This document provides an outline on sinonasal tumours. It discusses the relevant anatomy, epidemiology, classification, clinical features, investigations, staging, treatment and complications of sinonasal tumours. It notes that sinonasal tumours comprise a diverse group of benign and malignant neoplasms that often present non-specifically, leading to delays in diagnosis and management. The document outlines the different tumour types, their characteristics, staging systems used and multidisciplinary treatment approaches involving surgery, radiotherapy and chemotherapy. Early detection and management is emphasized for improving patient outcomes.

1. DEPARTMENT OF ENT, HEAD & NECK
SURGERY. JUTH
SINONASAL TUMOURS
OKOYE
11/12/20

2. OUTLINE
• INTRODUCTION
– STATEMENT OF IMPORTANCE
• RELEVANT ANATOMY
• EPIDEMIOLOGY
• AETIOLOGY
• CLINICAL FEATURES
• INVESTIGATIONS
• CLASSIFICATION
• STAGING
• TREATMENT
• COMPLICATIONS
• PROGNOSIS
• PREVENTION
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• Tumours of the sinonasal region comprise a
diverse group of BENIGN and MALIGNANT
neoplasms.
• The malignant type often masquerade as
chronic inflammatory conditions, thus they
may progress unrecognized and untreated.
.

4. STATEMENT OF IMPORTANCE
• The naturally hidden location of sinonasal
tumours at the early disease stages and its
nonspecific presentation contribute to delay in
management and thus morbidity and
mortality

5. RELEVANT ANATOMY

6. RELEVANT ANATOMY

7. RELEVANT ANATOMY

8. RELEVANT ANATOMY

9. RELEVANT ANATOMY
• Lymphatic drainage

10. SITES OF SINONASAL TUMORS
• Maxillary antrum- 60%
• Nasal cavity- 30%
• Ethmoid- 10%
• Sphenoid & frontal- rare.

11. EPIDEMIOLOGY
• It is a rare disease worldwide
• Account for less than 1% of all neoplasms
• The malignant type account for 3% of upper
aerodigestive tract neoplasms.
• Age- all age groups, Benign ones commonly
seen in children and the malignant types in
adults (4th to 7th decades of life).
• Sex- more in males than females (2:1 to 5:1)

12. AETIOLOGY/PREDISPOSING FACTORS
The exact cause is not known
• Wood dust exposure (hard & soft)
• Exposure to nickel, chrome, polycyclic
hydrocarbons, aflatoxin
• Ionizing radiation
• Tobacco
• Virus- HPV, EBV

13. CLASSIFICATION
• BENIGN
• MALIGNANT

14. BENIGN
• EPITHELIAL
– PAPILLOMAS (SQUAMOUS, INVERTED, FUNGIFORM)
– ADENOMAS (PLEOMORPHIC)
• NON-EPITHELIAL
– OSTEOMAS
– FIBROMAS
– CHONDROMAS
– HEMANGIOMAS
– NERVE SHEATH TUMOURS

15. MALIGNANT
• EPITHELIAL
– SQUAMOUS CELL CARCINOMAS
– ADENOCARCINOMAS
– ADENOID CYSTIC CARCINOMAS
– MELANOMAS
– ESTHESIONEUROBLASTOMAS
– MUCOEPIDERMOID CARCINOMAS
– TERATOMAS

16. MALIGNANT
• NON-EPITHELIAL
– RHABDOMYOSARCOMAS
– NEUROGENIC SARCOMAS
– FIBROSARCOMAS
– ANGIOSARCOMAS
– OSTEOGENIC SARCOMAS
– CHONDROSARCOMAS
– LYMPHOMAS

17. OSTEOMAS
• Is a form of mature lamellar bone tumour
• The most common site is frontal sinus, then
ethmoid and maxillary
• Types- Compact and Cancellous
• Age- 15-40yrs of age.
• Usually asymptomatic, but can obstruct ostium
• Treatment- Surgical excision, via Lynch-Howarth
or osteoplastic flap approach

18. OSTEOMAS

19. FIBROUS DYSPLASIA
• Slow growing benign tumour where medullary
bone is replaced by fibro-osseous tissue.
• Types- Monostotic and Polyostotic
• Commonly seen within the maxilla
• Usually asymptomatic
• Treatment- sculpturing excision

21. INVERTED PAPILLOMA
• A.K.A- Ringert’s tumour, Transitional cell,
Schneiderian cell papilloma.
• The squamous epithelium surrounding a
fibrovascular stroma with an endophytic growth.
• > males, 40- 70yrs of age
• Seen on lateral nasal wall, aggressive behaviour
• 5-15% chances of malignant transformation
• Treatment- Surgical excision via ESS or Lateral
Rhinotomy.

22. INVERTED PAPILLOMA

23. INVERTED PAPILLOMA

24. MALIGNANT SINONASAL TUMOURS
• The malignant epithelial tumours constitute
majority of sinonasal neoplasms
• SQUAMOUS CELL CARCINOMA (SCC) is the
most common, >80%.
• In the maxillary sinus, about 60%. Nasal cavity
-20-30%, Ethmoid,10-20%. 1% in the frontal
and sphenoid sinuses.
• Varying degrees of differentiation.

25. SQUAMOUS CELL CARCINOMA
• Is the most common malignant tumour in the
sinonasal tract
• Mostly found in Caucasians
• In their 5th and 6th decade
• It most commonly arises from the lateral nasal
wall followed by the nasal septum
• Its prognosis is related to extent and location

26. ADENOCARCINOMAS
• Representing 5-19% of sinonasal tumours,
• Common sites- upper nasal cavity and
ethmoid.
• Occupation- furniture making (wood dust),
leather work
• Classification- High and Low grade
• Treatment- Aggressive en bloc surgical
excision

27. ADENOID CYSTIC CARCINOMAS
Groups of small cells arranged in one of several
patterns-
• Tubular, Cribriform, Solid (low to high grade)
• Usually seen in maxillary antrum
• They all have predilection for perineural
invasion

28. MUCOEPIDERMOID CARCINOMA
• Extremely rare form of glandular carcinoma
• Composed of squamous cells and glandular,
mucus-producing basal cells.
• They have high propensity for distant
metastases

29. MALIGNANT MELANOMA
• Account for about 3% of all sinonasal tumours
• More in women than men
• Affect elderly
• Sites- nasal cavity and septum
• May or may not be pigmented
• Metastasizes less frequent than melanoma
elsewhere, but more often to the lungs and
brain

30. OLFACTORY NEUROBLASTOMA
• Arises from basal cell within the olfactory
neuroepithelium
• Age- bimodal
• More common in women
• Very vascular and bleeds profusely on biopsy
• Moderately radiosensitive

31. CLINICAL FEATURES
• The early symptoms are usually non specific-
nasal discharge, obstruction.
• Late symptoms will depends on the wall of the
sinus involved and the extent of involvement.
• The typical delay in diagnosis is commonly
cited as 8 months or more.

32. CLINICAL FEATURES
FACIAL
• Swelling of the cheek
• Pain
• Paresthesia
• Nasal deformity
• Skin ulceration

33. CLINICAL FEATURES

34. CLINICAL FEATURES
NASAL
• Nasal obstruction
• Nasal discharge
• Epistaxis
• Hyposmia
• Nasal deformity

35. SINONASAL TUMOURS

36. CLINICAL FEATURES
ORBITAL
• Swollen eyelid
• Proptosis
• Epiphora
• Diplopia
• Chemosis
• Visual loss
• Ophthalmoplegia

37. CLINICAL FEATURES
ORAL
• Trismus
• Poor oro-dental hygiene
• Palatal swelling
• Loosening of the tooth
• Ill-fitting denture
• Tenderness

38. CLINICAL FEATURES
NECK
• Lymph node
enlargement
NEUROLOGICAL
• Multiple cranial nerve
palsy
OTOLOGIC
• Aural fullness/blockage
• Referred otalgia

39. INVESTIGATIONS
SPECIFIC
• CT SCAN
• MRI
• ANGIOGRAPHY
• EUA / BIOPSY
GENERAL
• FBC, ESR
• U/E/Cr, FBS
• RVS
• Metastatic Work up

40. STAGING

41. STAGING

42. TNM- MAXILLARY TUMOUR
• Tx- Primary tumour cannot be assessed
• T0- No evidence of primary tumour
• Tis- Carcinoma in situ
• T1- Tumour limited to maxillary sinus mucosa
with no bony erosion or destruction.
• T2- Tumour causing bone erosion or destruction
including extension to the hard palate and/or the
middle nasal meatus, except extension to the
posterior maxillary wall and pterygoid plates

43. TNM- MAXILLARY TUMOUR
• T3- Tumour invades any of the following: Bone
of the posterior wall of the maxillary sinus,
subcutaneous tissue, medial wall or the floor
of the orbit, Pterygoid fossa and/or ethmoidal
sinuses.
• T4a- Tumour involving anterior orbital
contents, skin of the cheek, Pterygoid plates,
infratemporal fossa, cribriform plate, sphenoid
or frontal sinus

44. TNM- MAXILLARY TUMOUR
• T4b-Tumour invades any of the following:
Orbital apex, dura, brain, middle cranial fossa,
and/or cranial nerves other than V2,
nasopharynx or clivus.

45. TNM- NASAL CAVITY & ETHMOID
• Tx- Primary tumour cannot be assessed
• T0- No evidenced of primary tumour
• Tis- Carcinoma in situ
• T1- Tumour restricted to any one subsite of nasal
cavity or ethmoid sinus, +/_ bony invasion.
• T2- Tumour invading two subsites in a single
region or extending to involve an adjacent region
within the nasoethmoidal complex, +/_ bony
invasion.

46. TNM- NASAL CAVITY & ETHMOID
• T3- Tumour extend to invade the medial wall
or the floor of the orbit, maxillary sinus,
cribriform
• T4a-Tumour involving/invades any of the
following: anterior orbital contents, skin of the
nose or cheek, minimal extension to anterior
cranial fossa or pterygoid plates.

47. TNM- NASAL CAVITY & ETHMOID
• T4b- Tumour invades any of the following:
orbital apex, dura, brain, middle cranial fossa,
cranial nerves other than V2, nasopharynx or
clivus.

48. REGIONAL LYMPH NODE
• Nx- Regional nodes cannot be assessed
• N0- No regional lymph node metastasis
• N1- Metastasis in a single ipsilateral node, 3cm or
less
• N2a- Single ipsilateral node, >3cm but <6cm
• N2b- multiple ipsilateral nodes, none is >6cm
• N2c- Bilateral or contralateral nodes, none >6cm
• N3- Lymph node, >6cm

49. DISTANT METASTASIS (M)
• Mx- Distant metastasis cannot be assessed
• M0- No distant metastasis
• M1- Distant metastasis

50. • MULTIDISCIPLINARY- ENT Surgeon,
Orthodontist, Ophthalmologist, Speech
therapist, Radio-oncologist, Nutritionist
• MULTIMODAL-
– Surgery
– Radiotherapy
– Chemotherapy
TREATMENT

51. SURGERY
• ENDOSCOPIC APPROACH
• OPEN
– LATERAL RHINOTOMY
– MIDFACIAL DEGLOVING
– WEBER-FERGUSON
– CRANIOTOMY
• COMBINED

52. RADIOTHERAPY
• Either pre or post-operative
• About 65 Gy over 5weeks

53. CHEMOTHERAPY
• No definitive evidence that it improves
survival
• Platinum-based are effective against olfactory
neuroblastoma

54. COMPLICATIONS
• SURGERY
• RADIOTHERAPY
• CHEMOTHERAPY

55. PROGNOSIS
• 5-yr survival- 30- 70%
• Depends on the stage

56. REHABILITATION
Principles-
• Primary wound healing
• Preservation or reconstruction of the facial
contour
• Restoration of oronasal separation
• Separation of the nasal cavity from the cranial
cavity
• Prosthesis

57. FUTURE
• The role of endoscopic sinus surgery for the
resection of malignant tumours of the nasal
cavity and paranasal sinuses will continue to
evolve and the results closely scrutinized.
• The use of IMRT will continue to gain
acceptance and probably will be the standard
mode of radiation treatment given for all head
and neck patients in the future.

58. CONCLUSION
• Early presentation, high index of suspicion and
institution of management in these patients
will go a long way in improving their
treatment and quality of life

59. THANK YOU

60. REFERENCES
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Tumors and Tumor-Like Entities from the Fourth Edition of the World Health
Organization Classification of Head and Neck Tumors. AJNR Am J Neuroradiol.
2019 Apr. 40 (4):584-90.
• Caplan LS, Hall I, Levine RS, Zhu K. Preventable risk factors for nasal cancer. Ann
Epidemiol. 2000. 10:186-91.
• Weymuller EA, Gal TJ. Neoplasms of the nasal cavity. Cummings CW, Flint PW,
Harker LA et al. eds. Otolaryngology - Head and Neck surgery. 4th. Mosby; 2005.
• Gerth DJ, Tashiro J, Thaller SR. Pediatric sinonasal tumors in the United States:
incidence and outcomes. J Surg Res. 2014 Jul. 190 (1):214-20.
• d'Errico A, Pasian S, Baratti A, et al. A case-controlled study on occupational risk
factors for sino-nasal cancer. Occup Environ Med. 2009. 66:448-55.
• Benninger MS. The impact of cigarette smoking and environmental tobacco smoke
on nasal and sinus disease: a review of the literature. Am J Rhinol. 1999 Nov-Dec.
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