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Sino-nasal Tumours

Sino-nasal Tumours. Dr. Vishal Sharma. Benign Simple papilloma Ossifying Fibroma Osteoma Haemangioma Neurofibroma Intermediate Inverted papilloma. Malignant Squamous cell carcinoma Adenocarcinoma Anaplastic carcinoma Transitional cell carcinoma Malignant melanoma

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Sino-nasal Tumours

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  1. Sino-nasal Tumours Dr. Vishal Sharma

  2. Benign 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 Classification

  3. 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

  4. Frontal sinus osteoma

  5. Bicoronal osteoplastic flap

  6. Osteoma exposed

  7. Tumor removal + closing of bone flap

  8. 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

  9. Ossifying fibroma

  10. Ossifying fibroma

  11. 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

  12. 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 10­15% cases. • Radiotherapy is avoided.

  13. Anterior rhinoscopy

  14. 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.

  15. Punch Biopsy & H.P.E. Inward invasion of hyperplastic epithelium into underlying stroma. No evidence of malignancy.

  16. Moure’s lateral rhinotomy

  17. Osteotomy cuts

  18. Bone removed & tumor exposed

  19. Tumour removed & inicision closed

  20. Midfacial degloving approach

  21. Sino-nasal Malignancy

  22. 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

  23. Risk factors • Hardwood dust (adenocarcinoma) • Softwood dust (squamous carcinoma) • Nickel refining; chromium workers • Boot, shoe and textile workers • Mustard gas exposure • Human papilloma virus

  24. Maxillary sinus malignancy

  25. Early Clinical features Mimic maxillary sinusitis • Nasal stuffiness • Blood-stained nasal discharge • Facial paraesthesias or pain • Epiphora

  26. Spread

  27. Late Clinical features Medial spread: • Unilateral nasal obstruction • Unilateral purulent nasal discharge • Epistaxis • Unilateral, friable, nasal mass Anterior spread: • Cheek swelling • Invasion of facial skin

  28. Late Clinical features Inferior 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 .

  29. Late Clinical features Posterior 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

  30. Cheek swelling

  31. Cheek skin involvement

  32. Alveolar & Palatal swelling

  33. Nasal mass

  34. Diagnosis • Diagnostic nasal endoscopy • X-ray paranasal sinus: expansion & destruction of bony wall • C.T. Scan: axial & coronal cuts with contrast • Biopsy

  35. X-ray paranasal sinus

  36. C.T. Scan

  37. Ohngren’s Classification

  38. 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

  39. Lederman’s Classification

  40. 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

  41. 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

  42. 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

  43. Surgical Options 1. 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

  44. Total Maxillectomy

  45. Tarsorrhaphy

  46. Weber Fergusson incision

  47. Osteotomy cuts

  48. Total maxillectomy done & incision closed

  49. Palatal defect & prosthesis

  50. 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

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