DR Kamlesh Dubey
AIIMS NEW DELHI
 Epithelial:
 Sinonasal gland tumors
 Pleomorphic adenoma
 Myoepithelioma
 Oncocytoma
 Schneiderian papilloma
 Wart...
 Bone & Cartilage tumors:
 Osteoma
 Osteoid osteoma
 Fibrous dysplasia
 Ossifying fibroma
 Osteoblastoma
 Ameloblas...
 Displaced neural lesions(ectopic site):
 Nasal glioma
 Pituitary adenoma
 Soft tissue tumors:
 Vascular tumors:
 Ju...
SCHNEIDERIAN PAPILLOMA
 In 1600s C. Victor Schneider demonstrated nasal
mucosa :
 Produces catarrh not csf
 Ectodermal origin
 1854 Ward firs...
 Fungiform: 50% , nasal septum
 Cylindrical: 3%, lateral wall/sinuses
 Inverted: 47%, lateral wall
 arise in the nasal septum
 „ exophytic growth pattern
 „ do not grow down into the underlying normal
stroma
 „ associ...
 ragged, beefy appearance and
 „ histologically : composed of columnar cells
 „ pink cytoplasm
 „ nuclei are oval or r...
 The US National Cancer Institute has defined inverted
papilloma as a type of tumor in which surface
epithelial cells gro...
 Locally aggressive sinonasal tumor
 „ Arises from nasal respiratory epithelium,,
 which undergoes metaplastic change a...
 Schneiderian papilloma
 Schneider papilloma
 Inverting papilloma, Inverted papilloma
 Ringertz tumor
 epithelial pap...
 Benign/intermediate
 0.5% to 4% of sinonasal tumor
 Site of origin
 Age/Sex: male, 5-6th decades
Exophytic (tree) Inverted (nodule)
 appearance of the epithelium inverting into the
stroma
 with a distinct and intact basement membrane
 that separates a...
 Etiology : association between common
papillomas and the human papillomavirus (HPV)
 „ HPV types 6 and 11
 Kusiak and ...
 Grossly :: exophytic and polypoid
 „ more vascular than an inflammatory polyp
 „ gray to pink
 „ frond--like projecti...
epithelium distinct from the respiratory
(pseudostratified
ciliated columnar)
mucosa of the sinonasal cavity
-- may be squ...
 Tendency to recur
 Destructive capacity to surrounding structures
 Propensity to be associated with malignancy
 They are associated with malignancy, 5%
to 15% malignancy rates are most
generally accepted. Inverted papillomas are
mor...
 unilateral nasal obstruction (58%)
 „ epistaxis (17%)
 „ nasal drainage (14%)
 „ bilateral nasal obstruction (12%)
 ...
 Krouse summarized from 1967 to 1997
 primary sites of IP
 „ lateral nasal wall (82%)
 „ maxillary sinus (53.9%)
 „ e...
 KrouseType 1: Tumour totally confined to the nasal cavity. The tumour
can be localized to one wall or region of the nasa...
 Han et al. Group 1: Tumour involvement limited
to the nasal cavity, lateral nasal wall, medial
maxillary sinus, ethmoid ...
 Kamel et al. Type 1: Tumour originating from the
nasal septum or lateral nasal wall.
 Type 2: Tumour originating from t...
 Oikawa et al. T1: Tumour limited to nasal cavity.
 T2: Tumour limited to ethmoid sinus and / or medial
and superior por...
 cannady et al. Group A: Inverted papilloma
confined to the nasal cavity, ethmoid sinuses, or
medial maxillary wall.
 Gr...
 Typical presentation : unilat.polyps
 „ antral choanal polyp
 „ allergic fungal sinusitis
 „ squamous cell carcinoma
...
 „ CT and MRI are the common modalities
 „ CT is the most widely performed study
 „ bony changes
 „ bowing of the bone...
 convoluted cerebriform pattern on T2- or
enhanced T1-weighted images suggests inverted
papilloma as a histologic diagnos...
 Surgery
 „ Radiation therapy
 Surgical approaches:
 • Headlight intranasal polpectomy
 • Caldwell Luc procedure
 • Medial maxillectomy
 • Lateral ...
 Stammberger reported the first purely endoscopic
approach for treatment of SP, which was
performed in 15 patients in 198...
 Contraindicated in:
 massive involvement of the mucosa of the frontal
sinus
 and/or of a supraorbital cells
 intradur...
 Key point:
 to dissect the involved mucosa along the
subperiosteal plane
 to drill the underlying bone whenever requir...
 Initially via transnasal resection:
 50-80% recurrence
 Medial Maxillectomy via lateral rhinotomy:
 Gold Standard
 1...
 Predisposing factors:
 Tumor location
 Histology
 Multicentricity
 Method of removal
 Length of follow up
 Main fa...
 Bielamowicz et al:
 found a statistically significant difference between
the recurrence rates in patients treated with ...
Surgical approach Recurrence/case
series
Percentage Mean –follow up
Endoscopic
resection
173/1190 14.5% 3 years 1month
Lat...
FIBRO-OSSEOUS TUMORS
Classic entities:
 Osteoma
 Fibrous dysplasia
 Ossifying fibroma
 Definition :
Benign condition in which normal bone is replaced
by fibrous connective tissue due to a defect in
osteoblas...
 Pensler et al:
 investigated cultures derived from the involved
bone in two children with MFD and in one child
with Alb...
 Actual cause:
 set of mutations in the GNAS1 gene
 located on chromosome 20q13.2
 that normally codes for the alpha s...
 Genetically based developmental anomaly
 Defect in osteoblastic differentiation and
maturation
 replacement of normal ...
 Incidence not known
 Females > males
 No race predilection
 Initial symptoms manifest age 3-15
 Not heritable
 Ques...
 Cystic (21%)
- Radiolucency surrounded by solid rim
 Sclerotic (23%)
- Dense and homogenous
 Mixed (56%)
- “Ground gla...
 Monostotic
- Most common
- 25% involve head and neck
 Polyostotic
- 15% of cases
- 50% involve head and neck
 Eosinophilic granuloma
 Nonossifying fibroma
 Bone hemangioma
 Hyperparathyroidism
 Paget’s disease
 Brown’s tumor
...
 Polyostotic fibrous dysplasia
 Café-au-lait spots
 Endocrinopathology:
- Hyperthyroidism
- Precocious puberty in femal...
„ fibrous dysplasia characteristically has a
ground glass appearance on CT images. . It
generally presents in younger pati...
 Surgery:
 intended to relieve symptoms :
 visual impairment due to compression of the optic
nerve
 to correct aesthet...
 a true benign neoplasm
 occurs in the third and fourth decades of life
 preferentially in black women
 Manifestation:...
Aetiology:
 so far not been clarified.
 Trauma has been reported to play a major role in
the development of OF,
 especi...
 present between the second and fourth decades of life
 female incidence is more frequent than male incidence
a male to ...
 Differs from common OF by age (younger), location
(maxilla) & biologic behavior (sometime aggressive and/or
recurrent).
...
 Treatment of choice is dependent on the site of tumour
location
 Tumours invading the midfacial portion and the
sinonas...
 Since OF is very rare, larger series on pure
endonasal resection are not reported
 In case reports, some authors have a...
 Introduction:
Sinonasal osteomas are common entity seen in
patients. Rhinosinus osteomas are commonly asymptomatic and
a...
 Three accepted theories of etiology of osteomas
are:
1. Developmental
2. Traumatic
3. Infectious
 Developmental :
 Adu...
 Traumatic :
 Inflammatory process as the initiating force
 Bony trauma could be the root cause
 Could account for mal...
 possible aetio-pathogenetic role of traumatic and
inflammatory factors:
 Moretti A, Croce A, Leone O, D'Agostino L. Ost...
 Fu and Perzin classification:
 1. Ivory / compact osteoma:
 Otherwise also known as eburnated osteoma.
 In this type ...
 Behavior: Osteomas are very slow growing and are mostly
asymptomatic. They always stay benign and don't recur
after exci...
 Plain sinus radiographs are adequate for detecting
osteomas of paranasal sinuses.
 most commonly localized to the frontal
 sinus
 „ slow growing and well circumscribed
 „ symptoms attributable obstruc...
 Wait ,watch n scan
 Surgery:
 Indications:
 Rapid growth of tumor
 Symptomatic patients with chronic rhinosinusitis ...
 Frontoethmoidal and intraorbital osteomas: exploring
the limits of the endoscopic approach
(Turri-Zannoni et. al Arch. O...
 Exceptions:
 scarring of the frontal recess
 Distortion from previous surgery,
 very advanced disease and associated ...
Displaced/Ectopic tumors
 made of neuroglial elements consisting of
 glial cells in a connective tissue matrix
 with or without a fibrous connec...
 „ present as a red or bluish lump at or along the
 nasomaxillary suture, or as an intranasal mass.
 „ firm, noncompres...
 arise from the lateral wall of the nose or less
 often from the nasal septum.
 „ 60%extranasal
 „ 30% intranasal
 „ ...
 development similar to nasal dermoids.
 „ Abnormal closure of the fonticulus
 Develop from extracranial rests of glial...
 Bluish, soft, compressible, transilluminate,
pulsatile
 Enlarge with crying
 Positive Furstenberg test (bilateral comp...
 4% are found within the paranasal sinuses
 Schwannoma
 Neurofibroma
 Treatment via surgical resection
 When associat...
 Shrinivas SC, Deshmukh S, Pawar V, et al. Case
Study of Clinicopathological correlation of benign
sinonasal masses. Worl...
 slowly growing mass
 arise more frequently from the ophthalmic and
maxillary divisions of the trigeminal nerves
 also ...
 Macroscopically:
 well-delineated but nonencapsulated globular
 firm to rubbery yellow-tan mass
 Histologically:
 ce...
 Mey KH et al in a case series of five nasal
schwannoma
 Buob et al in a series of nasal schwannoma cases
 Unlike other...
 Immunohistochemistry :
 Positive stains: S100
 Negative stains: EMA, CD34, Ki-67/MIB1 (1-
5%)
 Treatment: radical sur...
 Rare, frequently misclassified
 Mean age 48 years, range 13-88 years; no gender
preference
 Usually primary intranasal...
 JNA
 Hemangioma
 The term hemangioma has traditionally been used
to describe a variety of developmental vascular
anomalies.
 Currently, ...
 These lesions are present from birth and persist
throughout life.
 As with hemangiomas, these lesions tend to
darken wi...
 Hemangiomas are the most common tumors of
infancy.
 They have a female gender predilection (3:1)
and are most common in...
 Types : depending on size of vessels
 Capillary
 Cavernous
 Mixed
 Multifocal angiomatosis:
when multiple or affecti...
 frequently occur in the head and neck region,
 • uncommon in the nasal cavity and paranasal sinuses,
 • cavernous and ...
 Trauma, viral oncogenes, inflammatory conditions and
the production of
 angiogenic growth factors may play a role in th...
 Clinical presentation and symptoms:
• epistaxis and/or hemoptysis
• enlarging lesion in the nasal cavity
 Macroscopy:
R...
 Differential Diagnosis
 • Antrochoanal polyp
 •Inverted papilloma
 • Hemangiopericytoma
 • Esthesioneuroblastoma
 T...
 misnamed; they are neither infectious nor
granulomatous
 usually occurs in children and young adults
 solitary, gliste...
 precise mechanism for the development of
pyogenic granuloma is unknown
 Postulated: Trauma, hormonal influences, viral
...
 Curettage
 Cryotherapy
 Excision: with preop ± embolization
 EES
 LASER
 Sclerotherapy
 Cumming’s 5th edition
 Scott-Brown’s 7th edition
 Rhinology journal(Official Journal of the
International and European...
Any Questions ?
Benign sinonasal masses presentation & management-1
Benign sinonasal masses presentation & management-1
Benign sinonasal masses presentation & management-1
Benign sinonasal masses presentation & management-1
Benign sinonasal masses presentation & management-1
Benign sinonasal masses presentation & management-1
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  1. 1. DR Kamlesh Dubey AIIMS NEW DELHI
  2. 2.  Epithelial:  Sinonasal gland tumors  Pleomorphic adenoma  Myoepithelioma  Oncocytoma  Schneiderian papilloma  Warts  Neuroectodermal tumors:  Paraganglioma  Schwannoma  Neurofibroma
  3. 3.  Bone & Cartilage tumors:  Osteoma  Osteoid osteoma  Fibrous dysplasia  Ossifying fibroma  Osteoblastoma  Ameloblastoma  nasal chondromesenchymal hamartoma  giant cell lesion  giant cell tumor  Chondroblastoma  chondroma
  4. 4.  Displaced neural lesions(ectopic site):  Nasal glioma  Pituitary adenoma  Soft tissue tumors:  Vascular tumors:  Juvenile nasopharyngeal angiofibroma(JNA)  Hemangioma  Hemangiopericytoma  Fibrous :  Nasal fibroma  Muscle tumors:  Leiomyoma  Rhabdomyoma
  5. 5. SCHNEIDERIAN PAPILLOMA
  6. 6.  In 1600s C. Victor Schneider demonstrated nasal mucosa :  Produces catarrh not csf  Ectodermal origin  1854 Ward first described Schneiderian papillomas (SPs) of the nose (i.e., sinonasal papilloma)  Kramer and Som classified SPs as true nasal neoplasms and described them as true papillomas  Ringertz was the first to identify the tendency of SPs to invert into the underlying connective tissue stroma, which differs from other types of papillomas
  7. 7.  Fungiform: 50% , nasal septum  Cylindrical: 3%, lateral wall/sinuses  Inverted: 47%, lateral wall
  8. 8.  arise in the nasal septum  „ exophytic growth pattern  „ do not grow down into the underlying normal stroma  „ associated with human papillomavirus  „ do not have a tendency to recur  >57% HPV DNA positivity
  9. 9.  ragged, beefy appearance and  „ histologically : composed of columnar cells  „ pink cytoplasm  „ nuclei are oval or round  „ many areas of mucin cysts  „ actually act very similar to inverted papillomas  More chances of malignancy
  10. 10.  The US National Cancer Institute has defined inverted papilloma as a type of tumor in which surface epithelial cells grow downward into the underlying supportive tissue  Inverted papillomas arise from the Schneiderian membrane, which is an invagination of the olfactory ectoderm that occurs during the fourth week of embryonic development. The mucosa creates a transitional zone between the endo-dermally derived respiratory epithelium of the nasopharynx and keratinizing squamous epithelium with the nasal vestibule
  11. 11.  Locally aggressive sinonasal tumor  „ Arises from nasal respiratory epithelium,,  which undergoes metaplastic change and  proliferation  „ characterized best by its local invasion,  tendency for recurrence, and association with malignancy
  12. 12.  Schneiderian papilloma  Schneider papilloma  Inverting papilloma, Inverted papilloma  Ringertz tumor  epithelial papilloma  Transitional cell papilloma
  13. 13.  Benign/intermediate  0.5% to 4% of sinonasal tumor  Site of origin  Age/Sex: male, 5-6th decades
  14. 14. Exophytic (tree) Inverted (nodule)
  15. 15.  appearance of the epithelium inverting into the stroma  with a distinct and intact basement membrane  that separates and defines the epithelial component from the underlying connective tissue  May be associated with:  Atypia  Ca in situ  Carcinoma:  Scc, transitional cell carcinoma, adenocarcinoma  Mucoepidermoid ca, verrucous ca
  16. 16.  Etiology : association between common papillomas and the human papillomavirus (HPV)  „ HPV types 6 and 11  Kusiak and Hudson described the presence of intracytoplasmic and intranuclear inclusion bodies in SPs  air pollution and industrial carcinogens  „ male: female ratio of 3:1. .  „ average age was 54.3 years  „ most common in the fifth and sixth decades Respler DS, Jahn A, Pater A, Pater MM. Isolation and characterization of papillomavirus DNA from nasal inverting (schneiderian) papillomas. Ann Otol Rhinol Laryngol. Mar- Apr 1987;96(2 Pt 1):170-3 Weber RS, Shillitoe EJ, Robbins KT, Luna MA, Batsakis JG, Donovan DT, et al. Prevalence of human papillomavirus in inverted nasal papillomas. Arch Otolaryngol Head Neck Surg. Jan 1988;114(1):23-6
  17. 17.  Grossly :: exophytic and polypoid  „ more vascular than an inflammatory polyp  „ gray to pink  „ frond--like projections that extend from the  main bulk of the specimen  „ Epithelium inverts into underlying stroma
  18. 18. epithelium distinct from the respiratory (pseudostratified ciliated columnar) mucosa of the sinonasal cavity -- may be squamous, transitional or respiratory -- epithelium proliferative and thickened -- lacks mucus--secreting cells and eosinophils
  19. 19.  Tendency to recur  Destructive capacity to surrounding structures  Propensity to be associated with malignancy
  20. 20.  They are associated with malignancy, 5% to 15% malignancy rates are most generally accepted. Inverted papillomas are more commonly associated with squamous cell carcinomas.  There are four types of association:  Metachronous squamous cell carcinoma.  Carcinoma in situ within the IP  Synchronous lesions  Malignant transformation
  21. 21.  unilateral nasal obstruction (58%)  „ epistaxis (17%)  „ nasal drainage (14%)  „ bilateral nasal obstruction (12%)  „ nasal mass (9%)  „ sinusitis (9%)  „ headache  „ diplopia  „ facial numbness  „ facial swelling  „ anosmia
  22. 22.  Krouse summarized from 1967 to 1997  primary sites of IP  „ lateral nasal wall (82%)  „ maxillary sinus (53.9%)  „ ethmoid sinus (31.6%)  „ septum (9.9%)  „ frontal sinus (6.5%)  „ sphenoid sinus (3.9%)
  23. 23.  KrouseType 1: Tumour totally confined to the nasal cavity. The tumour can be localized to one wall or region of the nasal cavity, or  can be bulky and extensive within the nasal cavity, but must not extend into the sinuses or into any extranasal compartment.  There must be no concurrent malignancy.  Type 2: Tumour involving the ostiomeatal complex, and ethmoid sinuses, and / or the medial portion of the maxillary sinus,  with or without involvement of the nasal cavity. There must be no concurrent malignancy.  Type 3: Tumour involving the lateral, inferior, superior, anterior, or posterior walls of the maxillary sinus, the sphenoid sinus,  and / or the frontal sinus, with or without involvement of the medial portion of the maxillary sinus, the ethmoid sinuses, or  the nasal cavity. There must be no concurrent malignancy.  Type 4: All Tumours with any extranasal / extrasinus extension to involve adjacent, contiguous structures such as the orbit,  the intracranial compartment, or the pterygomaxillary space. All tumours associated with malignancy
  24. 24.  Han et al. Group 1: Tumour involvement limited to the nasal cavity, lateral nasal wall, medial maxillary sinus, ethmoid sinus, and  sphenoid sinus.  Group 2: Same as group 1 except that tumour extends lateral to the medial maxillary wall.  Group 3: Tumour extends to involve the frontal sinus.  Group 4: Tumour extends outside the sinonasal cavities (i.e., orbital or intracranial extension).
  25. 25.  Kamel et al. Type 1: Tumour originating from the nasal septum or lateral nasal wall.  Type 2: Tumour originating from the maxillary sinus.  [This classification focuses on origin and not size / extent of tumour-does not analyze frontal sinus separately]
  26. 26.  Oikawa et al. T1: Tumour limited to nasal cavity.  T2: Tumour limited to ethmoid sinus and / or medial and superior portions of maxillary sinus.  T3: Tumour involves lateral, inferior, anterior, or posterior walls of maxillary sinus, sphenoid sinus, or frontal sinus.  T3-A: without extension to frontal sinus or supraorbital recess.  T3-B: involving frontal sinus or supraorbital recess.  T4: Tumour extends outside sinonasal cavities (orbital or intracranial extension) or associated with malignancy
  27. 27.  cannady et al. Group A: Inverted papilloma confined to the nasal cavity, ethmoid sinuses, or medial maxillary wall.  Group B: Inverted papilloma with involvement of any maxillary wall (other than the medial wall), or frontal sinus, or  sphenoid sinus.  Group C: Inverted papilloma with extension beyond the paranasal sinuses
  28. 28.  Typical presentation : unilat.polyps  „ antral choanal polyp  „ allergic fungal sinusitis  „ squamous cell carcinoma  „ adenocarcinoma  „ esthesioblastoma
  29. 29.  „ CT and MRI are the common modalities  „ CT is the most widely performed study  „ bony changes  „ bowing of the bones near the soft tissue  mass
  30. 30.  convoluted cerebriform pattern on T2- or enhanced T1-weighted images suggests inverted papilloma as a histologic diagnosis  Necrosis in a mass with such an appearance strongly suggests coexistent carcinoma  columnar pattern is a reliable MRI indicator of IP and reflects its histological architecture (positive predictive value of 95.8%)  combination of this finding with the absence of extended bone erosion allows for the confident discrimination of IPs from malignant tumors
  31. 31.  Surgery  „ Radiation therapy
  32. 32.  Surgical approaches:  • Headlight intranasal polpectomy  • Caldwell Luc procedure  • Medial maxillectomy  • Lateral rhinotomy  • External procedures of the frontal sinus  • Endoscopic intranasal polypectomy  • Endoscopic maxillary antrostomy/ethmoidectomy, Sphenoidotomy  • Endoscopic medial maxillectomy  • Median drainage procedure to gain access to the frontal sinus
  33. 33.  Stammberger reported the first purely endoscopic approach for treatment of SP, which was performed in 15 patients in 1981  Most reported endoscopic resections have involved piecemeal resection of the inverting papilloma followed by piecemeal resection of the lateral nasal wall
  34. 34.  Contraindicated in:  massive involvement of the mucosa of the frontal sinus  and/or of a supraorbital cells  intradural extension or transorbital extension  concomitant presence of a malignancy  presence of abundant scar tissue from previous surgery
  35. 35.  Key point:  to dissect the involved mucosa along the subperiosteal plane  to drill the underlying bone whenever required by imaging and/or intraoperative finding  Extent surgery:  site of the lesion  area of mucosa involved by the lesion
  36. 36.  Initially via transnasal resection:  50-80% recurrence  Medial Maxillectomy via lateral rhinotomy:  Gold Standard  10-20%  Endoscopic medial maxillectomy:  Key concepts:  Identify the origin of the papilloma  Bony removal of this region  Recurrent lesions:  Via medial maxillectomy vs. Endoscopic resection  22%
  37. 37.  Predisposing factors:  Tumor location  Histology  Multicentricity  Method of removal  Length of follow up  Main factor: thoroughness of removal
  38. 38.  Bielamowicz et al:  found a statistically significant difference between the recurrence rates in patients treated with medial maxillectomy (20%) versus those treated with a conservative resection (47%).  Mirza et al:  found that recurrence rates in 63 case series was  12.8% for endoscopic procedures (n = 484), 17.0% for lateral rhinotomy with medial maxillectomy (n = 1025)  34.2% forlimited resections such as nasal polypectomy (n = 600)
  39. 39. Surgical approach Recurrence/case series Percentage Mean –follow up Endoscopic resection 173/1190 14.5% 3 years 1month Lateral rhinotomy with medial maxillectomy 207/1239 16.7% 5 years 2 month Limited resection such as nasal polypectomy 208/606 34.4% Inadequate
  40. 40. FIBRO-OSSEOUS TUMORS
  41. 41. Classic entities:  Osteoma  Fibrous dysplasia  Ossifying fibroma
  42. 42.  Definition : Benign condition in which normal bone is replaced by fibrous connective tissue due to a defect in osteoblast differentiation and maturation
  43. 43.  Pensler et al:  investigated cultures derived from the involved bone in two children with MFD and in one child with Albright’s syndrome  showed a two- to threefold increased level of estrogen and progesterone receptors by radioimmunoassay and immunocytochemical assay  concluded that estrogen may play a major role in the bony metabolism of FD
  44. 44.  Actual cause:  set of mutations in the GNAS1 gene  located on chromosome 20q13.2  that normally codes for the alpha subunit of the G- protein
  45. 45.  Genetically based developmental anomaly  Defect in osteoblastic differentiation and maturation  replacement of normal bony tissue by fibrous tissue of variable cellularity and immature woven bone  Histology: slow replacement of medullary bone by abnormal fibrous tissue with different stages of bone metaplasia
  46. 46.  Incidence not known  Females > males  No race predilection  Initial symptoms manifest age 3-15  Not heritable  Questionable genetic transformation  Malignant transformation in < 1%
  47. 47.  Cystic (21%) - Radiolucency surrounded by solid rim  Sclerotic (23%) - Dense and homogenous  Mixed (56%) - “Ground glass appearance”
  48. 48.  Monostotic - Most common - 25% involve head and neck  Polyostotic - 15% of cases - 50% involve head and neck
  49. 49.  Eosinophilic granuloma  Nonossifying fibroma  Bone hemangioma  Hyperparathyroidism  Paget’s disease  Brown’s tumor  Aneurysmal bone cyst
  50. 50.  Polyostotic fibrous dysplasia  Café-au-lait spots  Endocrinopathology: - Hyperthyroidism - Precocious puberty in females
  51. 51. „ fibrous dysplasia characteristically has a ground glass appearance on CT images. . It generally presents in younger patients (children and adolescents), and its growth rate may decrease or stop after puberty
  52. 52.  Surgery:  intended to relieve symptoms :  visual impairment due to compression of the optic nerve  to correct aesthetic deformities  but not to remove the entire lesion  Radiotherapy is contraindicated  Medical treatment :  bisphosphonates (i.e., pamidronate)  with success in patients with extensive lesions associated with significant disfigurement and pain  Octreotide, anti hyperthyroid agents, antiandrogens
  53. 53.  a true benign neoplasm  occurs in the third and fourth decades of life  preferentially in black women  Manifestation:  space-occupying lesion in the nasal cavity  evident at endoscopic examination
  54. 54. Aetiology:  so far not been clarified.  Trauma has been reported to play a major role in the development of OF,  especially of the cemento-ossifying fibroma Histology: demarcated margins consisting of fibrous tissue with varying amounts of mineralized or calcified psammomatoid bodies
  55. 55.  present between the second and fourth decades of life  female incidence is more frequent than male incidence a male to female ratio of 1:5  Ossifying fibroma of the mandible is usually asymptomatic  Depending on its extent:  facial pain  Swelling  nasal obstruction  Rhinosinusitis  ocular symptoms
  56. 56.  Differs from common OF by age (younger), location (maxilla) & biologic behavior (sometime aggressive and/or recurrent).  Two microscopic types; trabecular & psammomatoid; age at diagnosis 11 and 22 respectively.  Maxilla often with impingement on sinuses, orbit, nose and cranium.
  57. 57.  Treatment of choice is dependent on the site of tumour location  Tumours invading the midfacial portion and the sinonasal tract:  more aggressive behavior  need surgical resection  surgical treatment :  requires radical resection/when possible a total removal of the tumour:  high rate of relapses  aggressive behavior of recurring tumors :with local destruction and potential invasion of adjacent vital structures
  58. 58.  Since OF is very rare, larger series on pure endonasal resection are not reported  In case reports, some authors have achieved tumour resection via an endoscopic approach  Draf et al. (480) reported on endonasal microendoscopic resection of four OF without any complications  OF with a large extension, most authors recommend a combined approach including craniofacial resection
  59. 59.  Introduction: Sinonasal osteomas are common entity seen in patients. Rhinosinus osteomas are commonly asymptomatic and are incidental findings on imaging studies.  History: Viega was the first to document sinus osteoma in 1506. In 1733, Vallisnieri described frontal sinus osteoma that protruded into the brain.  Epidemiology: Ostomas are the most common benign tumors of paranasal sinuses. This condition is more common in males. It is common in patients between their second and third decades of life.
  60. 60.  Three accepted theories of etiology of osteomas are: 1. Developmental 2. Traumatic 3. Infectious  Developmental :  Adult tissue contains embryonic remnants usually remaining dormant  Could be the reason for occurrence near frontoethmoidal suture lines
  61. 61.  Traumatic :  Inflammatory process as the initiating force  Bony trauma could be the root cause  Could account for male preponderance  Infectious :  This theory suggests that ostietis resulting from chronic infections could lead to osteoma formation in paranasal sinuses.
  62. 62.  possible aetio-pathogenetic role of traumatic and inflammatory factors:  Moretti A, Croce A, Leone O, D'Agostino L. Osteoma of maxillary sinus: case report. Acta Otorhinolaryngologica Italica2004;24(4):219-22  Naraghi M, Kashfi A. Endonasal endoscopic resection of ethmoido-orbital osteoma compressing the optic nerve. American Journal of Otolaryngology 2003;24(6):408-12.  Sayan NB, Ucok C, Karasu HA, Gunhan O. Peripheral osteoma of the oral and maxillofacial region: a study of 35 new cases. Journal of Oral & Maxillofacial Surgery 2002;60(11):1299-301.
  63. 63.  Fu and Perzin classification:  1. Ivory / compact osteoma:  Otherwise also known as eburnated osteoma.  In this type of osteoma the bone is very dense and lacks haversian canals.  These osteomas develop from membranous elements.  2. Osteoma spongiosum:  Also known as mature osteoma is composed of softer bone.  This type of osteomas are known to arise from cartilaginous elements.  These osteomas have little medullary component containing fibrofatty tissue.  3.Mixed
  64. 64.  Behavior: Osteomas are very slow growing and are mostly asymptomatic. They always stay benign and don't recur after excision.  The growth rate of osteomas of the paranasal sinuses Koivunen P et.al. Clin. Otolaryng Allied Sci 1997Apr;22(2):111-4  mean growth rate: 1.61mm/yr range 0.44 to 6.0 mm/yr  Common sites:  95% osteomas in the sinonasal region arise from the frontoethmoidal region.  80% of osteomas in the sinus region arise from the floor of frontal sinus
  65. 65.  Plain sinus radiographs are adequate for detecting osteomas of paranasal sinuses.
  66. 66.  most commonly localized to the frontal  sinus  „ slow growing and well circumscribed  „ symptoms attributable obstruction of the  drainage pathway of nearby sinuses  „ On endoscopy : firm masses with a smooth mucosal covering
  67. 67.  Wait ,watch n scan  Surgery:  Indications:  Rapid growth of tumor  Symptomatic patients with chronic rhinosinusitis due to tumor obstruction  Massive headache  Facial deformity  Smith & Calcaterra et al: Surgery if tumor occupies more than 50% of frontal sinus  Approaches :  Endonasal  External  Combined approach
  68. 68.  Frontoethmoidal and intraorbital osteomas: exploring the limits of the endoscopic approach (Turri-Zannoni et. al Arch. Otolar Head Neck Surg.2012 May)  Conclusion: The size of the osteoma, far lateral extension of the tumor in the frontal sinus beyond the lamina papyracea, and intraorbital involvement are no longer absolute contraindications for purely transnasal endoscopic resection. What is important is that the surgeon should not be dogmatic but rather be ready to change his or her mind during surgery, shifting to an external approach when required.
  69. 69.  Exceptions:  scarring of the frontal recess  Distortion from previous surgery,  very advanced disease and associated malignancy
  70. 70. Displaced/Ectopic tumors
  71. 71.  made of neuroglial elements consisting of  glial cells in a connective tissue matrix  with or without a fibrous connection to the dura  „ no fluid filled space connected to the  subarachnoid space
  72. 72.  „ present as a red or bluish lump at or along the  nasomaxillary suture, or as an intranasal mass.  „ firm, noncompressible  „ not increase in size with crying, and do not  transilluminate  „ not enlarge with bilateral compression of the internal jugular veins (Furstenberg test)  „ associated with a widened nose or with  hypertelorism secondary to growth of the mass
  73. 73.  arise from the lateral wall of the nose or less  often from the nasal septum.  „ 60%extranasal  „ 30% intranasal  „ 10% are both  „ 15% are connected to the dura  „ intranasal type associated with dural  attachment (35%) > extranasal type (9%).
  74. 74.  development similar to nasal dermoids.  „ Abnormal closure of the fonticulus  Develop from extracranial rests of glial tissue  Abnormal closure of fonticulus nasofrontalis, possibly encephaloceles which have lost CSF connection  tissue being left extracranially.  „ not always an intracranial connection to a glioma
  75. 75.  Bluish, soft, compressible, transilluminate, pulsatile  Enlarge with crying  Positive Furstenberg test (bilateral compression of internal jugular veins)  Originate medially in the nose  May have associated CSF leak
  76. 76.  4% are found within the paranasal sinuses  Schwannoma  Neurofibroma  Treatment via surgical resection  When associated with Von Recklinghausen’s syndrome: more aggressive (30% 5yr survival).
  77. 77.  Shrinivas SC, Deshmukh S, Pawar V, et al. Case Study of Clinicopathological correlation of benign sinonasal masses. World Articles in Ear, Nose and Throat 2012;5(1) :showed nasal schwannoma accounting for 2.4% of benign nasal masses  Vaideeswar P et al : schwannoma formed 2.5% (three cases) of all Sinonasal tumors
  78. 78.  slowly growing mass  arise more frequently from the ophthalmic and maxillary divisions of the trigeminal nerves  also originate from sympathetic fibers of the carotid plexus or parasympathetic fibers of the pterygopalatine ganglion  Symptoms depend on the location :  progressive nasal obstruction ± epistaxis  anosmia / hyposmia  headache  facial swelling and proptosis
  79. 79.  Macroscopically:  well-delineated but nonencapsulated globular  firm to rubbery yellow-tan mass  Histologically:  cellular Antoni A areas with Verocay bodies  hypocellular myxoid Antoni B areas  Immunocytohistochemistry:  strongly and diffusely immunoreactive for S-100 protein
  80. 80.  Mey KH et al in a case series of five nasal schwannoma  Buob et al in a series of nasal schwannoma cases  Unlike other areas nasal schwannoma is usually not encapsulated  According to these authors this peculiarity could be explained by the development of these tumours from Sinonasal mucosal autonomic nervous system fibres  which are devoid of perineural cells similar to the case of gastric Schwannoma
  81. 81.  Immunohistochemistry :  Positive stains: S100  Negative stains: EMA, CD34, Ki-67/MIB1 (1- 5%)  Treatment: radical surgical resection; no recurrence or metastases
  82. 82.  Rare, frequently misclassified  Mean age 48 years, range 13-88 years; no gender preference  Usually primary intranasal or paranasal mass; may also be an intracranial tumor invading sphenoid or frontal sinuses  Primary extracranial tumors have a good prognosis; intracranial lesions invading into upper respiratory tract are difficult to excise  Positive stains: EMA, vimentin  Negative stains: S100 (usually)
  83. 83.  JNA  Hemangioma
  84. 84.  The term hemangioma has traditionally been used to describe a variety of developmental vascular anomalies.  Currently, hemangiomas are considered to be benign tumors of infancy that are characterized by a rapid growth phase with endothelial cell proliferation, followed by a gradual involution. Most cannot be recognized at birth but make their appearance in most instances during the first 8 weeks of life.  Vascular malformations are structural anomalies of blood vessels without endothelial proliferation and are present at birth and persist throughout life.
  85. 85.  These lesions are present from birth and persist throughout life.  As with hemangiomas, these lesions tend to darken with age.  Low-flow venous malformations typically have a blue color and are easily compressible.  Arteriovenous malformations are high-flow lesions that result from persistent direct arterial and venous communications. A palpable thrill or bruit is often noticeable and the overlying skin typically feels warmer to the touch.
  86. 86.  Hemangiomas are the most common tumors of infancy.  They have a female gender predilection (3:1) and are most common in the White population.  60% of the hemangiomas occur in the head and neck region with 80% of them occurring as single lesions. Multiple lesions may be part of a syndrome.  About 50 % of all hemangiomas will show complete resolution by 5 years of age.
  87. 87.  Types : depending on size of vessels  Capillary  Cavernous  Mixed  Multifocal angiomatosis: when multiple or affecting a large segment of the body
  88. 88.  frequently occur in the head and neck region,  • uncommon in the nasal cavity and paranasal sinuses,  • cavernous and capillary types have been reported in the sinonasal region,  • represent less than 20% of all benign nasal cavity tumors,  • 80% arise from the nasal septum (Kiesselbach area), 15% arise from the lateral wall of the nasal cavity.  • originate from the soft tissues of the nasal cavity  • also occur in bones of the inferior or middle turbinate (> 1% bone tumors).  • cavernous hemangiomas usually do not present until adulthood (adults)  • in both sex with equal frequency,  • incidence peaks in the 4th decade of life.
  89. 89.  Trauma, viral oncogenes, inflammatory conditions and the production of  angiogenic growth factors may play a role in the development  hyperplastic, neovascular response to an angiogenic stimulus with imbalance of promoters and inhibitors  The occurrence and growth of these lesions during pregnancy may be  related to increased blood volume or hormonal influences.  Cavernous hemangioma in adults not undergo spontaneous involution  such as head and neck hemangioma in the paediatric population
  90. 90.  Clinical presentation and symptoms: • epistaxis and/or hemoptysis • enlarging lesion in the nasal cavity  Macroscopy: Red-blue, soft, spongy mass or nodule
  91. 91.  Differential Diagnosis  • Antrochoanal polyp  •Inverted papilloma  • Hemangiopericytoma  • Esthesioneuroblastoma  Treatment and prognosis:  • surgical resection via transnasal endoscopic approach,  • for extensive lesions: preoperative selective embolization,  • radiation therapy: for unresectable or inaccessible lesions,  • no recurrences after surgical removal have been reported.
  92. 92.  misnamed; they are neither infectious nor granulomatous  usually occurs in children and young adults  solitary, glistening red papule or nodule that is prone to bleeding and ulceration
  93. 93.  precise mechanism for the development of pyogenic granuloma is unknown  Postulated: Trauma, hormonal influences, viral oncogenes, underlying microscopic arteriovenous malformations, the production of angiogenic growth factors, and cytogenetic  Trauma: Nose picking, nasal packing, cauterization, shaving/hair removal, and nonspecific microtrauma  Isolated cases: Sturge-Weber or von Hippel- Lindau syndrome
  94. 94.  Curettage  Cryotherapy  Excision: with preop ± embolization  EES  LASER  Sclerotherapy
  95. 95.  Cumming’s 5th edition  Scott-Brown’s 7th edition  Rhinology journal(Official Journal of the International and European Rhinologic Societies)  European Position Paper on Endoscopic Management of Tumours of the Nose, Paranasal Sinuses and Skull Base(Professor Stammberger, Professor Lund)  Pubmed  medscap
  96. 96. Any Questions ?

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