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  • 1. DISEASES OF THE NOSE AND PARANASAL SINUSES RYAN DUNCAN, MD PGY-4 RESIDENT OTOLARYNGOLOGY-HEAD AND NECK SURGERY February 6, 2006
  • 2. NASAL ANATOMY
  • 3. NASAL ANATOMY
  • 4. NASAL ANATOMY
  • 5. Ethmoid Maxilla Palatine Lacrimal Pterygoid plate of Sphenoid Nasal Inferior Turbinate Bony Structure
  • 6.  
  • 7. 7 bones 4 paired sinuses 4 turbinates 3 meati Drainage system Nervous supply Vascular supply Related structures Sinus Anatomy Overview
  • 8. Arterial Supply External Carotid Maxillary A. Sphenopalatine Internal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear
  • 9.  
  • 10. Innervation
  • 11. VIRAL RHINITIS
    • Inflammation and swelling of the mucous membranes of the nose usually caused by rhinovirus (common cold)
    • Symptoms consist of runny nose, congestion, post-nasal drip, cough, and a low-grade fever
    • Diagnosis made by history; adjunct tests usually not necessary
  • 12. VIRAL RHINITIS
    • Complications may prolong illness
    • often triggers asthma attacks
    • Secondary infections: congestion in nose/ear blocks normal drainage allowing bacteria to grow  sinusitis, otitis media
  • 13. VIRAL RHINITIS-TREATMENT
    • No vaccines available
    • Echinacea, Vit C, Zinc effectiveness not confirmed
    • Currently available antiviral drugs not effective
    • Symptomatic treatment with antihistamines, decongestants, cough preparations
  • 14. Function of Paranasal Sinuses
    • Humidifying and warming inspired air
    • Regulation of intranasal pressure
    • Increasing surface area for olfaction
    • Lightening the skull
    • Resonance
    • Absorbing shock
    • Contribute to facial growth
    • generate 1 L mucus/day
  • 15. Rhinosinusitis
    • Introduction
    • 37 million Americans suffer from “sinusitis”
    • 25 million office visits in 1994-incidence increasing
    • Over $200 million spent on prescriptions for cold products; over half is for products containing antihistamines
    • 97 % of patients who see a physician with “cold symptoms” receive a prescription
  • 16. Rhinosinusitis
    • Defining “Sinusitis”
    • Acute rhinosinusitis (ARS)
    • Subacute rhinosinusitis (SARS)
    • Chronic rhinosinusitis (CRS)
    • Recurrent acute rhinosinusitis (RARS)
    • Acute superimposed upon chronic rhinosinusitis (ARS/CRS)
  • 17. Rhinosinusitis
    • Major Symptoms
    • Facial pain/pressure
    • Facial congestion
    • Nasal obstruction
    • Purulent PND
    • Altered sense of smell
    • Fever (ARS)
    • Minor Symptoms
    • Headache
    • Fever (all non-acute)
    • Halitosis
    • Fatigue
    • Dental pain
    • Cough
    • Ear pain/pressure
  • 18. Rhinosinusitis
    • Acute Rhinosinusitis
    • Duration < 4 weeks
    • > 2 major or 1 major and 2 minor factors or purulence seen on examination
    • Subacute Rhinosinusitis
    • Duration-4-12 weeks
  • 19. Middle turbinate MSO Septum
  • 20. Rhinosinusitis
    • Chronic Rhinosinusitis
    • Duration- > 12 weeks
    • Recurrent Acute Rhinosinusitis
    • > 4 episodes/yr. of ARS with symptoms lasting > 7 days with no intervening signs and symptoms of CRS
    • Acute Exacerbation of Chronic Rhinosinusitis
    • Sudden worsening of CRS
  • 21. Septum MT remnant MSO CRS -”Empty nose”-Pseudomonas, Staph. aureus
  • 22. Rhinosinusitis
    • Diagnosis
    • Physical examination-anterior rhinoscopy vs. nasal endoscopy
      • Edema
      • Hyperemia
      • Purulence
      • Polyps
  • 23. Rhinosinusitis
    • Diagnosis
    • Plain radiography of the paranasal sinuses
    • Magnetic resonance imaging
    • Computerized tomography (non-contrast)
      • Screening CT
      • Standard CT
      • Timing of CT
    • Other tests
  • 24. Rhinosinusitis
    • Management
    • Goals
      • Elimination of infection
      • Restoration of ventilation and drainage
  • 25. Rhinosinusitis
    • Surgical Management
    • Prior to 1985, most surgery via external approach with emphasis on maximum tissue removal
    • With introduction of functional endoscopic sinus surgery (FESS) in 1985, emphasis is on maximum tissue preservation
  • 26. Rhinosinusitis
    • Surgical Management
    • ARS-no role for surgery except for management of complications
    • CRS-indicated for medically refractory disease; 80-98 % improvement, revision rate < 10 %, major complications <0.3 %
    • RARS-focused surgery often helpful
  • 27. Techniques of Functional Endoscopic Sinus Surgery Uncinectomy LNW MT MT LNW
  • 28. Techniques of Functional Endoscopic Sinus Surgery 0 degree telescope 45 degree telescope Maxillary Antrostomy MSO Accessory ostium
  • 29. Rhinosinusitis
    • Surgical Management
    • Computer assisted surgery (CAS) of the anterior skull base and paranasal sinuses has been commercially available since 1996
    • CAS has allowed us to safely expand minimally invasive endoscopic transnasal techniques
  • 30.  
  • 31. Rhinosinusitis
    • Conclusion
    • “Sinusitis” is a complicated disease
    • Defining categories is beneficial
    • Management options are varied
    • Surgical therapy plays a role for a well-defined, small population of patients
  • 32. EPISTAXIS (nosebleeds)
  • 33. Why bleeding from the nose ?
    • Vascular organ secondary to incredible heating/humidification requirements
    • Vasculature runs just under mucosa (not squamous)
    • Arterial to venous anastamoses
    • ICA and ECA blood flow
  • 34. EPISTAXIS
    • External Carotid Artery
    • -Sphenopalatine artery
    • -Greater palatine artery
    • -Ascending pharyngeal artery
    • -Posterior nasal artery
    • -Superior Labial artery
    • Internal Carotid Artery
    • -Anterior Ethmoid artery
    • -Posterior Ethmoid artery
  • 35. Kesselbach’s Plexus/Little’s Area: -Anterior Ethmoid (Opth) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX ) Woodruff’s Plexus: -Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)
  • 36.  
  • 37. Anterior vs. Posterior
    • Maxillary sinus ostium
    • Anterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severe
    • Posterior: older population, usually from Woodruff’s plexus, more serious.
  • 38. Etiology
    • Local factors
      • Vascular
      • Infectious/Inflammatory
      • Trauma (most common)
      • Iatrogenic
      • Neoplasm
      • Dessication
      • Foreign Bodies/other
  • 39. Etiology
    • Systemic factors
      • Vascular
      • Infection/Inflammation
      • Coagulopathy
  • 40. Local Factors -- Vascular
    • ICA Aneurysms
      • extradural
      • cavernous sinus
  • 41. Local Factors - Infection/Inflammation
    • Rhinitis/Sinusitis
      • Allergic
      • Bacterial
      • Fungal
      • Viral
  • 42. Local Factors - Trauma
    • Nose picking
    • Nose blowing/sneezing
    • Nasal fracture
    • Nasogastric/nasotracheal intubation
    • Trauma to sinuses, orbits, middle ear, base of skull
    • Barotrauma
  • 43. Nasal Fracture with Septal Hematoma
  • 44. Local Factors - Iatrogenic nasal injury
    • Functional endoscopic sinus surgery
    • Rhinoplasty
    • Nasal reconstruction
  • 45. Local Factors - Neoplasm
    • Juvenile nasopharyngeal angiofibroma
    • Inverted papilloma
    • SCCA
    • Adenocarcinoma
    • Melanoma
    • Esthesioneuroblastoma
    • Lymphoma
  • 46.  
  • 47. Local Factors – Dessication
    • Cold, dry air—more common in wintertime
    • Dry heat—Phoenix and Death valley
    • Nasal oxygen
    • Anatomic abnormalities
    • Atrophic rhinitis
  • 48. Local Factors - Other
    • Self-inflicted (pedi) vs. traumatic foreign bodies
    • Intranasal parasites
    • Septal perforation
    • Chemical (cocaine, nasal sprays, ammonia, etc.)
  • 49. Systemic Factors -- Vascular
    • Hypertension/Arteriosclerosis
    • Hereditary Hemorrhagic Telangectasias (OWR)
  • 50. Epistaxis Osler-Weber- Rendu (HHT) R L
  • 51. Systemic Factors – Infection/Inflammation
    • Tuberculosis
    • Syphillis
    • Wegener’s Granulomatosis
    • Periarteritis nodosa
    • SLE
  • 52. Systemic Factors – Coagulopathies
    • Thrombocytopenia
    • Platelet dysfunction
      • Systemic disease (Uremia)
      • drug-induced (Coumadin/NSAIDs/Herbal supplements)
    • Clotting Factor Deficiencies
      • Hemophilia
      • VonWillebrand’s disease
      • Hepatic failure
    • Hematologic malignancies
  • 53. Etiology and Age
    • Children—foreign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o)
    • Adults—trauma, idiopathic
    • Middle age—tumors
    • Old age--hypertension
  • 54. Initial Management
    • ABC’s
    • Medical history/Medications
    • Vital signs—need IV?
    • Physical exam
      • Anterior rhinoscopy
      • Endoscopic rhinoscopy
    • Laboratory exam
    • Radiologic studies
  • 55. suction good light anesthetic silver nitrate merocels gelfoam bacitracin endoscopes suction bovie/bipolar Afrin T.C.A. surgicel epistat bayonet forcepts vaseline gauze
  • 56. Non-surgical treatments
    • Control of hypertension
    • Correction of coagulopathies/thrombocytopenia
      • FFP or whole blood/reversal of anticoagulant/platelets
    • Pressure/Expulsion of clots
    • Topical decongestants/vasocontrictors
    • Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie)
    • Nasal packing (effective 80-90% of time)
    • Greater palatine foramen block
  • 57. Non-surgical treatments – on d/c
    • Humidity/emolients
    • Discontinue offending meds
    • Nasal saline sprays
    • Avoidance of nose picking/blowing
    • Sneeze with mouth open
    • Avoid straining/bedrest
  • 58. Nasal packs
    • Anterior nasal packs
      • Traditional
      • Recent modifications
    • Posterior nasal packs
      • Traditional
      • Recent modifications
    • Ant/Post nasal packing
  • 59. TSS—Nugauze vs. Merocel Electron microscopy
  • 60. Posterior Packs – Admission
    • Elderly and those with other chronic diseases may need to be admitted to the ICU
    • Continuous cardiopulmonary monitoring
    • Antibiotics
    • Oxygen supplementation may be needed
    • Mild sedation/analgesia
    • IVF
  • 61. Indications for surgery/embolization
    • Continued bleeding despite nasal packing
    • Pt requires transfusion/admit hct of <38% (barlow)
    • Nasal anomaly precluding packing
    • Patient refusal/intolerance of packing
    • Posterior bleed vs. failed medical mgmt after >72hrs (wang vs. schaitkin)
  • 62. Selective Angiography/embolization
    • Helps identify location of bleeding
    • Embolization most effective in patients who
      • Still bleeding after surgical arterial ligation
      • Bleeding site difficult to reach surgically
      • Comorbidities prohibit general anesthetic
    • Effective only when bleeding is >.5 ml/min
    • 90+% success rate, complication rate of 0.1%
    • Only able to embolize external carotid & branches
    • Complications: minor (18-45%)/major (0-2%)
    • Contraindicated in bad atherosclerosis, Ethmoid bleed
  • 63. Surgical treatment
    • Transmaxillary IMA ligation
    • Intraoral IMA ligation
    • Anterior/Posterior Ethmoidal ligation
    • Transnasal Sphenopalatine ligation
    • External carotid artery ligation
    • Septodermoplasty/Laser ablation
  • 64. Transmaxillary IMA ligation
    • Waters view
    • Caldwell-Luc
    • Electrocautery of posterior wall before removal
    • Microscopic dissection and ligation of IMA --descending palatine & sphenopalantine most important
    • Recurrence rate (failure rate) of 10-15%
    • Complication rate of 25-30% (oa fistula,dental, n)
  • 65.  
  • 66. Intraoral IMA ligation
    • Posterior gingivobuccal incision beginning at second molar
    • Temporalis mm split and partially dissected
    • IMAX visualized, clipped and divided
    • Advantages: children/facial fractures
    • Disadvantages: more proximal ligation
    • Complications: trismus, damage to infraorbital n
  • 67. Ant./Post. Ethmoidal ligation
    • Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclear
    • Lynch incision
    • Fronto-ethmoid
    • suture line
    • 12-24-6
    • (14-18, 8-10, 4-6)
  • 68. Transnasal Endoscopic Sphenopalatine Artery ligation
    • Follow Middle Turbinate to posteriormost aspect
    • Vertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid. and inf. turbs)
    • Elevation of flap—ID neurovascular bundle at foramen
    • Ligation with titanium clip
    • Reapproximate flap
    • Complications –few, Failures—0-13%
  • 69. Transnasal Spheno-palatine Artery ligation
  • 70. ECA ligation
    • Effectiveness
    • Anterior border of SCM
    • ID ECA/ICA
    • Ligation after clear that surrounding structures are safe.
  • 71. Septodermoplasty/Laser
    • Remove mucosa from anterior ½ septum, floor of nose, lateral wall
    • STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autografts
    • Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod disease
    • Still bleed, but not as bad
    • Definitive treatment (severe disease)—closure of nose
  • 72. Statistically speaking,….
    • Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs.
    • Others compared all medical treatment to surgery and showed cost cut using medical management.
    • Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28%
    • Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equal
    • Failure rates: PP-30%, Sx-17%, Emb-4%
  • 73. Neoplasms of Nose and Paranasal Sinuses
    • Very rare 3%
    • Delay in diagnosis due to similarity to benign conditions
    • Nasal cavity
      • ½ benign
      • ½ malignant
    • Paranasal Sinuses
      • Malignant
  • 74. Neoplasm
    • Benign
      • Schneiderian papilloma
        • Squamous
        • Inverted-13 % incidence of malignant degeneration
        • Cylindrical
    • Malignant
      • Squamous cell carcinoma
      • Salivary gland tumors
      • Neuroepithelial tumors
  • 75.  
  • 76.  
  • 77. MRI demonstrating right nasal mass with no intracranial involvement Nasal mass
  • 78. Septum Nasal mass
  • 79. Angiofibroma
  • 80.  
  • 81.  
  • 82. Neoplasms of Nose and Paranasal Sinuses
    • Multimodality treatment
    • Orbital Preservation
    • Minimally invasive surgical techniques
  • 83. Epidemiology
    • Predominately of older males
    • Exposure:
      • Wood, nickel-refining processes
      • Industrial fumes, leather tanning
    • Cigarette and Alcohol consumption
      • No significant association has been shown
  • 84. Location
    • Maxillary sinus
      • 70%
    • Ethmoid sinus
      • 20%
    • Sphenoid
      • 3%
    • Frontal
      • 1%
  • 85. Presentation
    • Oral symptoms: 25-35%
      • Pain, trismus, alveolar ridge fullness, erosion
    • Nasal findings: 50%
      • Obstruction, epistaxis, rhinorrhea
    • Ocular findings: 25%
      • Epiphora, diplopia, proptosis
    • Facial signs
      • Paresthesias, asymmetry
  • 86. Radiography
    • CT
      • Bony erosion
      • Limitations with periorbita involvement
    • MRI
      • 94 -98% correlation with surgical findings
      • Inflammation/retained secretions: low T1, high T2
      • Hypercellular malignancy: low/intermediate on both
        • Enhancement with Gadolinium
  • 87. Benign Lesions
    • Polyps
    • Papillomas
    • Osteomas
    • Fibrous Dysplasia
    • Neurogenic tumors
  • 88. NASAL POLYPS
    • Benign, semitransparent lesions
    • Arise from nasal mucosa
    • Caused by chronic inflammation
    • a/w asthma, CF, aspirin intolerance, CRS, Allergic Rhinitis
  • 89. NASAL POLYPS
    • Nasal Endoscopy
    • CT/MRI
    • Medical Tx: topical/systemic steroids
    • Surgical Tx: FESS with polypectomy
  • 90. Papilloma
    • Vestibular papillomas
    • Schneiderian papillomas derived from schneiderian mucosa (squamous)
      • Fungiform: 50%, nasal septum
      • Cylindrical: 3%, lateral wall/sinuses
      • Inverted: 47%, lateral wall
  • 91. Inverted Papilloma
    • 4% of sinonasal tumors
    • Site of Origin: lateral nasal wall
    • Unilateral
    • Malignant degeneration in 2-13% (avg 10%)
  • 92. Inverted Papilloma Resection
    • 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%
  • 93. INVERTED PAPILLOMA
  • 94. Osteomas
    • Benign slow growing tumors of mature bone
    • Location:
      • Frontal, ethmoids, maxillary sinuses
    • When obstructing mucosal flow can lead to mucocele formation
    • Treatment is local excision
  • 95. Fibrous dysplasia
    • Dysplastic transformation of normal bone with collagen, fibroblasts, and osteoid material
    • Monostotic vs Polyostotic
    • Surgical excision for obstructing lesions
    • Malignant transformation to rhabdomyosarcoma has been seen with radiation
  • 96. Neurogenic tumors
    • 4% are found within the paranasal sinuses
    • Schwannomas
    • Neurofibromas
    • Treatment via surgical resection
    • Neurogenic Sarcomas are very aggressive and require surgical excision with post op chemo/XRT for residual disease.
    • When associated with Von Recklinghausen’s syndrome: more aggressive (30% 5yr survival).
  • 97. Malignant lesions
    • Squamous cell carcinoma
    • Adenoid cystic carcinoma
    • Mucoepidermoid carcinoma
    • Adenocarcinoma
    • Hemangiopericytoma
    • Melanoma
    • Olfactory neuroblastoma
    • Osteogenic sarcoma, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma
    • Lymphoma
    • Metastatic tumors
    • Sinonasal undifferentiated carcinoma
  • 98. Squamous cell carcinoma
    • Most common tumor (80%)
    • Location:
      • Maxillary sinus (70%)
      • Nasal cavity (20%)
    • 90% have local invasion by presentation
    • Lymphatic drainage:
      • First echelon: retropharyngeal nodes
      • Second echelon: subdigastric nodes
  • 99. Treatment
    • 88% present in advanced stages (T3/T4)
    • Surgical resection with postoperative radiation
      • Complex 3-D anatomy makes margins difficult
  • 100. Adenoid Cystic Carcinoma
    • 3 rd most common site is the nose/paranasal sinuses
    • Perineural spread
      • Anterograde and retrograde
    • Despite aggressive surgical resection and radiotherapy, most grow insidiously.
    • Neck metastasis is rare and usually a sign of local failure
    • Postoperative XRT is very important
  • 101. Mucoepidermoid Carcinoma
    • Extremely rare
    • Widespread local invasion makes resection difficult, therefore radiation is often indicated
  • 102. Adenocarcinoma
    • 2 nd most common malignant tumor in the maxillary and ethmoid sinuses
    • Present most often in the superior portions
      • Strong association with occupational exposures
    • High grade: solid growth pattern with poorly defined margins. 30% present with metastasis
    • Low grade: uniform and glandular with less incidence of perineural invasion/metastasis.
  • 103. Hemangiopericytoma
    • Pericytes of Zimmerman
    • Present as rubbery, pale/gray, well circumscribed lesions resembling nasal polyps
    • Treatment is surgical resection with postoperative XRT for positive margins
  • 104. Melanoma
    • 0.5- 1.5% of melanoma originates from the nasal cavity and paranasal sinus.
    • Anterior Septum: most common site
    • Treatment is wide local excision with/without postoperative radiation therapy
    • END not recommended
    • AFIP: Poor prognosis
      • 5yr: 11%
      • 20yr: 0.5%
  • 105. Olfactory Neuroblastoma Esthesioneuroblastoma
    • Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells.
    • Kadish Classification
      • A: confined to nasal cavity
      • B: involving the paranasal cavity
      • C: extending beyond these limits
  • 106. Olfactory Neuroblastoma Esthesioneuroblastoma
    • UCLA Staging system
      • T1: Tumor involving nasal cavity and/or paranasal sinus, excluding the sphenoid and superior most ethmoids
      • T2: Tumor involving the nasal cavity and/or paranasal sinus including sphenoid/cribriform plate
      • T3: Tumor extending into the orbit or anterior cranial fossa
      • T4: Tumor involving the brain
  • 107. Olfactory Neuroblastoma Esthesioneuroblastoma
    • Aggressive behavior
    • Local failure: 50-75%
    • Metastatic disease develops in 20-30%
    • Treatment:
      • En bloc surgical resection with postoperative XRT
  • 108. Sarcomas
    • Osteogenic Sarcoma
      • Most common primary malignancy of bone.
      • Mandible > Maxilla
      • Sunray radiographic appearance
    • Fibrosarcoma
    • Chondrosarcoma
  • 109. Rhabdomyosarcoma
    • Most common paranasal sinus malignancy in children
    • Non-orbital, parameningeal
    • Triple therapy is often necessary
    • Aggressive chemo/XRT has improved survival from 51% to 81% in patients with cranial nerve deficits/skull/intracranial involvement.
    • Adults, Surgical resection with postoperative XRT for positive margins.
  • 110. Lymphoma
    • Non-Hodgkins type
    • Treatment is by radiation, with or without chemotherapy
    • Survival drops to 10% for recurrent lesions
  • 111. Sinonasal Undifferentiated Carcinoma (SNUC)
    • Aggressive locally destructive lesion
    • Dependent on pathological differentiation from melanoma, lymphoma, and olfactory neuroblastoma
    • Preoperative chemotherapy and radiation may offer improved survival
  • 112. Metastatic Tumors
    • Renal cell carcinoma is the most common
    • Palliative treatment only
  • 113. Staging of Maxillary Sinus Tumors
  • 114. Staging of Maxillary Sinus Tumors
    • T1: limited to antral mucosa without bony erosion
    • T2: erosion or destruction of the infrastructure, including the hard palate and/or middle meatus
    • T3: Tumor invades: skin of cheek, posterior wall of sinus, inferior or medial wall of orbit, anterior ethmoid sinus
    • T4: tumor invades orbital contents and/or: cribriform plate, post ethmoids or sphenoid, nasopharynx, soft palate, pterygopalatine or infratemporal fossa or base of skull
  • 115. Surgery
    • Unresectable tumors:
      • Superior extension: frontal lobes
      • Lateral extension: cavernous sinus
      • Posterior extension: prevertebral fascia
      • Bilateral optic nerve involvement
  • 116. Surgery
    • Surgical approaches:
      • Endoscopic
      • Lateral rhinotomy
      • Transoral/transpalatal
      • Midfacial degloving
      • Weber-Fergusson
      • Combined craniofacial approach
    • Extent of resection
      • Medial maxillectomy
      • Inferior maxillectomy
      • Total maxillectomy
  • 117. MIDFACIAL DEGLOVING
  • 118. LATERAL RHINOTOMY
  • 119. CRANIOFACIAL APPROACH
  • 120. Treatment of the Orbit
    • Before 1970’s orbital exenteration was included in the radical resection
    • Preoperative radiation reduced tumor load and allowed for orbital preservation with clear surgical margins
    • Currently, the debate is centered on what “degree” of orbital invasion is allowed.
  • 121. Current indications for orbital exenteration
    • Involvement of the orbital apex
    • Involvement of the extraocular muscles
    • Involvement of the bulbar conjunctiva or sclera
    • Lid involvement beyond a reasonable hope for reconstruction
    • Non-resectable full thickness invasion through the periorbita into the retrobulbar fat
  • 122. Conclusions
    • Neoplasms of the nose and paranasal sinus are very rare and require a high index of suspicion for diagnosis
    • Most lesions present in advanced states and require multimodality therapy
  • 123. REFERENCES
    • www.utmb.edu/oto
    • http://www.emedicine.com/PED/topic1550.htm
    • http://www.merck.com/mmhe/sec19/ch221/ch221g.html

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