Neoplasms of the nose and paranasal sinus /certified fixed orthodontic courses by Indian dental academy

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Neoplasms of theNeoplasms of the
Nose and ParanasalNose and Paranasal
SinusSinusINDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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Neoplasms of Nose and ParanasalNeoplasms of Nose and Paranasal
SinusesSinuses
 Very rare 3%Very rare 3%
 Delay in diagnosis due to similarity to benignDelay in diagnosis due to similarity to benign
conditionsconditions
 Nasal cavityNasal cavity
 ½ benign½ benign
 ½ malignant½ malignant
 Paranasal SinusesParanasal Sinuses
 MalignantMalignant

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Neoplasms of Nose and ParanasalNeoplasms of Nose and Paranasal
SinusesSinuses
 Multimodality treatmentMultimodality treatment
 Orbital PreservationOrbital Preservation
 Minimally invasive surgical techniquesMinimally invasive surgical techniques

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EpidemiologyEpidemiology
 Predominately of older malesPredominately of older males
 Exposure:Exposure:
 Wood, nickel-refining processesWood, nickel-refining processes
 Industrial fumes, leather tanningIndustrial fumes, leather tanning
 Cigarette and Alcohol consumptionCigarette and Alcohol consumption
 No significant association has been shownNo significant association has been shown

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LocationLocation
 Maxillary sinusMaxillary sinus
 70%70%
 Ethmoid sinusEthmoid sinus
 20%20%
 SphenoidSphenoid
 3%3%
 FrontalFrontal
 1%1%

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PresentationPresentation
 Oral symptoms: 25-35%Oral symptoms: 25-35%
 Pain, trismus, alveolar ridge fullness, erosionPain, trismus, alveolar ridge fullness, erosion
 Nasal findings: 50%Nasal findings: 50%
 Obstruction, epistaxis, rhinorrheaObstruction, epistaxis, rhinorrhea
 Ocular findings: 25%Ocular findings: 25%
 Epiphora, diplopia, proptosisEpiphora, diplopia, proptosis
 Facial signsFacial signs
 Paresthesias, asymmetryParesthesias, asymmetry

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RadiographyRadiography
 CTCT
 Bony erosionBony erosion
 Limitations with periorbita involvementLimitations with periorbita involvement
 MRIMRI
 94 -98% correlation with surgical findings94 -98% correlation with surgical findings
 Inflammation/retained secretions: low T1, high T2Inflammation/retained secretions: low T1, high T2
 Hypercellular malignancy: low/intermediate on bothHypercellular malignancy: low/intermediate on both
 Enhancement with GadoliniumEnhancement with Gadolinium

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Benign LesionsBenign Lesions
 PapillomasPapillomas
 OsteomasOsteomas
 Fibrous DysplasiaFibrous Dysplasia
 Neurogenic tumorsNeurogenic tumors

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PapillomaPapilloma
 Vestibular papillomasVestibular papillomas
 Schneiderian papillomas derived fromSchneiderian papillomas derived from
schneiderian mucosa (squamous)schneiderian mucosa (squamous)
 Fungiform: 50%, nasal septumFungiform: 50%, nasal septum
 Cylindrical: 3%, lateral wall/sinusesCylindrical: 3%, lateral wall/sinuses
 Inverted: 47%, lateral wallInverted: 47%, lateral wall

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Inverted PapillomaInverted Papilloma
 4% of sinonasal tumors4% of sinonasal tumors
 Site of Origin: lateral nasal wallSite of Origin: lateral nasal wall
 UnilateralUnilateral
 Malignant degeneration in 2-13% (avg 10%)Malignant degeneration in 2-13% (avg 10%)

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Inverted PapillomaInverted Papilloma
ResectionResection
 Initially via transnasal resection:Initially via transnasal resection:
 50-80% recurrence50-80% recurrence
 Medial Maxillectomy via lateral rhinotomy:Medial Maxillectomy via lateral rhinotomy:
 Gold StandardGold Standard
 10-20%10-20%
 Endoscopic medial maxillectomy:Endoscopic medial maxillectomy:
 Key concepts:Key concepts:
 Identify the origin of the papillomaIdentify the origin of the papilloma
 Bony removal of this regionBony removal of this region
 Recurrent lesions:Recurrent lesions:
 Via medial maxillectomy vs. Endoscopic resectionVia medial maxillectomy vs. Endoscopic resection
 22%22%

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OsteomasOsteomas
 Benign slow growing tumors of mature boneBenign slow growing tumors of mature bone
 Location:Location:
 Frontal, ethmoids, maxillary sinusesFrontal, ethmoids, maxillary sinuses
 When obstructing mucosal flow can lead toWhen obstructing mucosal flow can lead to
mucocele formationmucocele formation
 Treatment is local excisionTreatment is local excision

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Fibrous dysplasiaFibrous dysplasia
 Dysplastic transformation of normal bone withDysplastic transformation of normal bone with
collagen, fibroblasts, and osteoid materialcollagen, fibroblasts, and osteoid material
 Monostotic vs PolyostoticMonostotic vs Polyostotic
 Surgical excision for obstructing lesionsSurgical excision for obstructing lesions
 Malignant transformation to rhabdomyosarcomaMalignant transformation to rhabdomyosarcoma
has been seen with radiationhas been seen with radiation

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Neurogenic tumorsNeurogenic tumors
 4% are found within the paranasal sinuses4% are found within the paranasal sinuses
 SchwannomasSchwannomas
 NeurofibromasNeurofibromas
 Treatment via surgical resectionTreatment via surgical resection
 Neurogenic Sarcomas are very aggressive andNeurogenic Sarcomas are very aggressive and
require surgical excision with post oprequire surgical excision with post op
chemo/XRT for residual disease.chemo/XRT for residual disease.
 When associated with Von Recklinghausen’sWhen associated with Von Recklinghausen’s
syndrome: more aggressive (30% 5yr survival).syndrome: more aggressive (30% 5yr survival).

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Malignant lesionsMalignant lesions
 Squamous cell carcinomaSquamous cell carcinoma
 Adenoid cystic carcinomaAdenoid cystic carcinoma
 Mucoepidermoid carcinomaMucoepidermoid carcinoma
 AdenocarcinomaAdenocarcinoma
 HemangiopericytomaHemangiopericytoma
 MelanomaMelanoma
 Olfactory neuroblastomaOlfactory neuroblastoma
 Osteogenic sarcoma, fibrosarcoma, chondrosarcoma,Osteogenic sarcoma, fibrosarcoma, chondrosarcoma,
rhabdomyosarcomarhabdomyosarcoma
 LymphomaLymphoma
 Metastatic tumorsMetastatic tumors
 Sinonasal undifferentiated carcinomaSinonasal undifferentiated carcinoma

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Squamous cell carcinomaSquamous cell carcinoma
 Most common tumor (80%)Most common tumor (80%)
 Location:Location:
 Maxillary sinus (70%)Maxillary sinus (70%)
 Nasal cavity (20%)Nasal cavity (20%)
 90% have local invasion by presentation90% have local invasion by presentation
 Lymphatic drainage:Lymphatic drainage:
 First echelon: retropharyngeal nodesFirst echelon: retropharyngeal nodes
 Second echelon: subdigastric nodesSecond echelon: subdigastric nodes

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TreatmentTreatment
 88% present in advanced stages (T3/T4)88% present in advanced stages (T3/T4)
 Surgical resection with postoperative radiationSurgical resection with postoperative radiation
 Complex 3-D anatomy makes margins difficultComplex 3-D anatomy makes margins difficult

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Adenoid Cystic CarcinomaAdenoid Cystic Carcinoma
 33rdrd
most common site is the nose/paranasalmost common site is the nose/paranasal
sinusessinuses
 Perineural spreadPerineural spread
 Anterograde and retrogradeAnterograde and retrograde
 Despite aggressive surgical resection andDespite aggressive surgical resection and
radiotherapy, most grow insidiously.radiotherapy, most grow insidiously.
 Neck metastasis is rare and usually a sign of localNeck metastasis is rare and usually a sign of local
failurefailure
 Postoperative XRT is very importantPostoperative XRT is very important

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Mucoepidermoid CarcinomaMucoepidermoid Carcinoma
 Extremely rareExtremely rare
 Widespread local invasion makes resectionWidespread local invasion makes resection
difficult, therefore radiation is often indicateddifficult, therefore radiation is often indicated

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AdenocarcinomaAdenocarcinoma
 22ndnd
most common malignant tumor in themost common malignant tumor in the
maxillary and ethmoid sinusesmaxillary and ethmoid sinuses
 Present most often in the superior portionsPresent most often in the superior portions
 Strong association with occupational exposuresStrong association with occupational exposures
 High grade: solid growth pattern with poorlyHigh grade: solid growth pattern with poorly
defined margins. 30% present with metastasisdefined margins. 30% present with metastasis
 Low grade: uniform and glandular with lessLow grade: uniform and glandular with less
incidence of perineural invasion/metastasis.incidence of perineural invasion/metastasis.

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HemangiopericytomaHemangiopericytoma
 Pericytes of ZimmermanPericytes of Zimmerman
 Present as rubbery, pale/gray, well circumscribedPresent as rubbery, pale/gray, well circumscribed
lesions resembling nasal polypslesions resembling nasal polyps
 Treatment is surgical resection with postoperative XRTTreatment is surgical resection with postoperative XRT
for positive marginsfor positive margins

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MelanomaMelanoma
 0.5- 1.5% of melanoma originates from the nasal0.5- 1.5% of melanoma originates from the nasal
cavity and paranasal sinus.cavity and paranasal sinus.
 Anterior Septum: most common siteAnterior Septum: most common site
 Treatment is wide local excision with/withoutTreatment is wide local excision with/without
postoperative radiation therapypostoperative radiation therapy
 END not recommendedEND not recommended
 AFIP: Poor prognosisAFIP: Poor prognosis
 5yr: 11%5yr: 11%
 20yr: 0.5%20yr: 0.5%

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Olfactory NeuroblastomaOlfactory Neuroblastoma
EsthesioneuroblastomaEsthesioneuroblastoma
 Originate from stem cells of neural crest originOriginate from stem cells of neural crest origin
that differentiate into olfactory sensory cells.that differentiate into olfactory sensory cells.
 Kadish ClassificationKadish Classification
 A: confined to nasal cavityA: confined to nasal cavity
 B: involving the paranasal cavityB: involving the paranasal cavity
 C: extending beyond these limitsC: extending beyond these limits

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 UCLA Staging systemUCLA Staging system
 T1: Tumor involving nasal cavity and/or paranasalT1: Tumor involving nasal cavity and/or paranasal
sinus, excluding the sphenoid and superior mostsinus, excluding the sphenoid and superior most
ethmoidsethmoids
 T2: Tumor involving the nasal cavity and/orT2: Tumor involving the nasal cavity and/or
paranasal sinus including sphenoid/cribriform plateparanasal sinus including sphenoid/cribriform plate
 T3: Tumor extending into the orbit or anteriorT3: Tumor extending into the orbit or anterior
cranial fossacranial fossa
 T4: Tumor involving the brainT4: Tumor involving the brain

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 Aggressive behaviorAggressive behavior
 Local failure: 50-75%Local failure: 50-75%
 Metastatic disease develops in 20-30%Metastatic disease develops in 20-30%
 Treatment:Treatment:
 En bloc surgical resection with postoperative XRTEn bloc surgical resection with postoperative XRT

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SarcomasSarcomas
 Osteogenic SarcomaOsteogenic Sarcoma
 Most common primary malignancy of bone.Most common primary malignancy of bone.
 Mandible > MaxillaMandible > Maxilla
 Sunray radiographic appearanceSunray radiographic appearance
 FibrosarcomaFibrosarcoma
 ChondrosarcomaChondrosarcoma

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RhabdomyosarcomaRhabdomyosarcoma
 Most common paranasal sinus malignancy inMost common paranasal sinus malignancy in
childrenchildren
 Non-orbital, parameningealNon-orbital, parameningeal
 Triple therapy is often necessaryTriple therapy is often necessary
 Aggressive chemo/XRT has improved survivalAggressive chemo/XRT has improved survival
from 51% to 81% in patients with cranial nervefrom 51% to 81% in patients with cranial nerve
deficits/skull/intracranial involvement.deficits/skull/intracranial involvement.
 Adults, Surgical resection with postoperativeAdults, Surgical resection with postoperative
XRT for positive margins.XRT for positive margins.

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LymphomaLymphoma
 Non-Hodgkins typeNon-Hodgkins type
 Treatment is by radiation, with or withoutTreatment is by radiation, with or without
chemotherapychemotherapy
 Survival drops to 10% for recurrent lesionsSurvival drops to 10% for recurrent lesions

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Sinonasal UndifferentiatedSinonasal Undifferentiated
CarcinomaCarcinoma
 Aggressive locally destructive lesionAggressive locally destructive lesion
 Dependent on pathological differentiation fromDependent on pathological differentiation from
melanoma, lymphoma, and olfactorymelanoma, lymphoma, and olfactory
neuroblastomaneuroblastoma
 Preoperative chemotherapy and radiation mayPreoperative chemotherapy and radiation may
offer improved survivaloffer improved survival

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Metastatic TumorsMetastatic Tumors
 Renal cell carcinoma is the most commonRenal cell carcinoma is the most common
 Palliative treatment onlyPalliative treatment only

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Staging of Maxillary Sinus TumorsStaging of Maxillary Sinus Tumors

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Staging of Maxillary Sinus TumorsStaging of Maxillary Sinus Tumors
 T1: limited to antral mucosa without bony erosionT1: limited to antral mucosa without bony erosion
 T2: erosion or destruction of the infrastructure,T2: erosion or destruction of the infrastructure,
including the hard palate and/or middle meatusincluding the hard palate and/or middle meatus
 T3: Tumor invades: skin of cheek, posterior wall ofT3: Tumor invades: skin of cheek, posterior wall of
sinus, inferior or medial wall of orbit, anterior ethmoidsinus, inferior or medial wall of orbit, anterior ethmoid
sinussinus
 T4: tumor invades orbital contents and/or: cribriformT4: tumor invades orbital contents and/or: cribriform
plate, post ethmoids or sphenoid, nasopharynx, softplate, post ethmoids or sphenoid, nasopharynx, soft
palate, pterygopalatine or infratemporal fossa or base ofpalate, pterygopalatine or infratemporal fossa or base of
skullskull

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SurgerySurgery
 Unresectable tumors:Unresectable tumors:
 Superior extension: frontal lobesSuperior extension: frontal lobes
 Lateral extension: cavernous sinusLateral extension: cavernous sinus
 Posterior extension: prevertebral fasciaPosterior extension: prevertebral fascia
 Bilateral optic nerve involvementBilateral optic nerve involvement

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SurgerySurgery
 Surgical approaches:Surgical approaches:
 EndoscopicEndoscopic
 Lateral rhinotomyLateral rhinotomy
 Transoral/transpalatalTransoral/transpalatal
 Midfacial deglovingMidfacial degloving
 Weber-FergussonWeber-Fergusson
 Combined craniofacial approachCombined craniofacial approach
 Extent of resectionExtent of resection
 Medial maxillectomyMedial maxillectomy
 Inferior maxillectomyInferior maxillectomy
 Total maxillectomyTotal maxillectomy

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TracheostomyTracheostomy
 130 maxillectomies only 7.7% required130 maxillectomies only 7.7% required
tracheostomytracheostomy
 Of those not receiving tracheostomy duringOf those not receiving tracheostomy during
surgery, only 0.9% experienced postoperativesurgery, only 0.9% experienced postoperative
airway complicationsairway complications
 Tracheostomy is unnecessary except in certainTracheostomy is unnecessary except in certain
circumstances (bulky packing/flaps,circumstances (bulky packing/flaps,
mandibulectomy)mandibulectomy)

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Treatment of the OrbitTreatment of the Orbit
 Before 1970’s orbital exenteration was includedBefore 1970’s orbital exenteration was included
in the radical resectionin the radical resection
 Preoperative radiation reduced tumor load andPreoperative radiation reduced tumor load and
allowed for orbital preservation with clearallowed for orbital preservation with clear
surgical marginssurgical margins
 Currently, the debate is centered on whatCurrently, the debate is centered on what
“degree” of orbital invasion is allowed.“degree” of orbital invasion is allowed.

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Current indications for orbitalCurrent indications for orbital
exenterationexenteration
 Involvement of the orbital apexInvolvement of the orbital apex
 Involvement of the extraocular musclesInvolvement of the extraocular muscles
 Involvement of the bulbar conjunctiva or scleraInvolvement of the bulbar conjunctiva or sclera
 Lid involvement beyond a reasonable hope forLid involvement beyond a reasonable hope for
reconstructionreconstruction
 Non-resectable full thickness invasion throughNon-resectable full thickness invasion through
the periorbita into the retrobulbar fatthe periorbita into the retrobulbar fat

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ConclusionsConclusions
 Neoplasms of the nose and paranasal sinus areNeoplasms of the nose and paranasal sinus are
very rare and require a high index of suspicionvery rare and require a high index of suspicion
for diagnosisfor diagnosis
 Most lesions present in advanced states andMost lesions present in advanced states and
require multimodality therapyrequire multimodality therapy

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BibliographyBibliography
 Bhattacharyya N. Cancer of the Nasal Cavity: Survival and Factors Influencing Prognosis. Archives of Oto-Bhattacharyya N. Cancer of the Nasal Cavity: Survival and Factors Influencing Prognosis. Archives of Oto-
HNS. Vol 128(9). September 2002. Pp 1079-1083.HNS. Vol 128(9). September 2002. Pp 1079-1083.
 Bradley P, Jones N, Robertson I. Diagnosis and Management of Esthesioneuroblastoma. Current Opinion inBradley P, Jones N, Robertson I. Diagnosis and Management of Esthesioneuroblastoma. Current Opinion in
Oto-HNS. Vol 11(2). April 2003. Pp 112-118.Oto-HNS. Vol 11(2). April 2003. Pp 112-118.
 Carrau R, Segas J, Nuss D, et al. Squamous Cell Carcinoma of the Sinonasal Tract Invading the Orbit.Carrau R, Segas J, Nuss D, et al. Squamous Cell Carcinoma of the Sinonasal Tract Invading the Orbit.
Laryngoscope. Vol 109 (2, part 1). February 1999. Pp 230-235.Laryngoscope. Vol 109 (2, part 1). February 1999. Pp 230-235.
 Devaiah A, Larsen C, Tawfik O, et al. Esthesioneuroblastoma: Endoscopic Nasal and Anterior CraniotomyDevaiah A, Larsen C, Tawfik O, et al. Esthesioneuroblastoma: Endoscopic Nasal and Anterior Craniotomy
Resection. Laryngoscope. Vol 113(12). December 2003. Pp2086-2090.Resection. Laryngoscope. Vol 113(12). December 2003. Pp2086-2090.
 Han J, Smith T, Loehrl T, et al. An Evolution in the Management of Sinonasal Inverting Papilloma.Han J, Smith T, Loehrl T, et al. An Evolution in the Management of Sinonasal Inverting Papilloma.
Laryngoscope. Vol 111(8). August 2001. Pp 1395-1400.Laryngoscope. Vol 111(8). August 2001. Pp 1395-1400.
 Imola M, Schramm V. Orbital Preservation in Surgical Management of Sinonasal Malignancy. Laryngoscope.Imola M, Schramm V. Orbital Preservation in Surgical Management of Sinonasal Malignancy. Laryngoscope.
Vol 112(8). August 2002. Pp 1357-1365.Vol 112(8). August 2002. Pp 1357-1365.
 Katzenmeyer K, Pou A. Neoplasms of the Nose and Paranasal Sinus. Dr. Quinn’s Online Textbook ofKatzenmeyer K, Pou A. Neoplasms of the Nose and Paranasal Sinus. Dr. Quinn’s Online Textbook of
Otolaryngology. June 7, 2000.Otolaryngology. June 7, 2000.
 Kraft M, Simmen D, Kaufmann T, et al. Laryngoscope. Vol 113(9). September 2003. Pp 1541-1547.Kraft M, Simmen D, Kaufmann T, et al. Laryngoscope. Vol 113(9). September 2003. Pp 1541-1547.
 McCary S, Levine P, Cantrell R. Preservation of the eye in the Treatment of Sinonasal Malignant NeoplasmsMcCary S, Levine P, Cantrell R. Preservation of the eye in the Treatment of Sinonasal Malignant Neoplasms
with Orbital Involvement: A Confirmation of the Original Treatise. Archives of Oto-HNS. Vol 122(6). Junewith Orbital Involvement: A Confirmation of the Original Treatise. Archives of Oto-HNS. Vol 122(6). June
1996. Pp 657-659.1996. Pp 657-659.
 Myers E, Suen J. Cancer of the Head and Neck, 3rd Edition: Neoplasms of the Nose and Paranasal Sinuses.Myers E, Suen J. Cancer of the Head and Neck, 3rd Edition: Neoplasms of the Nose and Paranasal Sinuses.
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