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1. Nasal Obstruction
INDIAN DENTAL ACADEMY
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2. History
 CC:
“I can’t breath through the left side of
my nose”
• What else do you want to ask the patient?
• HPI:
•
•
•
•
•
6-8 mo h/o left nasal obstruction.
Slowly progressive
Occasional epistaxis when bends over
Decreased sense of smell left nasal passage
No visual changes, no headaches
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3. Physical Exam
 Eyes:
EOMI, PERRL, no diplopia, no
proptosis
 Ears: TM’s clear
 Nose: Left nasal mass, edematous,
obstructing almost entire nasal passage
 OC/OP: No masses/lesions
 Neck: no LAD
 CN: II-XII intact
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4. Diagnostic Studies
 CT:
evaluate bony destruction
 MRI: evaluate soft tissue, differentiate
mucous from mass
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5. Differential Diagnosis
 V– hemangioma, AVM, juvenile nasoangiofibroma, hamartoma
 I – sinusitis, nasal polyposis, mucocele, allergic rhinitis,
T
– acquired nasal deformity
 A – Wegener’s granulomatosis, relapsing polychondritis
 M – none
 I – Sarcoid, rhinitis medimentosum
 N – mucosal melanoma, lymphoma, nasopharyngeal carcinoma,
extramedullary plasmacytoma, adenoid cystic carcinoma, adenocarcinoma,
squamous cell ca, papillomas, fibrous dysplasia, osteoma,
hemangiopericytoma, esthesioneuroblastoma, sarcomas, SNUC
 C – teratomas, dermoid,
 D – none
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6. Esthesioneuroblastoma
 Epidemiology:
– Male:female (1:1)
– Bimodal distribution 2nd and 6th decades
 Pathophyisiology:
– Neuroectodermal origin
– Arise from olfactory mucosa
– Common symptoms:


Unilateral nasal obstruction (70%)*
Epistaxis (46%)*
* Irish J, Dasgupta R, Freeman J, et al. Outcome and analysis of the surgical management of
esthesioneuroblastoma J Otolaryngol 1997; 26:1-7.
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7. Spectrum of lesions


Broad range of lesions arise
from the olfactory mucosa
Diverse cell poplulation in the
olfactory mucosa
– Sensory neurons
– Sustentacular cells
– Basal cells

Within olfactory neuroblastoma
a spectrum exists
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8. Histology
 Histologic
grading based on Hyams criteria
Grade I: 14%
Grade II: 48%
Grade III: 21%
Grade IV: 17%
 Prognostically
grouped as high or low grade
 Low grade: 56%, High grade 25%
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*Pilch B. Head and Neck Surgical Pathology. Lippencott. Philadelphia. 2001

9. Immunohistochemistry
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10. Histology
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11. Grading System

Kadish system
Stage A: limited to nasal cavity
Stage B: Extends into paranasal sinuses
Stage C: Extends beyond nasal cavity and paranasal sinuses

Dulguerov and Calcaterra*
T1: nasal cavity/paranasal sinuses (not sphenoid or superior most ethmoids)
T2: includes sphenoid w/ extension to/erosion of cribiform plate
T3: extends into orbit or anterior cranial fossa w/o dural invasion
T4: tumor involving brain
N0: no cervical lymphadenopathy
N1: any cervical metastasis
M0: no metastases
M1: distant metastases
* Dulguerov P, Allal A, Calcaterra T. Esthesioneuroblastoma: a meta-analysis and review. Lancet Oncol.
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2001; 2:683-690.

12. Grading Systems
Distribution of Patients:
 Kadish
– Stage A 12%
– Stage B 27%
– Stage C 61%
 Dulguerov
–
–
–
–
–
and Calcaterra
T1 25%
T2 25%
T3 33%
T4 17%
N1 5%
5 year survival:
 Kadish
– Stage A 72%
– Stage B 59%
– Stage C 47%
 Dulguerov
–
–
–
–
–
–
and Calcaterra
T1 81%
T2 93%
T3 59%
T4 48%
N0 64%
N1 29%
*Dulguerov P, Allal A, Calcaterra T. Esthesioneuroblastoma: a meta-analysis and review.
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Lancet Oncol. 2001; 2:683-690.

13. Treatment
 Surgery
and Radiation therapy is most commonly
accepted modality of treatment
 Chemotherapy may be indicated for advanced
lesions but is controversial*
 Treatment of the neck is controversial**
*Eden BV, Debo RF, Larner JM, et al. Esthesioneruroblastoma: long-term
outcome and patters of failure-the University of Virginia experience. Cancer.
1994;73:2556-2562.
** Davis RE, Weissler MC. Esthesioneuroblastom and neck metastasis. Head
Neck. 1992;14:477-482.
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14. Thank you
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