often requiring chronic management of crusting.

21. Radical Maxillectomy
Indications
the standard operation for advanced carcinoma of the maxilla.
Complete radical maxillectomy includes removal of the maxilla along with the nasal bone, the ethmoid sinus, and in some instances, the pterygoid plates.

22. Surgical Approach
The Weber-Fergusson incision is used with extensions around the eyelids to preserve those soft tissues
A skin or dermis graft is used to line the defect.
A preformed obturator can be of great assistance in the immediate postoperative period by acting as a support for packing.

23. Limitations
Even when orbital exenteration is included,
fails to provide when the tumor has escaped superiorly (ethmoidal roof) or posteriorly (orbital apex, pterygoid region).

24. Craniofacial Frontoethmoidectomy
Indications
designed to provide en bloc resection for tumors of the ethmoidal and frontal regions
If the tumor crosses the midline, the procedure may be performed bilaterally.

25. Benefits
Craniofacial exposure provides direct visualization of the cribriform plate and the fovea ethmoidalis and the potential for en bloc removal.
It also provides wide exposure to allow effective repair of dural tears, thus decreasing the chance of a postoperative CSF leak and intracranial infection.
would allow intraoperative irradiation or placement of a radioactive implant.
Limitations
If the tumor extends to the sphenoid sinus, the cavernous sinus, or transdurally, en bloc resection cannot be achieved.

26. Extended Craniofacial Resection
Indications
Extensive tumors involving the anterior skull base, with involvement of the pterygoid plates,
Bony Margins
The posterior line of resection is defined by the oval foramen, the round foramen, and the internal carotid artery. The excision may extend through the sphenoid sinus and up to the contralateral optic nerve.
Limitations
pterygoid plate erosion and cranial nerve invasion as indicators of inoperability.
it does not provide adequate en bloc resection for tumor at the orbit apex, in the nasopharynx, or deeply infiltrating the pterygoid space.

27. Benign tumors Papilloma Inverting papilloma Meningioma Neuroma
Hemangioma
Osteoma
Ameloblastoma
Fibrous dysplasia

28. Osteomas frontal sinus> the ethmoid sinus > maxilla.
When located away from the sinus osteum, an osteoma is silent ,followed with an interval radiograph in 1 to 2 years
when they interfere with sinus drainage or possibly when they impinge on the dura,they symptomized
If causes a mucocele, obliterative surgery or wide drainage is recommended
Chondromas develop anywhere in the sinonasal tract
resection should be more aggressive than with an osteoma, "fairly radical treatment.”

30. Schwannomas and Neurofibromas
arising from peripheral nerve components.
A schwannoma is an isolated encapsulated lesion, whereas a neurofibroma is woven into the nerve and is often one of multiple lesions.
cause symptoms :if may distort tissues by pressure or by obstruction of a sinus osteum.
evaluation, a contrast-enhanced CT scan,demonstrate a characteristic irregular patchy appearance
managed by conservative local resection.
malignant transformation occurs in about one of eight patients with multiple neurofibromatosis (von Recklinghausen's disease

31. Ossifying Fibromas and Cementomas
difficult to differentiate histologically from fibrous dysplasia
ossifying fibromas may be diagnosed by including clinical and radiographic criteria.
occur in primarily young adults,
typified radiographically by a sclerotic bony margin that is evident at surgical resection, when the lesion often "shells out" easily
Cementomas are described as a variant of ossifying
managed by local excision,
if any tumor is left, a recurrence is likely.

32. Fibrous dysplasia
Dysplastic transformation of normal bone with collagen, fibroblasts, and osteoid material
Surgical excision for obstructing lesions
Malignant transformation to rhabdomyosarcoma has been seen with radiation

34. Odontogenic Tumors for only 1% of all jaw tumors
include ameloblastoma and the calcifying epithelial tumor of Pindborg.
They are locally aggressive,
Manage: resection with a small margin of normal tissue
Most odontomas are emphasizing their benign nature

36. INTERMEDIATE NEOPLASMS
Inverted Papillomas
usually present as polypoid unilateral nasal masses.
On occasion, they may be found in association with allergic nasal polyp
malignant change approximates 10%.
A lateral rhinotomy incision combined with medial maxillectomy to allow adequate margins is the classic approach.may be removed endoscopically.

37. Inverting Papilloma
Usually arise from unilateral wall of nose and extend into ethmoid and maxillary sinuses
No true invasion of surrounding structures
Displacement, destruction by pressure necrosis
Complete excision necessary to prevent recurrence
Radiotherapy ineffective, may promote malignant transformation

39. Hemangiomas
On rare occasions, a primary hemangioma will occur in the maxilla.
pyogenic granuloma is mistaken for a true hemangioma
More frequently, the maxilla will become involved with a soft tissue hemangioma of the face or a vascular malformation of the skull.
Hemangiomas are typified by rarefaction on radiographs,
extirpation is indicated only for bleeding or major discomfort

41. Hemangiopericytomas
typically occur in the nose but may involve the sinuses.
"If there is one common denominator for it is the lack of uniformity in appearance, growth and biological behavior."
Clinical behavior from a slowly enlarging rubbery mass to an infiltrating aggressive neoplasm.
are locally aggressive
likely to recur delayed recurrence,

42. Hemangiopericytoma Pericytes of Zimmerman
Present as rubbery, pale/gray, well circumscribed lesions resembling nasal polyps
Treatment is surgical resection with postoperative XRT for positive margins

43. Meningioma Very rare Result of extracranial arachnoid cell clusters
Occur along cranial nerve tracts and skull foramina
Complete removal is curative
Radiation may stabilize inoperable casesplain
skull films may reveal hyperostosis of the ethmoidal region.

45. Malignant lesions Squamous cell carcinoma Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Adenocarcinoma
Hemangiopericytoma
Melanoma
Olfactory neuroblastoma
Osteogenic sarcoma, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma
Lymphoma
Metastatic tumors
Sinonasal undifferentiated carcinoma

46. RISK FACTORS S.C.C;aflatoxin found in certain foods and dust;
chromium,
nickel,
mustard gas,
polycyclic hydrocarbons, and other organic chemicals,
mesothorium (Thorotrast), a radiopaque dye used as a contrast medium within the antrum.
adenocarcinoma ;Wood dust has a particular association
Adenoid cystic carcinomas and adenocarcinomas are next in approximately 10%

47. Squamous cell carcinoma
Most common tumor (80%)
Location:
Maxillary sinus (70%)
Nasal cavity (20%)
90% have local invasion by presentation
Lymphatic drainage:
First echelon: retropharyngeal nodes
Second echelon: subdigastric nodes

48. Maxillary Sinus
T1 Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone
T2 Tumor causing bone erosion or destruction including extension into the hard palate and/or middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid plates
T3 Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses.
T4a Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
T4b Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus

49. Nasal Cavity and Ethmoid Sinus
T1 Tumor restricted to any one subsite, with or without bony invasion
T2 Tumor invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion
T3 Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate
T4a Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses
T4b Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than (V2), nasopharynx, or clivus

50. MRI and CT scanning should be required for staging of these neoplasms.

51. Management Definitive treatment has included surgery, irradiation,
and electrocoagulation in varying combinations. It does not seem that substantial improvements have been achieved in the past 50 years

52. Maxillary Sinus
Early (T1 and T2) lesions may be treated by surgical resection (maxillectomy) or irradiation
Most patients have advanced (T3 or T4) disease when first seen, which most authors agree requires combined therapy for optimal control
usually receiving the following types of management: surgery for cure, surgery with preoperative or postoperative irradiation, and irradiation with surgical salvage

53. Surgery Alone Tomor isolated to the antral mucosa.
have taken a more aggressive surgical posture and reported dramatic improvement in survival for patients with T3 and T4 lesions
Surgical management should include consideration of immediate rehabilitation.

54. immediate rehabilitation
prosthetics. reconstruction of maxillary sinus defects
skin graft ;
1-fibula osteocutaneous flap :midface reconstruction for lower maxillary defects.
2-when orbitozygomatic support is the objective,the scapula osteocutaneous flap is preferable. reconstruction of the orbital floor, palate, and zygoma.[21
3- Iliac crest osteomyocutaneous flaps ;when requair additional soft tissue bulk and bone
the major risks is "covering recurrent disease." However, disease recurrence at this site, is essentially untreatable, so this may be a moot point.

55. Combined Irradiation and Surgery
With T3 tumors, little difference exists between preoperative and postoperative irradiation.
Postoperative irradiation control microscopically positive resection margins.
preoperative irradiation seems to be the choice,more advanced lesions, where resectability is questionable,
the management of advanced maxillary sinus tumors is the need for orbital exenteration. indicates a doubling of survival for the management of ethmoid neoplasms (57% vs 26%),

56. Radiotherapy
Difficulties in the use of standard radiation therapy for paranasal sinus tumor arise from the fact that in air-filled spaces such as the sinuses, the range of particles and thus the dosimetry is subject to considerable unceratainty.
may cause significant morbidity to the eye and optic nerves,
or may result in significant underdosing of portions ofthe posterior ethmoid and maxillary sinuset

57. Chemoradiation Therapy
Dramatic response with combined chemotherapy and radiation seems to be possible even in the presence of bulky or unresectable disease,

58. Cervical Lymph Nodes
cervical lymph nodes indicate a very poor prognosis.
can be successfully managed with neck dissection.

59. Adenocarcinomas have association with woodworking
commonly found in the upper nasal cavity and ethmoid sinus
lethal by virtue of local progression.
Treated with en bloc resection when possible.
In contrast to adenoid cystic carcinomas, adenocarcinomas have a low incidence of distant metastasis, but the long-range survival is equally poor.

60. Management for esthesioneuroblastoma and adenocarcinoma is generally similar
craniofacial resection
postoperative radiation.
The addition of chemotherapy to the management of advanced esthesioneuroblastoma (T3 and T4) is now well established,
noted a decrease in survival with preservation of the orbital contents (26%) compared with orbital resection (57%).

61. Adenoid Cystic Carcinoma
3rd most common site is the nose/paranasal sinuses,
Common invalve antrum
Perineural spread
Anterograde and retrograde
Distant metastase
Neck metastasis is rare and usually a sign of local failure
Surgicaly and Postoperative XRT is very important

62. Complications
complications increases when surgery breaches the intracranial space /when high doses of irradiation are delivered to the orbit or intracranial contents.
SURGICAL COMPLICATION;
meningitis, brain abscess, CSF leak, postoperative wound hemorrhage.
complication of sinus irradiation.
Cataracts are the most common
osteoradionecrosis,
keratitis,
optic neuritis,
hypopituitarism.
Injury to the optic nerve .After high-dose irradiation that uses fields that include the whole orbit, one can expect loss of vision in 100% of cases.

63. Therapeutic Decision Making
   1.    Most tumors are at an advanced stage when first recognized and require aggressive multimodality treatment.    2.    Survival and local disease control are better when the orbit is included in the therapeutic plan (i.e., exenteration or irradiation).    3.    A significant chance of metastasis to the primary (pharyngeal) and secondary (cervical) nodes exists. They should be included in the primary treatment plan.    4.    Higher success rates have been reported with primary irradiation,    5.    The best regimen may prove to be a combination of chemotherapy, irradiation, and limited surgical débridement.    6.    The concept of intraarterial chemotherapy for advanced skull base tumors was advocated

64. Sarcomas successful therapy is wide en bloc resection,
Osteogenic sarcomas and chondrosarcomas more commonly in the mandible than in the maxilla.
They are usually lethal by local progression.
successful therapy is wide en bloc resection,
Irradiation seems to be an effective

65. Osteogenic Sarcoma

66. Hematopoietic and Lymphoid Tumors
The paranasal sinuses are an uncommon primary site for lymphomatous tumors
most important role of the otolaryngologist is to provide adequate tissue in good condition for histologic processing
Treatment is usually chemotherapy, although irradiation alone is adequate for stage I and stage II Hodgkin's

67. Malignant Melanomas Symptoms; black nasal discharge
and have a pigmented mass within the nose.
Frequently regional or distant metastases exist at the time of initial examination.
Although radical surgical removal is the standard of care
Irradiation has been considered inadequate but adjustments in fractionation may provide better results,

68. Melanoma 1% originate in sinonasal cavity 5th-8th decades
anterior septum
maxillary antrum
polypoid mass,
pigmentation?
5 yr = 38%
10 yr = 17%

69. PARANASAL SINUS NEOPLASMS IN CHILDREN
usually benign.
The common nasal sinus tumors are polyps arising on an allergic basis or in association with cystic fibrosis.
The most common true neoplasms are fibroosseous lesions and tumors of dental origin
malignant tumors are embryonal rhabdomyosarcomas,
usually managed surgically because:
(1) most lesions are radioinsensitive;
(2) irradiation in excess of 3000 rad will have a substantial effect on growth of the facial skeleton;
(3) there is a significant risk of radiation-induced malignant transformation.

70. Monostotic fibrous dysplasia
developmental defect of bone
in the pediatric age group (age 15 or younger)
common in the maxilla
sometimes requires wide local removal, including partial maxillectomy,
Ossifying fibromas and cementomas, in contrast, are well delineated and may be managed by local excision with a minimal margin.

71. Rhabdomyosarcomas are the most common malignant neoplasm of the upper respiratory tract in the pediatric age
surgical margins supplemented by irradiation and chemotherapy.
parameningeal involvement have a poor prognosis
This group of patients has benefited from a combining intrathecal chemotherapy and craniospinal irradiation.

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