classification, diagnosis , staging & management of sinonasal tumors

1. Tumors of
nasal cavity & paranasal
sinuses
By
Dr, Ibrahim Habib (M.D)
ENT consultant

2. ‫بسم هللا الرحمن الرحيم‬

4. ‫{ أقم الصالة لدلوك الشمس إلى غسق الليل وقرآن الفجر إن قرآن الفجر كان مشهودا }‬
‫اإلسراء : 87‬

5. Introduction
Cancers of nose & PNS : 3% of Head & Neck cancers .
Age : 5th up to 7th decade .
Predominately of older males .
Exposure:
Wood, nickel-refining processes
Industrial fumes, leather tanning
Cigarette and Alcohol consumption:
No significant association has been shown

6. location
3%
1%
20%
70%

7. • Floor : palatine process of maxilla
• Roof : cribriform plate .

8. Anatomy of maxillary antrum
Anterior : soft tissue of face .
Posterolateral : ITF , pterygopalatine F
Superior : Inferior orbital plate .
Inferiorly : hard palate ,
superior alveolar ridge

9. Anatomy of ethmoid sinuses
Anterior : lacrimal bone .
Medialy : lateral nasal wall.
Superior : Fovea ethmoidalis .

10. Anatomy of sphenoid sinus
Anteriorly : nasal cavity , ethmoid .
Posteriorly : clivus , brainstem .
Superiorly : pituitary fossa .
Laterally : cavernous sinuses & optic N .

11. Anatomy of frontal sinus
Anteriorly :
soft tissue of forehead .
Inferiorly :
orbit .
Posteriorly :
anterior cranial fossa .

12. 1- frontal sinus
2- ant. Ethmoid sinus
3- infundibulum
4- middle. Ethmoid
sinus
5- post. Ethmoid sinus
6- middle concha
7- sphenoid sinus
8- inf. concha
9- hard palate

13. Drainage of PNS
Maxillary sinus : middle meatus
Ethmoid sinuses “ anterior “ : middle meatus .
Ethmoid sinuses “ posterior “ : sphenoethmoid recess .
Sphenoid sinus : sphenoethmoid recess .
Frontal sinus : frontonasal duct .

15. Classification of sinonasal tumors

16. Benign ( epithelial ) Benign ( non Malignant Malignant (non
sinonasal tumors epithelial ) sinonasal (epithelial ) epithelial ) sinonasal
tumours sinonasal tumours tumours
- Schneiderian papilloma : Leiomyoma - squamous cell - chondrosarcoma .
inverted . chondromyxoid fibroma carcinoma : - Rabdomyosarcoma
Papillary ( septal ). Differentiated . .
Cylinderical Basaloid squamous .
- Squamous papilloma ( Adeosquamous
nasal vestibule )
- Adenoma . Adenocarcinoma . - lymphoproliferative
- Dermoid Adenoid cystic . Lymphoma
Mucoepidermoid Midline malignant reticulosis
Plasmacytoma
- Terato carcinosarcoma
- Lobular capillary Neuroendocrine Hemangiopercytoma
hemangioma . carcinoma . Angiosarcoma
- Hemangiopericytoma . Hyallinizing clear cell kaposi’sarcoma
- peripheral nerve sheath carcinoma
tumors
- Fibrous histocytoma . myxoma , fibromyxoma. - Melanoma . Fibrosarcoma
- fibroma . ameloblastoma - olfactory neuroblstoma Osteogenic sarcoma
- osteoma . . Malignant fibrous
- fibrosseus lesios . - sinonasal Histocytoma
undifferentiated
carcinoma (SNUC)
N.B. Secondary malignancy – Melanoma ,Thyroid , lung , kidney and G I T

17. Squamous Cell Carcinoma
• Most common sinonasal
malignancy
• 70% arise in antrum
• 30% arise in nasal cavity
• 15% with synchronus or
metachronus lesion
• Pre or co-existing papilloma is
risk factor
• 4-9%
• Look for necrosis on imaging
N.B. Squamous Cell Carcinoma in Inverted Papilloma

18. Adenocarcinoma
• 13-19% of SN
malignancies
• Arise from surface
epithelium and
seromucinous glands
• Intestinal, salivary,
neuroendocrine types
• Non-specific imaging
features
• Predilection for
ethmoid sinuses

19. Adenoid Cystic Ca
• <10% of SN malignancies
• 25% of adenocarcinomas
• Glandular origin
• Perineural growth pattern (60%)
• Neural cell adhesion molecule
(NCAM) in 93%
• Small lesions extend beyond
what is apparent
• Difficult to entirely remove
• Late recurrences and mets

20. Sinonasal Melanoma
• < 4% of SN neoplasms
• Melanocytes in mucosa
• Prefers nasal cavity
• Epistaxis
• Worse prognosis than
cutaneous types
• High recurrence and
mortality rates

21. Esthesioneuroblastoma
• Originate from olfactory
epithelium
• Two incidence peaks
• Adolescence
• 50 - 60 years
• Epistaxis
• High survival with
multimodality therapy
• Ca++ and peripheral cysts

22. Sinonasal Undifferentiated Ca (SNUC)
• Separate entity from SCCa,
ENB, and others
• Rare, high-grade malignancy
• 2-3:1 male predominance
• Broad age range from 3rd to
9th decades
• Characterized by aggressive
local growth, regional and
distant mets, and poor
survival

23. Sinonasal Lymphoma
• 44% of extranodal
lymphomas arise in SN
• Prefers nasal cavity
• Types
• T-cell (Asian)
• B-cell (US, Europe)
• T/NK-cell (LMG)
• Remodeling or erosion
• Homogeneous enhancement

24. Sarcomas and Other Malignancies
• Sarcomas
• Rhabdomyosarcoma
• Liposarcoma
• Leiomyosarcoma
• Fibrosarcoma
• Chondrosarcoma
• Osteosarcoma
• Plasmacytoma
• Metastases

26. symptoms
Early : asymptomatic .
Oral symptoms: 25-35%
, Toothache , trismus, alveolar ridge fullness, erosion ,
malocclosion .
Nasal findings: 50%
Obstruction, epistaxis, rhinorrhea , post nasal discharge , anosmia .
Ocular findings: 25%
Epiphora, diplopia, proptosis
Facial signs
Paresthesias, asymmetry

27. Physical examination
Nasal mass or polyposis .
Mass in the check or medical canthus .
Broadening of nasal dorsum .
Maxillary sinus involvement :
Mass in palate or upper alveolus .
Mass in upper gingivobuccal sulcus .
Malocclusion or loose teeth .
Advanced : Trismus .
Orbital :
Periorbital swelling , proptosis .
Epiphora , impaired occular mobility
Uncommon : Neck mass

28. Nasal endoscopy that shows a tumor in the left nasal wall

29. Investigations
Aim : detect the disease & its extention .
Extention : orbit , skull base , dura , Intracranial , great
vessels .
Presence of regional or distant metastasis

30. Presentation of tumours of nose & PNS
Nasal mass or polyposis )mass in check )

31. Broadening of nasal dorsum , proptosis , restricted occular mobility

32. C T scan
- Ideal
- surrounding bone erosion or destruction .
Tum : -
our
Calification .
Soft tissue denisty
Necrosis or hge
Vascular tum : enhancem
ors ent increase with contrast
Entrapped secretion : with low density
Lym node : regional L.N. , ( retropharyngeal ) L.N.
ph
. Staging
• Guide biopsy and surgery
• Treatm responseDistant m
ent etastasis .

33. Coronal section of nose & PNS shows soft tissue mass in region of Rt ethmoid air cell
pushing septum to other side with bony erosion of septum and fovea ethmoidalis )B)

34. CT Scan, of paranasal sinus, that shows the tumor( angiosarcoma ) in the left
nasal cavity

35. MRI
Advantages :
- excellent delineation of tumour from
surrounding inflammatory soft tissue and
retained secretions.
- obtained in multiple planes .
- no exposure to ionizing radiation .
- no artifact in the presence of dental filling .

36. Figures 1 and 2: MR shows a 3.0 x 4.0-cm mass arising from the mucosa of the right
ethmoid region with some areas of necrosis; the surrounding bony structure is intact
but its growth expands nasal septum and lamina papiracea -

37. Tumour secretion inflammation
T1 Intermediate signal No enhancement Low signal
T1 with contrast Diffuse enhancement No enhancement Low signal
T2 Intermediate signal High signal High signal
N.B. flow void --- vascular lesion .
With contrast -- perineural invasion, dural or intracranial involvements
L.N. -- Heterogenous on T2 , > 1 cm , peripheral enhancement with contrast using fat
suppresion

38. Angiography
Indications :
1- Evaluations of vascular tumours extention , vascular anatomy ,
selective embolization .
2- Skull base surgery with brain retraction , delineate intracranial
arterial and venous anatomy .
3- tumour encroaching on carotid a. , assess collaterals , may be
used with balloon occlusion testing .

39. P.E.T.
- Agent : 18 – F flurodeoxy glucose .
C – 11 methionine .
- Principle : image metabolic activity of head & neck . Tumors including nose
& PNS
Assess : Local , regional or systemic metastasis . -
. Direct biopsy -
• Therapy response
• Recurrence vs.
treatment change
• Re-staging
- Result : inferior to C.T. & MRI .

40. Biopsy
Aim : confirm diagnosis & plan appropriate ttt.
Route : 1- transnasl .
2- transoral .
3- direct access to the sinus :
Maxillary sinus : Transnasal , medial wall of
maxillary sinus .
Caldwell – Luc . Procedure .
Ethmoid sinuses : Endoscopic ethmoidectomy -
External ethmoidectomy .
Sphenoid sinus : endoscopically
Trans – septally
Frontal sinus : its floor .

42. Staging of sinonasal tumours

43. Ohngern 1933 staged maxillary Ohngern 1933 staged maxillary
sinus cancers (Infrastructure ) sinus cancers(Suprastructure)
Site Infrastructure to Ohngern line Suprastructure to Ohngern line
Symptoms Early Late
Spread Oral , nasal , I.T.F Pterygomaxillary fossa , middle &
anterior cranial fossa
Treatment More amenable to surgical resection Less amenable to surgical resection
prognosis Good Bad
Ohngern line : an imaginary line drawn from maxillary tuberosity to inner canthus .
Ohngern 1933 staged maxillary sinus cancers

44. Staging of non maxillary sinonasal malignancies
Stage I : tumor confined to site of origin .
Stage II : spread to adjacent sinuses , skin , nasopharynx ,
ptergomaxillary fossa , and or orbit .
Stage III : involvement of skull base , pterygoid plate and
or intracranial extension .

45. Staging system for olfactory neuroblastoma
Stage I : confined to primary site .
Stage II : presence of nodal metastasis .
Stage III : presence of distant metastasis .

46. AJCC staging for PNS
primary tumor ( T ) of maxillary sinus
- Tx primary T can’t be assessed .
- To : no evidence of primary T.
- Tis : carcinoma in situ .
- T1 : T limited to antral mucosa with no erosion nor
destruction of bone .
- T2 Tumour causing erosion or destruction except for
posterior antral wall , including extention into m.m. of
hard palate and / or middle nasal meatus .

47. AJCC staging for PNS
primary tumor ( T ) of maxillary sinus
- T3 Tumour invade any of the following : bone of posterior wall of
maxillary sinus , subcutaneous tissue , skin of check , floor or
medial wall of orbit , I.T.F. , pterygoid plates , ethmoid sinuses .
- T4a (resectable): anterior orbit,
skin, infratemporal fossa, pterygoid
plates, cribriform plate, frontal or
sphenoid sinuses
- T4b (unresectable): orbital apex,
dura, brain, middle fossa, clivus,
nasopharynx, CNs (other than V2)-

48. Staging of ethmoid sinus
- T1 tumour confined to the ethmoid with or without bone
erosion .
- T2 Tumour extends into nasal cavity .
- T3 Tumour extends into ant. Orbit and / or maxillary
sinus .
- T4 Tumour with intracranial extension , orbital
extension including apex , involving sphenoid and / or
frontal sinus and / or skin of external nose .

49. Nodal involvement in sinonasal tumours
. Nodal involvement infrequent despite advanced stage
• Depends on primary site, extent, and histology
• 8-18% with nodes at presentaion
. Nodal stage based on: N1: Single ipsilat ≤ 3cm
• N2:
• Number
• a: Single ipsilat 3 – 6cm
• Uni- or bilateral
• b: Multiple ipsilat ≤
• Size
6cm
-Nodal drainage • c: Bilat or contralat ≤
• Facial, parotid, submandibular 6cm
• Retropharyngeal • N3: ≥ 6cm node
• Then L II

50. staging
- stage o Tis No Mo
- stage I T1 No Mo
- stage II T2 No Mo
- stage III T3 No Mo
- T1-T3 N1 Mo
- stage IV A T4 No Mo
T4 N1 Mo
- stage IV B any T N2 Mo
any T N2 Mo
- stage IV c any T any N M1
( N ) lymph node . ( M ) distant metastasis .

51. TNM Staging of Maxillary Carcinomas
• Stage I: Limited to mucosa
• Stage II: Bone involvement
(NOT posterior wall)
• Stage III:
• T3 lesion
• TI or T2 lesions with N1
• Stage IV
• T4 lesion
• Any T with N2/N3 or M1

53. Management of sinonasal tumours

54. Surgical management Indication Surgical management Indication
of early primary of
lesion Advanced primary
lesion
Infrastructure lesions confined to Radical maxillectomy advanced lesions
maxillectomy floor of maxillary sinus confined to maxillary
. sinus advanced
lesions confined to
maxillary sinus
Medial maxillectomy lesions confined to Craniofacial resection extension of disease
medial wall of into the frontal
maxillary sinus sinuses and / or
cribriform plate
Partial or complete lesions confined to Palliative disease is extended
septectomy septum radiotherapy into brain , sphenoid
rostrum , cavernous
sinus & internal
carotid a

55. Midfacial degloving approach.. Surgical Treatment of Squamous Cell
Carcinoma of the Sinuses.

56. Combined bicoronal approach and Dieffenbach-Weber-Fergusson incision. Surgical
Treatment of Squamous Cell Carcinoma of the Sinuses..

57. Management of orbit Indication Orbital complications N.B.
in sinonasal tumors where R.T.
Resection of a small cases with minimal epiphora , keratitis , complications with
portion of the periorbital diplopia , pain , pre-operative R.T. are
periorbita & involvement without exophthalmos , and mostly minor and
reconstruct with full penetration into loss of vision . transient .
fascial graft the orbital fat .
Resection of orbit with invasion of the complications are
periorbita , the more frequent when
infraorbital nerve , or post operative R.T. is
the orbital apex used

58. Reconstruction and Prosthetic Rehabilitation
- Aim : - prevent contracture of the check , to separate
oral & nasal cavities , and to provide support for the
globe .
- An obturator should be made preoperatively from an
impression of the hard palate .

59. . Algorithm to depict tissue options for midface reconstruction

60. Treatment of maxillary sinus carcinoma(A) 66-year-old woman with total maxillectomy defect
and orocutaneous fistula status after surgery and radiotherapy. (B) Cranial bone grafts used to
reconstruct orbitozygomatic structure surrounded by rectus abdominus free flap. (C) 3-year
postoperative result. (D) Intraoral view of 3-year postoperative result.

61. Management of tumours of nose &
PNS
(1) The Neck
No :
T1 – T2 :
electve ND is not generally performed.
T3 – T4 :
R.T. post. Operative . Upper neck & retro-ph. L.Ns .
N+ve with resectable 1ry :
MRND . Or dissect 1-V & retropharyngeal chain .

62. Management of tumours of nose &
PNS
(1) The Neck )late node metastasis)
- 5 – 45% occure after 2-3 yrs .
- rarely occurs in absence of synchronous local or distant
recurrence you should search for .
- TTT aggressively : R.N.D.
- 5 yr survival rate was 39% after ttt of delayed metastasis
.
- N.B. None with nodes at presentation survived 3 years .

63. Radiotherapy as an adjuvant therapy in
management of sinonasal tumours
- 1- combined with surgery in advanced resectable
lesions . Pre. Or post. Operative .
- 2- Single modality for :
- advanced unresectable lesions .
- patients unwilling or unable to undergo surgery .
- Average 5 yrs survival rates 10 – 15 % ( total doses up to 79 Gy ) .

64. chemotherapy as an adjuvant therapy in
management of sinonasal tumours
- Combination chemotherapy with pre. Or post.
Operative R.T. in :
- Olfactory neuroblastoma & SN undifferentiated ca.
- Japanese researchers use combination of R.T. , intra-
arterial 5 – fluorouracil ( 5 FU ) and local debridement
or cryosurgery for maxillary sinus cancer .

65. - Knegt ‘s regimen in using topical chemotherapy as an
adjuvant Therapy in management of sinonasal tumours
.The regimen
1-antrostomy and debulking of the tumour .
2-The tumour bed is then packed with topical 5FU
emulsion .
3- The pack are removed and any residual necrotic
material is debrided as often as necessary .
He reported 5-yr survival of 71% .

66. prognosis
The advancement of skull base surgery , cure rates for
patients with sinonasal tumours ,
form 39-76% have been achieved

67. Tumours have good chance of cure :
1- early maxillary tumours .
2- patients with nasal cavity tumours .
3- well differentiated adenocarcinoma 90% .
4- low grade minor salivary gland tumour .
5- olfactory neuroblastoma :
100% stage A & 75% stage B & 60% stage C . Survival .
6- sq. cell ca. arising in inverted papilloma .

68. Tumours with bad prognosis
1- Advanced maxillary cancer .
2- lesions involving pterygoid plates or
pterygopalatine fossa .
3- lesions involving brain , dura , nasopharynx ,
sphenoid .
4- lesions involving orbital contents .