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Sino-nasal Tumours Dr. Vishal Sharma.

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1 Sino-nasal Tumours Dr. Vishal Sharma

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 x-ray
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 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: complete surgical excision

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 from the lateral wall of nose Presents as unilateral, friable, pale, pink mass arising from middle meatus Diagnosis made by punch biopsy

12 Inverted papilloma Treatment: 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 10­15% cases. Radiotherapy is avoided.

13 Anterior rhinoscopy

14 Contrast C.T. scan P.N.S. Left intra-nasal mass with opacification of maxillary and ethmoid sinuses (African continent sign). Bone destruction of lateral nasal wall.

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

16 Moure’s lateral rhinotomy

17 Osteotomy cuts

18 Bone removed & tumor exposed

19 Tumour removed & inicision closed

20 Midfacial degloving approach

21 Sino-nasal Malignancy

22 Epidemiology O.5% of all body cancers
15% of all upper respiratory neoplasm Maxillary sinus is most common 80-85% are squamous cell carcinoma Male : female = 2:1 Commonly seen in years

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

24 Maxillary sinus malignancy

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

26 Spread

27 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

28 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 .

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

30 Cheek swelling

31 Cheek skin involvement

32 Alveolar & Palatal swelling

33 Nasal mass

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

35 X-ray paranasal sinus

36 C.T. Scan

37 Ohngren’s Classification

38 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

39 Lederman’s Classification

40 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

41 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

42 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

43 Surgical Options 1. Total maxillectomy (Weber Fergusson incision) = malignancy limited to maxilla 2. Radical maxillectomy with orbital exenteration (Weber Fergusson Diffenbach incision) = involvement of orbital fat 3. Anterior Cranio Facial Resection (extended lateral rhinotomy incision) = involvement of cribriform plate, frontal sinus

44 Total Maxillectomy

45 Tarsorrhaphy

46 Weber Fergusson incision

47 Osteotomy cuts

48 Total maxillectomy done & incision closed

49 Palatal defect & prosthesis

50 Orbital exenteration indications
Involvement of orbital apex Involvement of extra-ocular muscles Involvement of bulbar conjunctiva or sclera Lid involvement beyond a reasonable hope for reconstruction Non-resectable full thickness invasion through periorbita into retrobulbar fat

51 Orbital exenteration

52 Cranio-facial resection

53 Thank You

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