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DISEASES OF THE NOSE DISEASES OF THE NOSE AND PARANASAL AND PARANASAL
SINUSESSINUSESRYAN DUNCAN, MDRYAN DUNCAN, MD
PGY-4 RESIDENTPGY-4 RESIDENTOTOLARYNGOLOGY-HEAD AND NECK SURGERYOTOLARYNGOLOGY-HEAD AND NECK SURGERY
February 6, 2006February 6, 2006
NASAL ANATOMYNASAL ANATOMY
NASAL ANATOMYNASAL ANATOMY
NASAL ANATOMYNASAL ANATOMY
EthmoidMaxillaPalatineLacrimalPterygoid plate of
SphenoidNasal Inferior Turbinate
Bony Structure
7 bones4 paired sinuses4 turbinates3 meatiDrainage systemNervous supplyVascular supplyRelated structures
Sinus Anatomy Overview
Arterial Supply
External Carotid Maxillary A. SphenopalatineInternal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear
Innervation
VIRAL RHINITISVIRAL RHINITIS
Inflammation and swelling of the Inflammation and swelling of the mucous membranes of the nose usually mucous membranes of the nose usually caused by rhinovirus (common cold)caused by rhinovirus (common cold)
Symptoms consist of runny nose, Symptoms consist of runny nose, congestion, post-nasal drip, cough, and congestion, post-nasal drip, cough, and a low-grade fever a low-grade fever
Diagnosis made by history; adjunct Diagnosis made by history; adjunct tests usually not necessarytests usually not necessary
VIRAL RHINITISVIRAL RHINITIS
Complications may prolong illnessComplications may prolong illness often triggers asthma attacks often triggers asthma attacks Secondary infections: congestion in Secondary infections: congestion in
nose/ear blocks normal drainage nose/ear blocks normal drainage allowing bacteria to grow allowing bacteria to grow sinusitis, sinusitis, otitis mediaotitis media
VIRAL RHINITIS-TREATMENTVIRAL RHINITIS-TREATMENT
No vaccines availableNo vaccines available Echinacea, Vit C, Zinc effectiveness Echinacea, Vit C, Zinc effectiveness
not confirmed not confirmed Currently available antiviral drugs not Currently available antiviral drugs not
effectiveeffective Symptomatic treatment with Symptomatic treatment with
antihistamines, decongestants, cough antihistamines, decongestants, cough preparationspreparations
Function of Paranasal SinusesFunction of Paranasal Sinuses
Humidifying and warming inspired airHumidifying and warming inspired air Regulation of intranasal pressureRegulation of intranasal pressure Increasing surface area for olfactionIncreasing surface area for olfaction Lightening the skullLightening the skull ResonanceResonance Absorbing shockAbsorbing shock Contribute to facial growthContribute to facial growth generate 1 L mucus/daygenerate 1 L mucus/day
RhinosinusitisRhinosinusitis
IntroductionIntroduction 37 million Americans suffer from 37 million Americans suffer from
“sinusitis”“sinusitis” 25 million office visits in 1994-incidence 25 million office visits in 1994-incidence
increasingincreasing Over $200 million spent on prescriptions Over $200 million spent on prescriptions
for cold products; over half is for products for cold products; over half is for products containing antihistaminescontaining antihistamines
97 % of patients who see a physician with 97 % of patients who see a physician with “cold symptoms” receive a prescription“cold symptoms” receive a prescription
RhinosinusitisRhinosinusitis
Defining “Sinusitis”Defining “Sinusitis” Acute rhinosinusitis (ARS)Acute rhinosinusitis (ARS) Subacute rhinosinusitis (SARS)Subacute rhinosinusitis (SARS) Chronic rhinosinusitis (CRS)Chronic rhinosinusitis (CRS) Recurrent acute rhinosinusitis (RARS)Recurrent acute rhinosinusitis (RARS) Acute superimposed upon chronic Acute superimposed upon chronic
rhinosinusitis (ARS/CRS)rhinosinusitis (ARS/CRS)
RhinosinusitisRhinosinusitis
Major SymptomsMajor Symptoms Facial pain/pressureFacial pain/pressure Facial congestionFacial congestion Nasal obstructionNasal obstruction Purulent PNDPurulent PND Altered sense of Altered sense of
smellsmell Fever (ARS)Fever (ARS)
Minor SymptomsMinor Symptoms HeadacheHeadache Fever (all non-acute)Fever (all non-acute) HalitosisHalitosis FatigueFatigue Dental painDental pain CoughCough Ear pain/pressureEar pain/pressure
RhinosinusitisRhinosinusitis
Acute RhinosinusitisAcute Rhinosinusitis Duration Duration << 4 weeks 4 weeks >> 2 major or 1 major and 2 minor 2 major or 1 major and 2 minor
factors or purulence seen on factors or purulence seen on examinationexamination
Subacute RhinosinusitisSubacute Rhinosinusitis Duration-4-12 weeksDuration-4-12 weeks
Middle turbinate
MSO
Septum
RhinosinusitisRhinosinusitis
Chronic RhinosinusitisChronic Rhinosinusitis Duration-Duration->> 12 weeks 12 weeks
Recurrent Acute RhinosinusitisRecurrent Acute Rhinosinusitis >> 4 episodes/yr. of ARS with symptoms 4 episodes/yr. of ARS with symptoms
lasting lasting >> 7 days with no intervening 7 days with no intervening signs and symptoms of CRSsigns and symptoms of CRS
Acute Exacerbation of Chronic Acute Exacerbation of Chronic RhinosinusitisRhinosinusitis
Sudden worsening of CRSSudden worsening of CRS
Septum
MT remnant
MSO
CRS-”Empty nose”-Pseudomonas, Staph. aureus
RhinosinusitisRhinosinusitis
DiagnosisDiagnosis Physical examination-anterior Physical examination-anterior
rhinoscopy vs. nasal endoscopyrhinoscopy vs. nasal endoscopy EdemaEdema HyperemiaHyperemia PurulencePurulence PolypsPolyps
RhinosinusitisRhinosinusitis
DiagnosisDiagnosis Plain radiography of the paranasal Plain radiography of the paranasal
sinusessinuses Magnetic resonance imagingMagnetic resonance imaging Computerized tomography (non-contrast)Computerized tomography (non-contrast)
Screening CTScreening CT Standard CTStandard CT Timing of CTTiming of CT
Other testsOther tests
RhinosinusitisRhinosinusitis
ManagementManagement GoalsGoals
Elimination of infectionElimination of infection Restoration of ventilation and drainageRestoration of ventilation and drainage
RhinosinusitisRhinosinusitis
Surgical ManagementSurgical Management Prior to 1985, most surgery via Prior to 1985, most surgery via
external approach with emphasis on external approach with emphasis on maximum tissue removalmaximum tissue removal
With introduction of functional With introduction of functional endoscopic sinus surgery (FESS) in endoscopic sinus surgery (FESS) in 1985, emphasis is on maximum 1985, emphasis is on maximum tissue preservationtissue preservation
RhinosinusitisRhinosinusitis
Surgical ManagementSurgical Management ARS-no role for surgery except for ARS-no role for surgery except for
management of complicationsmanagement of complications CRS-indicated for medically refractory CRS-indicated for medically refractory
disease; 80-98 % improvement, disease; 80-98 % improvement, revision rate < 10 %, major revision rate < 10 %, major complications <0.3 %complications <0.3 %
RARS-focused surgery often helpfulRARS-focused surgery often helpful
Techniques of Functional Techniques of Functional Endoscopic Sinus SurgeryEndoscopic Sinus Surgery
Uncinectomy
LNW
MT
MT
LNW
Techniques of Functional Techniques of Functional Endoscopic Sinus SurgeryEndoscopic Sinus Surgery
0 degree telescope 45 degree telescope
Maxillary Antrostomy
MSO
Accessoryostium
RhinosinusitisRhinosinusitis
Surgical ManagementSurgical Management Computer assisted surgery (CAS) of Computer assisted surgery (CAS) of
the anterior skull base and paranasal the anterior skull base and paranasal sinuses has been commercially sinuses has been commercially available since 1996available since 1996
CAS has allowed us to safely expand CAS has allowed us to safely expand minimally invasive endoscopic minimally invasive endoscopic transnasal techniquestransnasal techniques
RhinosinusitisRhinosinusitis
ConclusionConclusion ““Sinusitis” is a complicated diseaseSinusitis” is a complicated disease Defining categories is beneficialDefining categories is beneficial Management options are varied Management options are varied Surgical therapy plays a role for a Surgical therapy plays a role for a
well-defined, small population of well-defined, small population of patientspatients
EPISTAXISEPISTAXIS(nosebleeds)(nosebleeds)
Why bleeding from the nose Why bleeding from the nose ??
Vascular organ secondary to Vascular organ secondary to incredible heating/humidification incredible heating/humidification requirementsrequirements
Vasculature runs just under mucosa Vasculature runs just under mucosa (not squamous)(not squamous)
Arterial to venous anastamosesArterial to venous anastamoses ICA and ECA blood flowICA and ECA blood flow
EPISTAXISEPISTAXIS
External Carotid ArteryExternal Carotid Artery -Sphenopalatine artery-Sphenopalatine artery -Greater palatine artery-Greater palatine artery -Ascending pharyngeal artery-Ascending pharyngeal artery -Posterior nasal artery-Posterior nasal artery -Superior Labial artery-Superior Labial artery Internal Carotid ArteryInternal Carotid Artery -Anterior Ethmoid artery-Anterior Ethmoid artery -Posterior Ethmoid artery-Posterior Ethmoid artery
Kesselbach’s Plexus/Little’s Area:
-Anterior Ethmoid (Opth)
-Superior Labial A (Facial)
-Sphenopalatine A (IMAX)
-Greater Palatine (IMAX)
Woodruff’s Plexus:
-Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)
Anterior vs. PosteriorAnterior vs. Posterior
Maxillary sinus ostiumMaxillary sinus ostium Anterior: younger, usually septal vs. Anterior: younger, usually septal vs.
anterior ethmoid, most common anterior ethmoid, most common (>90%), typically less severe(>90%), typically less severe
Posterior: older population, usually Posterior: older population, usually from Woodruff’s plexus, more from Woodruff’s plexus, more serious.serious.
EtiologyEtiology
Local factorsLocal factors VascularVascular Infectious/InflammatoryInfectious/Inflammatory Trauma (most common)Trauma (most common) IatrogenicIatrogenic NeoplasmNeoplasm DessicationDessication Foreign Bodies/otherForeign Bodies/other
EtiologyEtiology
Systemic factorsSystemic factors VascularVascular Infection/InflammationInfection/Inflammation Coagulopathy Coagulopathy
Local Factors -- VascularLocal Factors -- Vascular
ICA Aneurysms ICA Aneurysms extradural extradural cavernous sinus cavernous sinus
Local Factors - Local Factors - Infection/InflammationInfection/Inflammation
Rhinitis/SinusitisRhinitis/Sinusitis AllergicAllergic BacterialBacterial FungalFungal ViralViral
Local Factors - TraumaLocal Factors - Trauma
Nose pickingNose picking Nose blowing/sneezingNose blowing/sneezing Nasal fractureNasal fracture Nasogastric/nasotracheal intubationNasogastric/nasotracheal intubation Trauma to sinuses, orbits, middle Trauma to sinuses, orbits, middle
ear, base of skullear, base of skull BarotraumaBarotrauma
Nasal Fracture with Septal Hematoma
Local Factors - Iatrogenic nasal Local Factors - Iatrogenic nasal injuryinjury
Functional endoscopic sinus surgeryFunctional endoscopic sinus surgery RhinoplastyRhinoplasty Nasal reconstructionNasal reconstruction
Local Factors - NeoplasmLocal Factors - Neoplasm
Juvenile nasopharyngeal angiofibromaJuvenile nasopharyngeal angiofibroma Inverted papillomaInverted papilloma SCCASCCA AdenocarcinomaAdenocarcinoma MelanomaMelanoma EsthesioneuroblastomaEsthesioneuroblastoma LymphomaLymphoma
Local Factors – Local Factors – Dessication Dessication
Cold, dry air—more common in Cold, dry air—more common in wintertimewintertime
Dry heat—Phoenix and Death valleyDry heat—Phoenix and Death valley Nasal oxygenNasal oxygen Anatomic abnormalitiesAnatomic abnormalities Atrophic rhinitisAtrophic rhinitis
Local Factors - OtherLocal Factors - Other
Self-inflicted (pedi) vs. traumatic foreign Self-inflicted (pedi) vs. traumatic foreign bodiesbodies
Intranasal parasitesIntranasal parasites Septal perforationSeptal perforation Chemical (cocaine, nasal sprays, ammonia, Chemical (cocaine, nasal sprays, ammonia,
etc.)etc.)
Systemic Factors -- VascularSystemic Factors -- Vascular
Hypertension/ArteriosclerosisHypertension/Arteriosclerosis Hereditary Hemorrhagic Hereditary Hemorrhagic
Telangectasias (OWR)Telangectasias (OWR)
EpistaxisEpistaxis
Osler-Weber- Rendu (HHT)
R L
Systemic Factors – Systemic Factors – Infection/InflammationInfection/Inflammation
TuberculosisTuberculosis SyphillisSyphillis Wegener’s GranulomatosisWegener’s Granulomatosis Periarteritis nodosaPeriarteritis nodosa SLESLE
Systemic Factors – Systemic Factors – CoagulopathiesCoagulopathies
ThrombocytopeniaThrombocytopenia Platelet dysfunctionPlatelet dysfunction
Systemic disease (Uremia)Systemic disease (Uremia) drug-induced (Coumadin/NSAIDs/Herbal drug-induced (Coumadin/NSAIDs/Herbal
supplements)supplements) Clotting Factor DeficienciesClotting Factor Deficiencies
HemophiliaHemophilia VonWillebrand’s diseaseVonWillebrand’s disease Hepatic failureHepatic failure
Hematologic malignanciesHematologic malignancies
Etiology and AgeEtiology and Age
Children—foreign body, nose picking, Children—foreign body, nose picking, nasal diptheria (1/3 with chronic nasal diptheria (1/3 with chronic bleeds have coagulation d/o)bleeds have coagulation d/o)
Adults—trauma, idiopathicAdults—trauma, idiopathic Middle age—tumorsMiddle age—tumors Old age--hypertensionOld age--hypertension
Initial ManagementInitial Management
ABC’sABC’s Medical history/MedicationsMedical history/Medications Vital signs—need IV?Vital signs—need IV? Physical examPhysical exam
Anterior rhinoscopyAnterior rhinoscopy Endoscopic rhinoscopyEndoscopic rhinoscopy
Laboratory examLaboratory exam Radiologic studiesRadiologic studies
suction
good lightanesthetic
silver nitrate
merocels
gelfoam
bacitracin
endoscopes
suction bovie/bipolar
Afrin
T.C.A.
surgicel
epistat
bayonet forceptsvaseline gauze
Non-surgical treatments Non-surgical treatments Control of hypertension Control of hypertension Correction of Correction of
coagulopathies/thrombocytopenia coagulopathies/thrombocytopenia FFP or whole blood/reversal of FFP or whole blood/reversal of
anticoagulant/plateletsanticoagulant/platelets Pressure/Expulsion of clotsPressure/Expulsion of clots Topical decongestants/vasocontrictorsTopical decongestants/vasocontrictors Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie)Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie) Nasal packing (effective 80-90% of time)Nasal packing (effective 80-90% of time) Greater palatine foramen blockGreater palatine foramen block
Non-surgical treatments – Non-surgical treatments – on d/con d/c
Humidity/emolientsHumidity/emolients Discontinue offending medsDiscontinue offending meds Nasal saline spraysNasal saline sprays Avoidance of nose picking/blowingAvoidance of nose picking/blowing Sneeze with mouth openSneeze with mouth open Avoid straining/bedrestAvoid straining/bedrest
Nasal packsNasal packs
Anterior nasal packsAnterior nasal packs TraditionalTraditional Recent modificationsRecent modifications
Posterior nasal packsPosterior nasal packs Traditional Traditional Recent modificationsRecent modifications
Ant/Post nasal packingAnt/Post nasal packing
TSS—Nugauze vs. Merocel
Electron microscopy
Posterior Packs – Admission Posterior Packs – Admission
Elderly and those with other chronic Elderly and those with other chronic diseases may need to be admitted to the diseases may need to be admitted to the ICUICU
Continuous cardiopulmonary monitoringContinuous cardiopulmonary monitoring AntibioticsAntibiotics Oxygen supplementation may be neededOxygen supplementation may be needed Mild sedation/analgesiaMild sedation/analgesia IVFIVF
Indications for Indications for surgery/embolizationsurgery/embolization
Continued bleeding despite nasal Continued bleeding despite nasal packingpacking
Pt requires transfusion/admit hct of Pt requires transfusion/admit hct of <38% (barlow)<38% (barlow)
Nasal anomaly precluding packingNasal anomaly precluding packing Patient refusal/intolerance of packingPatient refusal/intolerance of packing Posterior bleed vs. failed medical mgmt Posterior bleed vs. failed medical mgmt
after >72hrs (wang vs. schaitkin)after >72hrs (wang vs. schaitkin)
Selective Selective Angiography/embolizationAngiography/embolization
Helps identify location of bleedingHelps identify location of bleeding Embolization most effective in patients whoEmbolization most effective in patients who
Still bleeding after surgical arterial ligationStill bleeding after surgical arterial ligation Bleeding site difficult to reach surgicallyBleeding site difficult to reach surgically Comorbidities prohibit general anestheticComorbidities prohibit general anesthetic
Effective only when bleeding is >.5 ml/minEffective only when bleeding is >.5 ml/min 90+% success rate, complication rate of 0.1%90+% success rate, complication rate of 0.1% Only able to embolize external carotid & branchesOnly able to embolize external carotid & branches Complications: minor (18-45%)/major (0-2%)Complications: minor (18-45%)/major (0-2%) Contraindicated in bad atherosclerosis, Ethmoid Contraindicated in bad atherosclerosis, Ethmoid
bleedbleed
Surgical treatmentSurgical treatment
Transmaxillary IMA ligationTransmaxillary IMA ligation Intraoral IMA ligationIntraoral IMA ligation Anterior/Posterior Ethmoidal ligationAnterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligationTransnasal Sphenopalatine ligation External carotid artery ligationExternal carotid artery ligation
Septodermoplasty/Laser ablationSeptodermoplasty/Laser ablation
Transmaxillary IMA ligationTransmaxillary IMA ligation
Waters view Waters view Caldwell-LucCaldwell-Luc Electrocautery of posterior wall before Electrocautery of posterior wall before
removalremoval Microscopic dissection and ligation of IMA --Microscopic dissection and ligation of IMA --
descending palatine & sphenopalantine descending palatine & sphenopalantine most importantmost important
Recurrence rate (failure rate) of 10-15%Recurrence rate (failure rate) of 10-15% Complication rate of 25-30% (oa Complication rate of 25-30% (oa
fistula,dental, n)fistula,dental, n)
Intraoral IMA ligationIntraoral IMA ligation
Posterior gingivobuccal incision beginning Posterior gingivobuccal incision beginning at second molarat second molar
Temporalis mm split and partially dissectedTemporalis mm split and partially dissected IMAX visualized, clipped and dividedIMAX visualized, clipped and divided Advantages: children/facial fracturesAdvantages: children/facial fractures Disadvantages: more proximal ligationDisadvantages: more proximal ligation Complications: trismus, damage to Complications: trismus, damage to
infraorbital ninfraorbital n
Ant./Post. Ethmoidal ligationAnt./Post. Ethmoidal ligation
Patients s/p IMAX ligation still bleeding, Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in superior nasal cavity epistaxis, or in conjunction when source unclearconjunction when source unclear
Lynch incisionLynch incision Fronto-ethmoidFronto-ethmoid suture linesuture line 12-24-6 12-24-6 (14-18, 8-10, 4-6)(14-18, 8-10, 4-6)
Transnasal Endoscopic Transnasal Endoscopic Sphenopalatine Artery Sphenopalatine Artery
ligationligation Follow Middle Turbinate to posteriormost Follow Middle Turbinate to posteriormost
aspectaspect Vertical mucoperiosteal incision 7-8mm Vertical mucoperiosteal incision 7-8mm
anterior to post middle turb (between mid. anterior to post middle turb (between mid. and inf. turbs)and inf. turbs)
Elevation of flap—ID neurovascular bundle Elevation of flap—ID neurovascular bundle at foramenat foramen
Ligation with titanium clipLigation with titanium clip Reapproximate flapReapproximate flap Complications –few, Failures—0-13%Complications –few, Failures—0-13%
Transnasal Spheno-palatine Artery ligation
ECA ligationECA ligation
EffectivenessEffectiveness Anterior border of SCMAnterior border of SCM ID ECA/ICAID ECA/ICA Ligation after clear that surrounding Ligation after clear that surrounding
structures are safe.structures are safe.
Septodermoplasty/LaserSeptodermoplasty/Laser
Remove mucosa from anterior ½ Remove mucosa from anterior ½ septum, floor of nose, lateral wallseptum, floor of nose, lateral wall
STSG vs. cutaneous, myocutaneous, STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autograftsmicrovascular free flaps vs. Autografts
Neodymium-yttrium-garnet (Nd-YAG) Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid laser or Argon laser + topical steroid best nonsurg rx for mild/mod diseasebest nonsurg rx for mild/mod disease
Still bleed, but not as badStill bleed, but not as bad Definitive treatment (severe disease)—Definitive treatment (severe disease)—
closure of noseclosure of nose
Statistically speaking,….Statistically speaking,…. Some authors (Wang and Vogel) showed surgical Some authors (Wang and Vogel) showed surgical
intervention to have lower failure rates (14.3 vs. intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those shorter hospital stays (2.2 less) than those w/posterior packs.w/posterior packs.
Others compared all medical treatment to surgery Others compared all medical treatment to surgery and showed cost cut using medical management.and showed cost cut using medical management.
Complication rates: posterior packs-25-40%, Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28%embolization 27%, IMAX ligation 28%
Cost analysis: IMAX vs. Embolization vs. Surgical Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equalCautery—about equal
Failure rates: PP-30%, Sx-17%, Emb-4%Failure rates: PP-30%, Sx-17%, Emb-4%
Neoplasms of Nose and Neoplasms of Nose and Paranasal SinusesParanasal Sinuses
Very rare 3%Very rare 3% Delay in diagnosis due to similarity to Delay in diagnosis due to similarity to
benign conditionsbenign conditions Nasal cavityNasal cavity
½ benign½ benign ½ malignant½ malignant
Paranasal SinusesParanasal Sinuses MalignantMalignant
NeoplasmNeoplasm
BenignBenign Schneiderian papillomaSchneiderian papilloma
SquamousSquamous Inverted-13 % incidence of malignant Inverted-13 % incidence of malignant
degenerationdegeneration CylindricalCylindrical
MalignantMalignant Squamous cell carcinomaSquamous cell carcinoma Salivary gland tumorsSalivary gland tumors Neuroepithelial tumorsNeuroepithelial tumors
MRI demonstrating right nasal masswith no intracranial involvement
Nasalmass
Septum
Nasal mass
Angiofibroma
Neoplasms of Nose and Neoplasms of Nose and Paranasal SinusesParanasal Sinuses
Multimodality treatmentMultimodality treatment Orbital PreservationOrbital Preservation Minimally invasive surgical Minimally invasive surgical
techniquestechniques
EpidemiologyEpidemiology
Predominately of older malesPredominately of older males Exposure:Exposure:
Wood, nickel-refining processesWood, nickel-refining processes Industrial fumes, leather tanning Industrial fumes, leather tanning
Cigarette and Alcohol consumptionCigarette and Alcohol consumption No significant association has been No significant association has been
shownshown
LocationLocation
Maxillary sinusMaxillary sinus 70%70%
Ethmoid sinusEthmoid sinus 20%20%
SphenoidSphenoid 3%3%
FrontalFrontal 1%1%
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
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 Hypercellular malignancy: low/intermediate on
bothboth Enhancement with GadoliniumEnhancement with Gadolinium
Benign LesionsBenign Lesions
PolypsPolyps PapillomasPapillomas OsteomasOsteomas Fibrous DysplasiaFibrous Dysplasia Neurogenic tumorsNeurogenic tumors
NASAL POLYPSNASAL POLYPS Benign, Benign,
semitransparent lesionssemitransparent lesions Arise from nasal Arise from nasal
mucosamucosa Caused by chronic Caused by chronic
inflammationinflammation a/w asthma, CF, aspirin a/w asthma, CF, aspirin
intolerance, CRS, intolerance, CRS, Allergic RhinitisAllergic Rhinitis
NASAL POLYPSNASAL POLYPS
Nasal EndoscopyNasal Endoscopy CT/MRICT/MRI Medical Tx: Medical Tx:
topical/systemic topical/systemic steroidssteroids
Surgical Tx: FESS Surgical Tx: FESS with polypectomywith polypectomy
PapillomaPapilloma
Vestibular papillomasVestibular papillomas Schneiderian papillomas derived Schneiderian papillomas derived
from schneiderian mucosa from schneiderian mucosa (squamous)(squamous) Fungiform: 50%, nasal septumFungiform: 50%, nasal septum Cylindrical: 3%, lateral wall/sinusesCylindrical: 3%, lateral wall/sinuses Inverted: 47%, lateral wallInverted: 47%, lateral wall
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% Malignant degeneration in 2-13%
(avg 10%)(avg 10%)
Inverted PapillomaInverted PapillomaResectionResection
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%
INVERTED PAPILLOMAINVERTED PAPILLOMA
OsteomasOsteomas
Benign slow growing tumors of Benign slow growing tumors of mature bonemature bone
Location:Location: Frontal, ethmoids, maxillary sinusesFrontal, ethmoids, maxillary sinuses
When obstructing mucosal flow can When obstructing mucosal flow can lead to mucocele formationlead to mucocele formation
Treatment is local excisionTreatment is local excision
Fibrous dysplasiaFibrous dysplasia
Dysplastic transformation of normal Dysplastic transformation of normal bone with collagen, fibroblasts, and bone with collagen, fibroblasts, and osteoid materialosteoid material
Monostotic vs PolyostoticMonostotic vs Polyostotic Surgical excision for obstructing lesionsSurgical excision for obstructing lesions Malignant transformation to Malignant transformation to
rhabdomyosarcoma has been seen rhabdomyosarcoma has been seen with radiationwith radiation
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 Neurogenic Sarcomas are very aggressive
and require surgical excision with post op and require surgical excision with post op chemo/XRT for residual disease.chemo/XRT for residual disease.
When associated with Von Recklinghausen’s When associated with Von Recklinghausen’s syndrome: more aggressive (30% 5yr syndrome: more aggressive (30% 5yr survival).survival).
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, Osteogenic sarcoma, fibrosarcoma,
chondrosarcoma, rhabdomyosarcomachondrosarcoma, rhabdomyosarcoma LymphomaLymphoma Metastatic tumorsMetastatic tumors Sinonasal undifferentiated carcinomaSinonasal undifferentiated carcinoma
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
TreatmentTreatment
88% present in advanced stages 88% present in advanced stages (T3/T4)(T3/T4)
Surgical resection with postoperative Surgical resection with postoperative radiationradiation Complex 3-D anatomy makes margins Complex 3-D anatomy makes margins
difficultdifficult
Adenoid Cystic CarcinomaAdenoid Cystic Carcinoma
33rdrd most common site is the most common site is the nose/paranasal sinusesnose/paranasal sinuses
Perineural spreadPerineural spread Anterograde and retrogradeAnterograde and retrograde
Despite aggressive surgical resection Despite aggressive surgical resection and radiotherapy, most grow insidiously.and radiotherapy, most grow insidiously.
Neck metastasis is rare and usually a Neck metastasis is rare and usually a sign of local failuresign of local failure
Postoperative XRT is very importantPostoperative XRT is very important
Mucoepidermoid CarcinomaMucoepidermoid Carcinoma
Extremely rareExtremely rare Widespread local invasion makes Widespread local invasion makes
resection difficult, therefore radiation resection difficult, therefore radiation is often indicatedis often indicated
AdenocarcinomaAdenocarcinoma 22ndnd most common malignant tumor in the most 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 poorly High grade: solid growth pattern with poorly
defined margins. 30% present with metastasisdefined margins. 30% present with metastasis Low grade: uniform and glandular with less Low grade: uniform and glandular with less
incidence of perineural invasion/metastasis.incidence of perineural invasion/metastasis.
HemangiopericytomaHemangiopericytoma
Pericytes of ZimmermanPericytes of Zimmerman Present as rubbery, pale/gray, well Present as rubbery, pale/gray, well
circumscribed lesions resembling nasal polypscircumscribed lesions resembling nasal polyps Treatment is surgical resection with Treatment is surgical resection with
postoperative XRT for positive marginspostoperative XRT for positive margins
MelanomaMelanoma
0.5- 1.5% of melanoma originates from the 0.5- 1.5% of melanoma originates from the nasal cavity and paranasal sinus.nasal cavity and paranasal sinus.
Anterior Septum: most common siteAnterior Septum: most common site Treatment is wide local excision Treatment is wide local excision
with/without postoperative radiation with/without postoperative radiation therapytherapy
END not recommendedEND not recommended AFIP: Poor prognosisAFIP: Poor prognosis
5yr: 11%5yr: 11% 20yr: 0.5%20yr: 0.5%
Olfactory NeuroblastomaOlfactory NeuroblastomaEsthesioneuroblastomaEsthesioneuroblastoma
Originate from stem cells of neural Originate from stem cells of neural crest origin that differentiate into crest origin that differentiate into olfactory sensory cells.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
Olfactory NeuroblastomaOlfactory NeuroblastomaEsthesioneuroblastomaEsthesioneuroblastoma
UCLA Staging systemUCLA Staging system T1: Tumor involving nasal cavity and/or T1: Tumor involving nasal cavity and/or
paranasal sinus, excluding the sphenoid and paranasal sinus, excluding the sphenoid and superior most ethmoidssuperior most ethmoids
T2: Tumor involving the nasal cavity and/or T2: Tumor involving the nasal cavity and/or paranasal sinus including sphenoid/cribriform paranasal sinus including sphenoid/cribriform plateplate
T3: Tumor extending into the orbit or anterior T3: Tumor extending into the orbit or anterior cranial fossacranial fossa
T4: Tumor involving the brainT4: Tumor involving the brain
Olfactory NeuroblastomaOlfactory NeuroblastomaEsthesioneuroblastomaEsthesioneuroblastoma
Aggressive behaviorAggressive behavior Local failure: 50-75%Local failure: 50-75% Metastatic disease develops in 20-Metastatic disease develops in 20-
30%30% Treatment:Treatment:
En bloc surgical resection with En bloc surgical resection with postoperative XRTpostoperative XRT
SarcomasSarcomas
Osteogenic SarcomaOsteogenic Sarcoma Most common primary malignancy of Most common primary malignancy of
bone.bone. Mandible > MaxillaMandible > Maxilla Sunray radiographic appearanceSunray radiographic appearance
FibrosarcomaFibrosarcoma ChondrosarcomaChondrosarcoma
RhabdomyosarcomaRhabdomyosarcoma
Most common paranasal sinus malignancy in Most 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 Aggressive chemo/XRT has improved
survival from 51% to 81% in patients with survival from 51% to 81% in patients with cranial nerve deficits/skull/intracranial cranial nerve deficits/skull/intracranial involvement.involvement.
Adults, Surgical resection with postoperative Adults, Surgical resection with postoperative XRT for positive margins.XRT for positive margins.
LymphomaLymphoma
Non-Hodgkins typeNon-Hodgkins type Treatment is by radiation, with or Treatment is by radiation, with or
without chemotherapywithout chemotherapy Survival drops to 10% for recurrent Survival drops to 10% for recurrent
lesionslesions
Sinonasal Undifferentiated Sinonasal Undifferentiated Carcinoma (SNUC)Carcinoma (SNUC)
Aggressive locally destructive lesionAggressive locally destructive lesion Dependent on pathological Dependent on pathological
differentiation from melanoma, differentiation from melanoma, lymphoma, and olfactory lymphoma, and olfactory neuroblastomaneuroblastoma
Preoperative chemotherapy and Preoperative chemotherapy and radiation may offer improved survivalradiation may offer improved survival
Metastatic TumorsMetastatic Tumors
Renal cell carcinoma is the most Renal cell carcinoma is the most commoncommon
Palliative treatment onlyPalliative treatment only
Staging of Maxillary Sinus Staging of Maxillary Sinus TumorsTumors
Staging of Maxillary Sinus Staging of Maxillary Sinus TumorsTumors
T1: limited to antral mucosa without bony T1: limited to antral mucosa without bony erosionerosion
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 T3: Tumor invades: skin of cheek, posterior wall of sinus, inferior or medial wall of orbit, wall of sinus, inferior or medial wall of orbit, anterior ethmoid sinusanterior ethmoid sinus
T4: tumor invades orbital contents and/or: T4: tumor invades orbital contents and/or: cribriform plate, post ethmoids or sphenoid, cribriform plate, post ethmoids or sphenoid, nasopharynx, soft palate, pterygopalatine or nasopharynx, soft palate, pterygopalatine or infratemporal fossa or base of skullinfratemporal fossa or base of skull
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
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
MIDFACIAL DEGLOVINGMIDFACIAL DEGLOVING
LATERAL RHINOTOMYLATERAL RHINOTOMY
CRANIOFACIAL APPROACHCRANIOFACIAL APPROACH
Treatment of the OrbitTreatment of the Orbit
Before 1970’s orbital exenteration was Before 1970’s orbital exenteration was included in the radical resectionincluded in the radical resection
Preoperative radiation reduced tumor Preoperative radiation reduced tumor load and allowed for orbital load and allowed for orbital preservation with clear surgical marginspreservation with clear surgical margins
Currently, the debate is centered on Currently, the debate is centered on what “degree” of orbital invasion is what “degree” of orbital invasion is allowed.allowed.
Current indications for orbital Current 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 Involvement of the bulbar conjunctiva or
sclerasclera Lid involvement beyond a reasonable hope Lid involvement beyond a reasonable hope
for reconstructionfor reconstruction Non-resectable full thickness invasion Non-resectable full thickness invasion
through the periorbita into the retrobulbar through the periorbita into the retrobulbar fatfat
ConclusionsConclusions
Neoplasms of the nose and paranasal Neoplasms of the nose and paranasal sinus are very rare and require a sinus are very rare and require a high index of suspicion for diagnosishigh index of suspicion for diagnosis
Most lesions present in advanced Most lesions present in advanced states and require multimodality states and require multimodality therapytherapy
REFERENCESREFERENCES
www.utmb.edu/otowww.utmb.edu/oto http://www.emedicine.com/PED/topichttp://www.emedicine.com/PED/topic
1550.htm1550.htm http://www.merck.com/mmhe/http://www.merck.com/mmhe/
sec19/ch221/ch221g.htmlsec19/ch221/ch221g.html