sino-nasal mass, diagnosis, treatment approach , surgery

1. SINONASAL MALIGNANCY
DR SAFIKA ZAMAN
DEPT OF ENT AND HEAD NECK SURGERY
VIMS, RKMSP

2. CONTENTS
 Introduction
 Surgical anatomy
 Epidemiology
 Histopathological classification
 TNM Classification
 Presentation
 Diagnosis
 Management and various approaches

3. INTRODUCTION
 They represent the area of greatest histological
diversity.
 Complex anatomy , close to multiple vital structure.
 Presentation is late.
 Advances in endoscopic surgical approaches,
radiotherapy and imaging techniques that have
improved the clinical management

4. SURGICAL ANATOMY
 Proximity of the orbit and skull
base.
 Compromise oncologic resection.

5. ETHMOID BONE
 Can be viewed as a cross (perpendicular
plate, crista galli and cribriform plate) with
the two labyrinths hanging at either side
composed of a number of individual cells
 The cells are divided into an anterior and
posterior group by the basal lamella of the
middle turbinate.

6. CONT…
 lateral lamella of the cribriform niche offers a
route into the anterior cranial fossa as do the
anterior and posterior ethmoidal foramina.
 The length and depth of the cribriform niche
vary considerably.
 Route into the orbit.
 Anterior and posterior ethmoid vessels

7. SPHENOID BONE
 Variable in size and shape.
 Optic nerve and internal carotid artery
run in the lateral wall.
 Opticocarotid recess is variable in
depth.
 The cavernous sinus lies laterally
 Foramen rotundum (V2) and pterygoid
canal

8. CONT ..
 Tumours invading the medial orbit may run
subperiosteally to the apex and thence into the middle
cranial fossa.
 The superior and inferior orbital fissures also offer routes
of tumour exit and entry.
 The inferior fissure communicates with the pterygopalatine
fossa medially and the infratemporal fossa

9. CONT..
 the superior fissure leads to the
cavernous sinus.

10. MAXILLARY SINUS
 The maxillary sinus is a bony
box bounded by eye, nose,
mouth, cheek, pterygoid
space and nasopharynx.

11. MAXILLARY SINUS
 Natural areas of weakness exist into the nose via ostium and fontanelles, into the mouth via the premolar
and molar teeth roots and into the eye and cheek via the infraorbital canal and foramen.
 The medial wall has a large opening, the maxillary hiatus.
 Pterygomaxillary fissure, through which the maxillary artery runs. This, in turn, connects with the
pterygopalatine fossa and the infratemporal fossa.

12. PTERYGOPALATINE FOSSA

13. LYMPHATIC DRAINAGE OF NOSE
 The vessels from the anterior third of the
nasal cavity follow the vessels of the external
nose and end up in the submaxillary nodes.
 Vessels from the posterior two thirds of the
nasal cavity and from the ethmoid sinuses
drain partly to the retropharyngeal nodes and
partly to the superior deep cervical nodes.

14. EPIDEMIOLOGY
 Malignant tumours of the nose
and sinuses are rare constituting
approximately 3 per cent of head
and neck malignancy
 Majority present in the sixth and
seventh decades
 Male to female ratio is
approximately 2:1.
 Most common are sino-nasal
squamous-cell carcinoma and
intestinal-type adenocarcinoma

15. AETIOLOGICAL FACTORS
Source- text book of Stell Maran

16. HISTOLOGY

17. CONT…
Llorente, J. L. et al. Nat. Rev. Clin. Oncol. advance online publication 17
June 2014; doi:10.1038/nrclinonc.2014.97

18. CONT…
Llorente, J. L. et al. Nat. Rev. Clin. Oncol. advance online
publication 17 June 2014; doi:10.1038/nrclinonc.2014.97

19. INVERTED PAPILLOMAS
Inverted papilloma is a neoplasm,with 9% to 15% chance of
malignant transformation.
Human papilloma virus (HPV) type 16 and HPV-18 have been
implicated in the development of SNSCC, mainly in cases of
malignant transformation from inverted papillomas.
Syrjänen, K. & Syrjänen, S. Detection of human
papillomavirus in sinonasal papillomas:
systematic review and meta-analysis.
Laryngoscope 123, 181–192 (2013)

20. SQUAMOUS CELL CARCINOMA
 The degree of differentiation varies and may be
getting poorer with time.
 Most common neoplasm
 Mainly in 5th and 6th decade
 Most common site is maxillary antrum
 Main modality of treatment is surgery and
radiotherapy.

21. ADENOCARCINOMA
 These tumours usually arise in the middle meatus
and spread into the ethmoid
 Adenocarcinoma is generally rather radio-resistant
but combined therapy is usually offered
 The use of topical 5-fluorouracil and surgical
debulking has been advocated by some

22. ADENOID CYSTIC CARCINOMA
 Spread along peri-neural lymphatics which compromises attempts
at excision.
 Embolize along these routes and is known to produce blood-borne
metastases, classically to the lung.
 Lymphatic spread is rare.
 The natural history can be extensive, with good five year figures,

23. MALIGNANT MELANOMA
 Rare mucosal neoplasm of neural crest origin usually
affecting the elderly.
 Affects the nasal mucosa and presents with nasal blockage
and bleeding.
 Satellite lesions and areas of amelanotic tumour can make
it difficult to determine tumour extent.

24. OLFACTORY NEUROBLASTOMA
 Classically arises from olfactory epithelium in the
upper nasal vault although can originate elsewhere in
the nose.
 As a neuroendocrine tumour, metabolites such as
vanilyl mandelic acid may be detected.
 Treatment is endoscopic resection with chemo
radiotherapy

25. LYMPHOMA
 B-cell tumours present as an infiltrating indurated mass often
affecting the external nose and soft tissues.
 T/NK-cell tumours are associated with Epstein–Barr exposure and are
therefore more common in the Far East
 Plasmacytoma
 They produce aggressive destructive lesions of the midface,
 Treatment is chemotherapy.

26. CHONDROSARCOMAS
 Arises often from the septum or maxillary alveolus,
and spread superiorly into the skull base and
inferiorly into the palate.
 The age range includes both young and old and
the tumour is generally more aggressive in
younger patients.
 Craniofacial resection usually offers the best
treatment, tumours are not radiosensitive

27. TNM CLASSIFICATION

28. TNM CLASSIFICATION

29. TNM CLASSIFICATION

30. CLINICAL FEATURS
Source- text book of Stell Maran

31. HOW TO IDENTIFY EARLY

32. EXAMINATION
 Examination of nasal cavity / endoscopic examination
 Examination of oral cavity – involvement of alveolus, palatal mobility,
 Oro-pharyngeal extension
 Neck examination for neck nodes
 Facial examination to see skin involvement, trismus , proptosis.
 Examination of eye – color vision , extra ocular muscle paralysis , vision acuity
 Cranial nerve examination

33. NCCN WORKUP

34. IMAGING
Source- text book of Stell Maran

35. CT SCAN
 CT imaging in axial and coronal sections, preferably with contrast enhancement.
 Bony details
 Bone erosion by the tumour
 Tumour extension into adjacent areas

36. MRI SCAN
 MRI protocols generally include axial and
coronal T1-weighted, T2-weighted, STIR and T1-
weighted gadolinium-enhanced scans.
 Dural and brain involvement.
 MRI is considered the standard imaging
modality for postoperative surveillance.
 Peri-neural tumour spread, and differentiating
tumour from secretions.

37. BIOPSY
 Endoscopy guided biopsy which represents
the disease without breaking the tissue plane.

38. MULTIDISCIPLINARY TEAM
 Surgery
 Medical oncology
 Radiation oncology
 Radiology, nuclear medicine
 Pathology..
 MDT workup will ensure accurate assessment, evidence based
decision-making, and the most advantageous treatment
planning and delivery of care.

39. PRINCIPLES OF MANAGEMENT
Low grade neoplasm Itermediate grade High grade
Adenocarcinoma
esthesioneurolastoma
Adenoid cystic carcinoma
SCC
SNUC
Sarcomas

40. APPROACH

45. HISTORY OF MAXILLECTOMY
Conceptually described by Lazars in 1826
Performed in 1828 by Syme
1927-Portman and Retrouvey described a sublabial-transoral approach
In 1954, Smith described the extended maxillectomy
Fairbanks-Barbosa was the first to report an infratemporal fossa (ITF) approach
1977, Sessions and Larson coined the term "medial maxillectomy“
Endoscopic medial maxillectomy – recent addition.

46. ANAESTHESIA
 General anaesthesia in the reversed Trendelenburg position with 15–20 degree of head elevation.
 Nasal mucosal vasoconstriction is achieved by instilling 2–4mL of Moffat’s solution (10 per cent cocaine,
2 mL, 1:1000 adrenaline 2mL and 0.9 per cent sodium bicarbonate 1 mL)
 In the case of craniofacial resection, patients are started on phenytoin 200 mg/day 48 hours before
surgery
 A broad-spectrum antibiotic, e.g. co-amoxicillin clavulanate or a cephalosporin and metronidazole, is
generally administered with induction.

47. CRANIOFACIAL RESECTION
 INDICATIONS: Malignant tumours which require surgical
resection, involving the anterior skull base.
 CONTRAINDICATIONS: Extensive frontal lobe and/or middle
cranial fossa involvement or bilateral orbital invasion/optic
chiasm.
-mucosal malignant melanoma sino-nasal undifferentiated
carcinoma, lymphoma, plasmacytoma. distant metastasis

48. INCISION
 Extended lateral rhinotomy is
made on the side of maximal
tumour involvement

49. TECHNIQUE
 Soft tissue mobilization
 Exposure
 Define tumour relationship with the orbit.
 lacrimal fossa and the medial orbital wall
exposure.
 shield-shaped craniotomy is performed above
the level of the supraorbital rim to include the
frontal sinus.
 Exposure and bone drilling
Source- text book of Stell Maran

50. CRANIOFACIAL RESECTION
Source- text book of Stell Maran

51. COMPLICATIONS
Immidiate intermediate Late
convulsions
haemorrhage
air embolism
cerebrovascular accident
confusion
pulmonary embolism
meningitis
aerocele
haemorrhage
frontal abscess/encephalitis
bone necrosis/fistula
cerebrospinal fluid leak
epilepsy
epiphora
diplopia
serous otitis media
sinusitis/mucocele
cellulitis
pituitary deficiency

52. MIDFACIAL DEGLOVING
INDICATIONS
 Selected malignant tumours affecting the nasal cavity, maxilla,
ethmoids, sphenoid, pterygopalatine and infratemporal fossae.
 A bilateral maxillectomy can be performed via this approach if
required.
CONTRAINDICATIONS
 The limits of resection are posterior wall of the sphenoid, pterygoid
plates and muscles, superiorly the skull base and laterally the
coronoid process of the mandible.

53. CONT…
Source- text book of Stell Maran

54. CONT..
Source- text book of Stell
Maran

55. COMPLICATIONS
Immidiate Late
haemorrhage
– facial bruising
– infraorbital paraesthesia
vestibular stenosis
– oro-antral fistula
– epiphora
– septal perforation
– upward tip rotation.

56. TRANSFACIAL APPROACHES – INCISIONS

57. LATERAL RHINOTOMY
 INDICATIONS
- Any malignant tumour affecting the nasal septum,
-lateral wall and extending into ethmoid, sphenoid,
-maxillary sinuses and up to the anterior skull base.
 CONTRAINDICATIONS
-Malignant tumours which have spread beyond these areas
when an extended procedure is required, i.e.craniofacial,
maxillectomy.

58. COMPLICATIONS
Early Late
Haemorrhage
Orital edema
CSF leak
Epiphora
Diplopia
Alar lift , vestibular stenosis
Facial paraesthesia
Frontal sinus ostructon
Infection mucocele

59. MAXILLECTOMY
 Indication: Malignant tumour of the maxilla involving the
inferior , superior , anterior and posterior wall.
 Contraindications : skull base extension

60. OSTEOTOMIES

61. LIVERPOOL CLASSIFICATION

62. COMPLICATIONS
Early Late
Haemorrhage
Infection
Epiphora
Parasthesia
Ectropion
Facial contracture
Diplopia

63. TOTAL RHINECTOMY
 Occasionally, extensive tumours in the nasal cavity will
involve the external nose resulting in the need to
completely excise the nose.
 Common pathology - vestibule and septum and
malignant mucosal melanoma.

64. THE MANAGEMENT ALGORITHM OF ORBIT
Involvement of the orbit is an
important predictor of
recurrence-free, disease-
specific and overall survival
Source- text book of Stell Maran

65. ENDOSCOPIC APPROACH
 Lower morbidity,
 Better postoperative quality of life,
 Faster hospitalization days

66. ENDOSCOPIC VS OPEN
On multivariate analysis,
surgical treatment
modality did not influence
prognosis. Furthermore, after
PSM, there was no difference
in 5Y-OS between the
endoscopic- or open score–
matched groups
Comparison of endoscopic and open resection of sinonasal squamous cell
carcinoma: a propensity score–matched analysis of 652 patients
Suat Kılıc¸, BA1 , Sarah S. Kılıc¸, MA2, Soly Baredes, MD, FACS1,3, Richard Chan Woo Park, MD, FACS1,
Omar Mahmoud, MD, PhD2, Jeffrey D. Suh, MD, FACS4, Stacey T. Gray, MD, FACS5,6 and
Jean Anderson Eloy, MD, FACS1,3,7,

67. ENDOSCOPIC APPROACH – PRINCIPLE
 “centripetal” tumor removal-starting at the periphery of the tumor attachment zone,
 Macroscopic margin of healthy tissue,
 Monobloc resection is rarely possible- complete resection of the tumor insertion zone is most important
requirement

68. ENDOSCOPIC APPROACHES
 Medial maxillectomy with a frank section of the lacrimal duct
 Prelacrimal approach,
 Denker endoscopic approach for access to the maxillary sinus
 Frontal sinus -Draf I, II, or III
 Technique for septectomy – allow 4-handed surgery

69. hristopher Pool, Meghan Wilson, Endoscopic resection of juvenile nasopharyngeal angiofibromas,
Operative Techniques in Otolaryngology-Head and Neck Surgery, 10.1016/j.otot.2021.01.004, 32, 1,
(20-25), (2021).
Crossref

70. ENDOSCOPIC DENKERS APPROACH

72. COMPLICATIONS OF ENDOSCOPIC SURGERY

73. ADJUVANT THERAPY
 Intensity‐modulated radiation therapy (IMRT) was a major advance in radiotherapy allowing for
improved targeting of the tumour while sparing the optic nerves, brainstem, and brain parenchyma.
 Charged particle therapy with protons or carbon ions are an additional modality
 Chemotherapy has been utilized in the neoadjuvant setting and concurrently with radiation either as
definitive therapy or in the adjuvant setting

75. RECONSTRUCTION
 Nasoseptal flap, turbinate flap,
 Regional flaps -temporal fascia flap, pericranial flap,
 Free flap-anterolateral thigh flap, forearm flap,
 The most commonly used is the nasoseptal flap

76. COMBINED OPEN AND ENDOSCOPIC APPROACHES
 Tumors that are located in both the
intracranial and extracranial
compartments and for which the
intracranial invasion is too important
for a purely endoscopic approach

77. NECK DISSECTION
 Neck dissection in sinonasal cancers is usually recommended only if there is clinicoradiological lymph
node involvement.

79. RECENT ADVANCES MOLECULAR PATHOLOGY
Llorente, J. L. et al. Nat. Rev. Clin. Oncol. advance online publication 17 June
2014; doi:10.1038/nrclinonc.2014.97

80. BIOLOGICALS
Contemporary Multidisciplinary Management ofSinonasal Mucosal Melanoma
This article was published in the following Dove Press journal:
OncoTargets and Therapy
Shorook Na’ara1,2Abhishek Mukherjee3Salem Billan2,4Ziv Gil1,2

81. CANCERS OF THE NASAL CAVITY OR PARANASAL SINUS BETWEEN
2010 AND 2016( AMERICAN CANCER SOCIETY)

82. PROPORTION AND SURVIVAL RATE

83. THANK YOU