TUMOURS OF NASAL CAVITY & PARANASAL SINUSES Col Shoaib Ahmed Consultant ENT Head & Neck Surgeon MBBS (Honours) FCPS(Pakistan) FRCS(Glasgow)

Review of Anatomy Paranasal sinuses are air filled cavities that communicate with the nasal cavity There are close anatomical relations with orbit & skull base Cranial nerves 1st, 2nd, 3rd ,4th , 5th and 6th are in close vicinity

Unique Features of Sinonasal Tumours Relatively rare of head & neck tumours Present late Large air filled sinuses with no vital structure in immediate vicinity → remain clinically silent Highly non specific early symptoms – (rhinorrhea & nasal obstruction) → receive scant attention Wide variety of pathological lesions Extension to anatomically critical areas Generally advanced disease with poor clinical outcome

Classification BENIGN Inverted papilloma Non epithelial Fibroma Chondroma Hemangioma Nerve sheath tumour

Classification contd. MALIGNANT Squamous cell carcinoma Non epithelial Adenocarcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Olfactory neuroblastoma / Esthesioneuroblastoma Non epithelial Sarcomas Lymphoma Giant cell tumour

Environmental Factors associated with sinonasal malignancy Wood dust Nickel Hydrocarbons Chromium Organic oils Isopropyl oil

Clinical Features EARLY Nasal obstruction Rhinorrhea LATE Epistaxis Proptosis Facial pain / swelling Cranial nerve dysfunction Trismus

How to identify early on ? Can be readily mimicked by common respiratory conditions (e.g. Sinusitis ) ↓ Unilaterality of symptoms & signs Persistent & progressive symptoms No improvement with antibiotics / anti histamines Unilateral facial pain / numbness / fullness Short span of symptoms suggests a malignant tumour

Clinical Examination Thorough ENT head & neck examination ↓ Trismus Orbit Neurological exam (cranial nerves 1st to 6th) Cervical lymph nodes

Diagnosis Always done after imaging Clinical Imaging (X rays, CT , MRI , PET ) Biopsy Always done after imaging (highly vascular lesion, or intra cranial) Generally under LA

Radiological Imaging Plain X rays have lesser value ! 45 degrees Occipitomental projection – “X ray PNS”

Plain X- rays - Findings Unilateral findings Opaque sinus Gross bone destruction

CT scans Initial investigation of choice Shows bony details Areas of bone destruction Extension into adjacent areas

Normal CT scan Frontal sinus Ethmoid sinuses

CT scan Unilateral sinonasal mass Bony erosion of lateral nasal wall and skull base

Inverted papilloma

Olfactory neuroblastoma in a 14 year old

MRI Better soft tissue detail Useful to detect intracranial extension Able to distinguish nasal secretions from tumour Indicates extension into dural venous sinuses

Positron Emission Tomography (PET scan) Routine evaluation for recurrent disease after primary tumour Mainly used for squamous cell carcinoma Very expensive modality

TREATMENT OPTIONS Palliation Surgery Radiotherapy Combined surgery & radiotherapy Chemotherapy Palliation Lymphomas

Olfactory Neuroblastoma in a young lady

CONCLUSION These are rare tumours with poor survival & are generally advanced at presentation Comprise of several histologic types with varying biological behaviour Early diagnosis requires being alert for any persistent unilateral symptoms Diagnosis is based on CT, MRI and biopsy For cure, extensive mutilating surgery followed by reconstruction is often required

DEPARTMENT OF ENT HEAD & NECK SURGERY COMBINED MILITARY HOSPITAL RAWALPINDI

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