Sino-nasal Tumours Dr. Vishal Sharma. Classification Benign Simple papilloma Ossifying Fibroma...
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Transcript of Sino-nasal Tumours Dr. Vishal Sharma. Classification Benign Simple papilloma Ossifying Fibroma...
Sino-nasal Tumours
Dr. Vishal Sharma
ClassificationBenign
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
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
Frontal sinus osteoma
Bicoronal osteoplastic flap
Osteoma exposed
Tumor removal + closing of bone flap
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
Ossifying fibroma
Ossifying fibroma
Inverted papilloma
Locally aggressive sino-nasal tumour
Synonyms: Ringertz or Schneiderian papilloma
Common in males between 50-70 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
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 10 15% cases.
Radiotherapy is avoided.
Anterior rhinoscopy
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.
Punch Biopsy & H.P.E.Inward invasion of hyperplastic epithelium into
underlying stroma. No evidence of malignancy.
Moure’s lateral rhinotomy
Osteotomy cuts
Bone removed & tumor exposed
Tumour removed & inicision closed
Midfacial degloving approach
Sino-nasal Malignancy
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 45-60 years
Risk factors
Hardwood dust (adenocarcinoma)
Softwood dust (squamous carcinoma)
Nickel refining; chromium workers
Boot, shoe and textile workers
Mustard gas exposure
Human papilloma virus
Maxillary sinus malignancy
Early Clinical features
Mimic maxillary sinusitis
Nasal stuffiness
Blood-stained nasal discharge
Facial paraesthesias or pain
Epiphora
Spread
Medial spread:
Unilateral nasal obstruction
Unilateral purulent nasal discharge
Epistaxis
Unilateral, friable, nasal mass
Anterior spread:
Cheek swelling
Invasion of facial skin
Late Clinical features
.
Late Clinical featuresInferior 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
Late Clinical featuresPosterior 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
Cheek swelling
Cheek skin involvement
Alveolar & Palatal swelling
Nasal mass
Diagnostic nasal endoscopy
X-ray paranasal sinus: expansion & destruction
of bony wall
C.T. Scan: axial & coronal cuts with contrast
Biopsy
Diagnosis
X-ray paranasal sinus
C.T. Scan
Ohngren’s Classification
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
Lederman’s Classification
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
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
Treatment
T1 & T2 = Surgery or Radiotherapy
T3 = Surgery + Radiotherapy
T4 = Surgery + Radiotherapy + Chemotherapy
Europeans: pre-operative Radiotherapy (5000-
6500 cGy) surgery after 4-6 weeks
Americans: Surgery post-operative
Radiotherapy after 4-6 weeks
Surgical Options1. 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
Total Maxillectomy
Tarsorrhaphy
Weber Fergusson incision
Osteotomy cuts
Total maxillectomy done & incision closed
Palatal defect & prosthesis
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
Orbital exenteration
Cranio-facial resection
Thank You