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Sino-nasal Tumours Dr.Mohammad aloulah.

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1 Sino-nasal Tumours Dr.Mohammad aloulah

2 Classification Benign Simple papilloma Ossifying Fibroma Osteoma
Haemangioma Neurofibroma Intermediate Inverted papilloma Malignant Squamous cell carcinoma Adenocarcinoma Anaplastic carcinoma Transitional cell carcinoma Malignant melanoma Salivary gland tumours Rhabdomyosarcoma

3 Oeteoma Osteomas are common incidental finding in frontal sinus CT scan Majority are asymptomatic & do not grow Surgery is done for symptomatic osteomas or those that rapidly increase in size Complete removal of tumor with its base attachment is done by FESS, bicoronal osteoplastic flap technique

4 Frontal sinus osteoma

5 Bicoronal osteoplastic flap

6 Osteoma exposed

7 Tumor removal + closing of bone flap

8 Ossifying fibroma Synonym: Fibrous dysplasia
Normal medullary bone is replaced by abnormal proliferation of fibrous tissue, resulting in distortion & expansion of bone C.T. scan: ground - glass appearance with regions of osteolysis & calcification Treatment: surgical excision for symptomatic Pt

9 Ossifying fibroma

10 Ossifying fibroma

11 Inverted papilloma Locally aggressive sino-nasal tumour
Synonyms: Ringertz or Schneiderian papilloma Common in males between years It arises commonly from the lateral wall of nose Presents as unilateral, Bilatral, friable, pale, pink mass arising from middle meatus Diagnosis made by punch biopsy

12 Inverted papilloma Treatment: 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.

13 Anterior rhinoscopy

14 Contrast C.T. scan P.N.S. Left intra-nasal mass with opacification of maxillary and ethmoid sinus

15 Punch Biopsy & H.P.E. Inward invasion of hyperplastic epithelium into
underlying stroma. No evidence of malignancy.

16 lateral rhinotomy

17 Bone removed & tumor exposed

18 Tumour removed & inicision closed

19 Midfacial degloving approach

20 Sino-nasal Malignancy

21 Epidemiology Uncommon tumors - >1% of all neoplasms
Produces very little symptoms Commonly mistaken for rhinosinusitis Average delay from first symptom to diagnosis is about 6 months Accurate staging is still not possible – Current staging system is only for maxillary & ethmoid sinuses

22 Epidemiology Incidence – 1% per 100,000 / year
Commonly develop during 5th – 6th decades of life Twice as common in men than women Common sino-nasal malignancy – Primary epithelial tumors followed by non-epithelial malignant tumors Tumors 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

23 Common sinonasal malignancy
Squamous cell carcinoma – commonest Adenocarcinomas Adenocystic carcinomas Undifferentiated carcinomas Non Hodgkin's lymphoma Melanomas

24 Adenocarcinoma


26 Risk factors Hardwood dust (adenocarcinoma)
Softwood dust (squamous carcinoma) Nickel refining; chromium workers Boot, shoe and textile workers Mustard gas exposure Human papilloma virus

27 Maxillary sinus malignancy

28 Early Clinical features
Mimic maxillary sinusitis Nasal stuffiness Blood-stained nasal discharge Facial paraesthesias or pain Epiphora

29 Spread

30 Late Clinical features
Medial spread: Unilateral nasal obstruction Unilateral purulent nasal discharge Epistaxis Unilateral, friable, nasal mass Anterior spread: Cheek swelling Invasion of facial skin

31 Late Clinical features
Inferior spread: Expansion of alveolus with dental pain Loosening of teeth, poor fitting of dentures Swelling in hard palate or alveolus Superior spread: Proptosis Diplopia Ocular pain .

32 Late Clinical features
Posterior spread: Pterygoid muscle involvement  trismus Intracranial spread via: Ethmoids, cribriform plate Lymphatic spread: Neck node metastases in late stages Systemic spread: Lungs, bone

33 Cheek swelling

34 Cheek skin involvement

35 Alveolar & Palatal swelling

36 Nasal mass

37 Diagnosis Diagnostic nasal endoscopy
X-ray paranasal sinus: expansion & destruction of bony wall C.T. Scan: axial & coronal cuts with contrast Biopsy

38 C.T. Scan

39 Ohngren’s Classification

40 Ohngren's Classification
Ohngren's line: An imaginary plane extending between medial canthus of eye & angle of mandible Supra structural growths situated above this plane have a poorer prognosis Intra structural growths situated below this plane have better prognosis

41 Lederman’s Classification

42 Lederman’s Classification
2 horizontal lines of Sebileau pass through floors of orbits & maxillary sinus, producing: Suprastructure: ethmoid, sphenoid & frontal sinuses; olfactory area of nose Mesostructure: maxillary sinus & respiratory part of nose Infrastructure: alveolar process

43 T.N.M. Staging T1 = tumor confined to antral mucosa
T2 = bone destruction of hard palate / middle meatus T3 = involvement of skin of cheek, floor or medial wall of orbit, ethmoid sinus, posterior antral wall, pterygoid plates, infratemporal fossa T4 = involvement of orbital contents, cribriform plate, frontal or sphenoid sinus, skull base, nasopharynx

44 Treatment T1 & T2 = Surgery or Radiotherapy
T3 = Surgery + Radiotherapy T4 = Surgery + Radiotherapy + Chemotherapy Europeans: pre-operative Radiotherapy ( cGy)  surgery after 4-6 weeks Americans: Surgery  post-operative Radiotherapy after 4-6 weeks

45 Surgical Options Total maxillectomy malignancy limited to maxilla
2. Radical maxillectomy with orbital exenteration involvement of orbital fat 3. Anterior Cranio Facial Resection (extended lateral rhinotomy incision) = involvement of cribriform plate, frontal sinus

46 Palatal defect & prosthesis

47 Orbital exenteration indications
Involvement of orbital apex Involvement of extra-ocular muscles Involvement of bulbar conjunctiva or sclera Non-resectable full thickness invasion through periorbita into retrobulbar fat

48 Thank You

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