This document provides an overview of nose and paranasal sinus malignancies. It discusses their epidemiology, common types including squamous cell carcinoma and adenocarcinoma, risk factors such as wood dust exposure, clinical presentation, imaging, staging systems, and treatment options including surgery and radiotherapy. Nose and paranasal sinus cancers are uncommon but can cause significant morbidity due to their location near critical structures like the orbit and brain. Accurate diagnosis is challenging as symptoms often mimic rhinosinusitis initially. Treatment aims to balance tumor control with preserving quality of life and important functions.
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Malignant tumors involving paranasal sinuses
1. Nose & PNS Malignancy
Current concepts
Balasubramanian Thiagarajan
Otolaryngology online
Drtbalu's otolaryngology online
2. Introduction
· Uncommon tumors - >1% of all neoplasms
· Diverse group – some unique to nose alone
· 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
3. Reality
· Surgery & chemoradiotherapy main trt modalities available
· Treatment modalities inflict considerable morbidity
· Facial disfigurement / Interference with mastication / loss of sight
· Quality of life – considered while choosing treatment modality
4. 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
6. Adenocarcinoma
· Third most common epithelial malignancy next only to sinonasal gland carcinoma.
· 4 times frequent in men. ? Occupational exposure to wood dust.
· Commonly arise from olfactory cleft.
· Usually appears polypoidal
· Unilateral expansion of olfactory cavity and opacification in imaging - ? suspicion
10. Wood dust
· Adenocarcinoma
· Wood workers – 500 times common
· Exposure to hard wood dust – Ebony, mahogany, oak.
· Exposure threshold - > 5mg / m3 / day
· Chemicals used in wood processing have been eliminated as a cause
· Even short periods of exposure can cause adenocarcinoma (< 5 years)
11. Industrial risk
· Wood industry
· Textile industry
· Bakery
· Textile
· Nuclear industry
· Farming
· Construction
· Mining
12. Human papilloma virus
· HPV-6 / HPV-11 demonstrated in 10% of squamous cell carcinoma nose & pns.
· HPV – 16 / HPV – 19 are known to cause more virulent cancers.
· Presence of squamo columnar junctions in the nose predisposes to HPV induced cancers.
13. Tumor spread
· Local invasion
· Orbital spread common – thin walls, nerves and blood vessels cause dehiscence
· Roof of frontal sinus is thin – perforations + for olfactory nerves to pass
14. Ohngren's Line
· Line running from medial canthus to angle of
mandible
· Prognosis of suprastructure tumors worse (This
was before advent of craniofacial resection)
15. Lymphatic drainage
· Lymphatic drainage of this area is scanty.
· Anterior / Posterior pathway
· Anterior pathway – 1st echelon nodes (facial, parotid, submandibular nodes)
· Posterior pathway – 1st echelon nodes (retropharyngeal nodes)
· Anteroinferior nasal cavity, skin of nasal vestibule – anterior pathway
· Rest of nose and sinuses drain via posterior pathway
20. MRI
· Differentiates tumor from soft tissue
· Differentiates secretions from tumor mass
· Demonstrates perineural spread
· Not affected by dental fillings
· Can be imaged in sagittal plane
· Coronal MRI – Foramen rotundum, vidian canal, foramen ovale and optic canal can be seen
21. Angiogram
· Tumors surround carotid artery
· Carotid artery needs to be sacrificed in order to obtain clear surgical margins
· Balloon occlusion tests should be performed to estimate the risk of cerebral infarction if carotid needs to be
sacrificed.
23. Squamous cell carcinoma
· Most common sinonasal malignancy.
· Common during 7th decade / males.
· Arises – lateral nasal wall. 50% arises from turbinates.
· 85% are well differentiated and keratinizing.
· 15% of inverted papilloma turns malignant
24. Adenocarcinoma
· Wood workers
· 9% of all sino nasal malignancies
· Common 6th – 7th decades
· Common in upper nasal cavity / ethmoidal sinuses
· Growth rate slow
· Metastasis uncommon
· Histological types: Papillary, sessile, mucoid, neuroendocrine, intestinal, undifferentiated.
25. Adenoid cystic carcinoma
· 5% of all sinonasal malignancies
· Slow growth, perineural spread, vascular spread
· Maxillary sinus commonly affected
· Long history of facial pain defying diagnosis
26. Olfactory neuroblastoma
· Arises from basal cells of olfactory epithelium
· 5% of sinonasal malignancies
· Bimodal distribution (20 and 50 yrs old peak).
· More common in women than men
· Paraneoplastic syndrome +
27. Kadish staging system
· Stage A – Tumor limited to nasal cavity
· Stage B – Tumor limited to nose and sinuses
· Stage C – Tumor extending beyond the confines of nose and sinuses
· Stage D – distant metastasis
28. ULCA Staging
Stage
Description
T1
Tumor involving the nasal cavity or
paranasal sinuses (excluding sphenoid) or
both, sparing the most superior ethmoidal
air cells
T2
Tumor involving the nasal cavity or
paranasal sinuses (including the sphenoid)
or both with extension to or erosion of the
cribriform plate
T3
Tumor extending into the orbit or
protruding into the anterior cranial fossa
T4
Tumor involving the brain
30. Melanoma
· 4% of sinonasal malignancies
· Common in women than men
· Affects elderly
· Nasal cavity / septum common sites
· Polypoidal / ulceration
· Metastasis less frequently to nodes
· Lungs / brain metastasis common
36. Irradiation
· Preop irradiation preferable
· Post op irradiation is suitable only for slow growing tumors
· 200 rads x 5 days a week – 6 weeks (6000rads)
38. Medial maxillectomy
· Good access to nasal cavities / ethmoids /
nasopharynx / sphenoid / pterygopalatine fossa
· Moore's incision
· Incision may be continued into nasal cavity
40. Anterior craniofacial resections
· Type I – Craniofacial / transorbital resection. This procedure is extended medial maxillectomy with
resection of ethmoid roof and orbital periosteum
· Type II – Medial maxillectomy with window craniotomy using frown line incision
· Type III – Neurosurgeon helps. Transfacial with neurosurgical approach like frontolateral craniotomy