This document provides an overview of nose and paranasal sinus malignancies. It discusses their epidemiology, common types including squamous cell carcinoma and adenocarcinoma, risk factors such as wood dust exposure, clinical presentation, imaging, staging systems, and treatment options including surgery and radiotherapy. Nose and paranasal sinus cancers are uncommon but can cause significant morbidity due to their location near critical structures like the orbit and brain. Accurate diagnosis is challenging as symptoms often mimic rhinosinusitis initially. Treatment aims to balance tumor control with preserving quality of life and important functions.

1. Nose & PNS Malignancy
Current concepts
Balasubramanian Thiagarajan
Otolaryngology online
Drtbalu's otolaryngology online

2. Introduction
· Uncommon tumors - >1% of all neoplasms
· Diverse group – some unique to nose alone
· Produces very little symptoms
· Commonly mistaken for rhinosinusitis
· Average delay from first symptom to diagnosis is about 6 months
· Accurate staging is still not possible – Current staging system is only for maxillary & ethmoid sinuses

3. Reality
· Surgery & chemoradiotherapy main trt modalities available
· Treatment modalities inflict considerable morbidity
· Facial disfigurement / Interference with mastication / loss of sight
· Quality of life – considered while choosing treatment modality

4. Epidemiology
· Incidence – 1% per 100,000 / year
· Commonly develop during 5th – 6th decades of life
· Twice as common in men than women
· Common sino-nasal malignancy – Primary epithelial tumors followed by non-epithelial malignant tumors
· Tumors arising from nose 25% and tumors arising from sinuses 75%
· 60% of squamous carcinomas arise from maxillary sinus, 20% from nasal cavity rest from ethmoids. 1% arise from sphenoid

5. Common sinonasal malignancy
· Squamous cell carcinoma – commonest
· Adenocarcinomas
· Adenocystic carcinomas
· Undifferentiated carcinomas
· Non Hodgkin's lymphoma
· Melanomas

6. Adenocarcinoma
· Third most common epithelial malignancy next only to sinonasal gland carcinoma.
· 4 times frequent in men. ? Occupational exposure to wood dust.
· Commonly arise from olfactory cleft.
· Usually appears polypoidal
· Unilateral expansion of olfactory cavity and opacification in imaging - ? suspicion

7. Adenocarcinoma - Imaging

8. Etiology
· Exposure to carcinogen
· Smoking / alcoholism
· Viral

9. Carcinogen
· Wood dust
· Nickel
· Chromium
· Polycyclic hydrocarbon
· Aflatoxin
· Thorotrast – (watch dial makers)

10. Wood dust
· Adenocarcinoma
· Wood workers – 500 times common
· Exposure to hard wood dust – Ebony, mahogany, oak.
· Exposure threshold - > 5mg / m3 / day
· Chemicals used in wood processing have been eliminated as a cause
· Even short periods of exposure can cause adenocarcinoma (< 5 years)

11. Industrial risk
· Wood industry
· Textile industry
· Bakery
· Textile
· Nuclear industry
· Farming
· Construction
· Mining

12. Human papilloma virus
· HPV-6 / HPV-11 demonstrated in 10% of squamous cell carcinoma nose & pns.
· HPV – 16 / HPV – 19 are known to cause more virulent cancers.
· Presence of squamo columnar junctions in the nose predisposes to HPV induced cancers.

13. Tumor spread
· Local invasion
· Orbital spread common – thin walls, nerves and blood vessels cause dehiscence
· Roof of frontal sinus is thin – perforations + for olfactory nerves to pass

14. Ohngren's Line
· Line running from medial canthus to angle of
mandible
· Prognosis of suprastructure tumors worse (This
was before advent of craniofacial resection)

15. Lymphatic drainage
· Lymphatic drainage of this area is scanty.
· Anterior / Posterior pathway
· Anterior pathway – 1st echelon nodes (facial, parotid, submandibular nodes)
· Posterior pathway – 1st echelon nodes (retropharyngeal nodes)
· Anteroinferior nasal cavity, skin of nasal vestibule – anterior pathway
· Rest of nose and sinuses drain via posterior pathway

16. Tumor spread

17. Clinical features
· Oral symptoms – Pain, trismus, alveolar ridge fullness, erosion, loosening teeth, ill fitting dentures (2530%).
· Nasal symptoms – Obstruction, epistaxis, rhinorrhoea (50%).
· Ocular symptoms – Epiphora, diplopia, proptosis, blindness (25%).
· Facial signs – Paresthesias, asymmetry

18. Clinical

19. Radiology

20. MRI
· Differentiates tumor from soft tissue
· Differentiates secretions from tumor mass
· Demonstrates perineural spread
· Not affected by dental fillings
· Can be imaged in sagittal plane
· Coronal MRI – Foramen rotundum, vidian canal, foramen ovale and optic canal can be seen

21. Angiogram
· Tumors surround carotid artery
· Carotid artery needs to be sacrificed in order to obtain clear surgical margins
· Balloon occlusion tests should be performed to estimate the risk of cerebral infarction if carotid needs to be
sacrificed.

22. CT imaging

23. Squamous cell carcinoma
· Most common sinonasal malignancy.
· Common during 7th decade / males.
· Arises – lateral nasal wall. 50% arises from turbinates.
· 85% are well differentiated and keratinizing.
· 15% of inverted papilloma turns malignant

24. Adenocarcinoma
· Wood workers
· 9% of all sino nasal malignancies
· Common 6th – 7th decades
· Common in upper nasal cavity / ethmoidal sinuses
· Growth rate slow
· Metastasis uncommon
· Histological types: Papillary, sessile, mucoid, neuroendocrine, intestinal, undifferentiated.

25. Adenoid cystic carcinoma
· 5% of all sinonasal malignancies
· Slow growth, perineural spread, vascular spread
· Maxillary sinus commonly affected
· Long history of facial pain defying diagnosis

26. Olfactory neuroblastoma
· Arises from basal cells of olfactory epithelium
· 5% of sinonasal malignancies
· Bimodal distribution (20 and 50 yrs old peak).
· More common in women than men
· Paraneoplastic syndrome +

27. Kadish staging system
· Stage A – Tumor limited to nasal cavity
· Stage B – Tumor limited to nose and sinuses
· Stage C – Tumor extending beyond the confines of nose and sinuses
· Stage D – distant metastasis

28. ULCA Staging
Stage
Description
T1
Tumor involving the nasal cavity or
paranasal sinuses (excluding sphenoid) or
both, sparing the most superior ethmoidal
air cells
T2
Tumor involving the nasal cavity or
paranasal sinuses (including the sphenoid)
or both with extension to or erosion of the
cribriform plate
T3
Tumor extending into the orbit or
protruding into the anterior cranial fossa
T4
Tumor involving the brain

29. Undifferentiated carcinoma
· Anaplastic
· Aggressive tumor
· Produces fewer symptoms
· Chemoradiation +

30. Melanoma
· 4% of sinonasal malignancies
· Common in women than men
· Affects elderly
· Nasal cavity / septum common sites
· Polypoidal / ulceration
· Metastasis less frequently to nodes
· Lungs / brain metastasis common

31. Lederman's classification
· Lines of Sebileau
· Supra, meso and infrastructures
· Prognosis worsens from below upwards

32. Growth maxilla – staging TNM
T1
Tumor confined to antrum – No bone
erosion
T2
Tumor with bone destruction except
posterior wall of antrum
T3
Erosion of posterior wall /
infratemporal fossa / pterygoid plates /
orbit / ethmoid sinus
T4a
Anterior orbital contents / cribriform
plate / sphenoid / frontal sinus
T4b
Orbital apex / dura / brain / middle
fossa / nasopharynx / clivus

33. Ethmoid sinus - TNM
T1
Tumor confined to ethmoid / with
or without bone erosion
T2
Tumor extending into nasal cavity
T3
Tumor extending to anterior orbit /
maxillary sinus
T4a
Anterior orbital contents / Skin of
nose or cheek / minimal anterior
cranial invasion / pterygoid plates /
sphenoid / frontal sinus
Orbital apex / dura / brain / middle
cranial fossa / cranial nerves other
than V2 / nasopharynx / Nasal
cavity
T4b

34. Nasal cavity
Subsites recognized – septum / floor / lateral wall / vestibule
T1
Tumor involving one subsite
T2
Tumor involving two subsites / ethmoid
T3
Tumor eroding to anterior orbit / maxillary sinus
T4a
Anterior orbit / skin of nose and cheek / minimal anterior cranial
fossa extension / pterygoid plates / sphenoid / frontal sinus
T4b
Orbital apex / dura / brain / middle cranial fossa / nasopharynx /
clivus / cranial nerves other than V2

35. Treatment
· Surgery
· Radiotherapy
· ? Chemotherapy
· Combination

36. Irradiation
· Preop irradiation preferable
· Post op irradiation is suitable only for slow growing tumors
· 200 rads x 5 days a week – 6 weeks (6000rads)

37. Surgery
· Partial maxillectomy
· Total maxillectomy
· Extended maxillectomy

38. Medial maxillectomy
· Good access to nasal cavities / ethmoids /
nasopharynx / sphenoid / pterygopalatine fossa
· Moore's incision
· Incision may be continued into nasal cavity

39. Medial maxillectomy - osteotomy

40. Anterior craniofacial resections
· Type I – Craniofacial / transorbital resection. This procedure is extended medial maxillectomy with
resection of ethmoid roof and orbital periosteum
· Type II – Medial maxillectomy with window craniotomy using frown line incision
· Type III – Neurosurgeon helps. Transfacial with neurosurgical approach like frontolateral craniotomy

41. Thank you