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Neoplasms of nose and pns
- 1. Neoplasms of Nose and PNS Dr. Krishna Koirala 2019-12-30
- 2. Classification • Benign –Everted papilloma –Osteoma –Chondroma –Ossifying Fibroma –Hemangioma • Intermediate – Inverted papilloma – Hemangiopericytoma – Oncocytoma • Malignant − Squamous cell carcinoma − Basal cell carcinoma − Adenocarcinoma − Sarcomas − Undifferentiated carcinoma − Malignant melanoma − Minor salivary gland tumors
- 3. Osteoma • Common incidental finding in sinus x-rays • Most common in frontal sinus • Mostly asymptomatic and do not grow • Surgery required for symptomatic osteomas or those that rapidly increase in size • Complete removal of tumor with its base - done by bicoronal osteoplastic flap technique
- 7. Tumor removal and closure of bone flap
- 8. Ossifying fibroma (Fibrous dysplasia) • Normal medullary bone replaced by abnormal proliferation of fibrous tissue, resulting in distortion and expansion of bone • C.T. scan : ground - glass appearance with regions of osteolysis and calcification • Treatment : complete surgical excision • Recurrence common
- 10. Inverted papilloma • Locally aggressive intermediate sino- nasal tumour • Synonyms: Ringertz tumor, Schneiderian papilloma , Cylindrical cell papilloma • Common in males between 50-70 years • Arises from the lateral wall of nose • Presents as unilateral, friable, leaf like fleshy mass arising from middle meatus • Diagnosis : tissue biopsy
- 11. C.T. scan Nose and P.N.S. Contrast coronal cuts • Intra-nasal and maxillary mass with opacification of maxillary and ethmoid sinuses • Bone destruction of lateral nasal wall
- 12. H.P.E. : Inward invasion of hyperplastic epithelium into underlying stroma
- 13. • Treatment: − Medial maxillectomy and en bloc ethmoidectomy by lateral rhinotomy or midfacial degloving approach is the standard • Squamous cell ca present in 10 -15% cases • Radiotherapy is avoided • Marked tendency to recur after surgical removal − 80% after intrananasal removal − 60% after Caldwell –Luc surgery − 30% after medial maxillectomy
- 15. Osteotomy cuts
- 16. Bone removal and & tumor exposure
- 17. Tumour removed and incision closed
- 19. Malignant tumors
- 20. Epidemiology • O.5% of all body cancers • 15% of all Head and Neck malignancies • Maxillary sinus is the most common • Squamous cell carcinoma : 80-85% • Adenocarcinoma common in ethmoid • Male : female = 2:1 • Common age group : 45-60 years
- 21. Risk factors • Hardwood dust (adenocarcinoma) • Softwood dust (squamous cell carcinoma) • Nickel refining; chromium workers • Boot, shoe and textile workers • Mustard gas exposure • Human papilloma virus ??
- 23. Early Clinical features • Mimics maxillary sinusitis − Nasal stuffiness − Blood-stained nasal discharge − Facial paraesthesia or pain − Epiphora
- 24. Spread
- 25. Late clinical features • Medial spread − Unilateral nasal obstruction − Unilateral purulent nasal discharge − Epistaxis − Unilateral, friable, nasal mass • Anterior spread − Cheek swelling − Invasion of facial skin
- 26. • Inferior spread − Expansion of alveolus with dental pain − Loosening of teeth, poor fitting of dentures − Swelling in hard palate or alveolus • Superior spread − Proptosis − Diplopia − Ocular pain
- 28. • Posterior spread − Pterygoid muscle involvement trismus • Intracranial spread − Via Ethmoid, cribriform plate or foramen lacerum • Lymphatic spread − Neck node metastases in late stages • Systemic spread − Lungs, bone ,liver
- 29. Diagnosis • Diagnostic nasal endoscopy • X-ray paranasal sinus : Expansion and destruction of bony wall • C.T. Scan axial & coronal cuts with contrast • Biopsy
- 31. Classification • Ohngren's Classification – Ohngren's line: An imaginary plane extending between medial canthus of eye and angle of mandible – Supra structural growths situated above this plane have a poorer prognosis – Infra structural growths situated below this plane have better prognosis
- 32. • Lederman’s Classification − 2 horizontal lines of Sebileau pass through floors of orbits & maxillary sinus, producing − Suprastructure : Ethmoid, sphenoid & frontal sinuses; olfactory area of nose − Mesostructure : maxillary sinus & respiratory part of nose − Infrastructure: alveolar process
- 34. T.N.M. Staging • T1 – Tumor confined to antral mucosa • T2 – Bone destruction of hard palate / middle meatus • T3 – Involvement of skin of cheek, floor or medial wall of orbit, ethmoid sinus, posterior antral wall, pterygoid plates, infratemporal fossa • T4 – Involvement of orbital contents, cribriform plate, frontal or sphenoid sinus, skull base, nasopharynx
- 35. Treatment options • T1 /T2 : Surgery or Radiotherapy • T3 : Surgery + Radiotherapy • T4 : Surgery + Radiotherapy +Chemotherapy − Europeans: Pre-operative Radiotherapy (5000-6500 c Gy) surgery after 4-6 weeks − Americans: Surgery post-operative Radiotherapy after 4-6 weeks
- 36. Surgical Options • Total maxillectomy (Weber Fergusson incision) − Malignancy limited to maxilla • Radical maxillectomy with orbital exenteretion (Weber Fergusson Diffenbach incision) − Involvement of orbital fat • Anterior Cranio Facial Resection (extended lateral rhinotomy incision) − Involvement of cribriform plate, frontal sinus
- 38. Tarsorrhaphy
- 40. Osteotomy cuts
- 41. Total maxillectomy done and incision closed
- 42. Palatal defect and prosthesis
- 43. Indications of orbital exenteretion • Involvement of orbital apex • Involvement of extra-ocular muscles • Involvement of bulbar conjunctiva or sclera • Lid involvement beyond a reasonable hope for reconstruction • Non - resectable full thickness invasion through periorbita into retrobulbar fat
- 45. Post-operative defect and prosthesis
- 46. Cranio-facial resection • Lateral rhinotomy incision combined with midline forehead incision