H & P examination
• The sinonasal, ocular, and neurologic systems
should be studied in detail
• Ant & post rhinoscopy
• Nasal endoscopy
Radiographic studies are essential as the full
extent of a sinonasal neoplasm cannot be
established even with modern fiberoptic
Both CT& MRI are the effective ways to
delineate the extent of tumor extracranially and
Key areas include the bony orbital walls,
cribiform plate, fovea ethmoidalis, posterior wall
of the maxillary sinus, pterygopalatine fossa, the
sphenoid sinus, and the posterior table of the
Difficult to differentiate between: Tumor vs. inflammation
• 94% accuracy
• Inflammatory tissue & secretions:
• Tumor: intermediate T1 & T2,
Enhancement with Gadolinium
• MRI is excellent for determining
perineural spread, involvement of
the dura, or involvement
medial wall of maxilla is the preferred route
Needle biopsy is sufficient
Biopsy via Caldwell-Luc approach (canine fossa
puncture) is not recommended because of the
potential to seed the gingivobuccal sulcus and
cheek skin with tumor.
a line that is drawn
from the angle of
mandible to the medial
Ohngren indicated that
tumors that presented
above this line
posteriorly, tended to
have a worse prognosis
3.CHEMOTHERAPY:VERY LIMITED ROLE
The goal of surgery for nasal cavity and paranasal sinus
tumors is to achieve en bloc resection of all involved bone and
soft tissue with clear margins while maximizing the cosmetic
and functional outcome.
Limited nasal cavity lesions may be resected with medial
Ethmoid lesions usually require medial maxillectomy and en
combined craniofacial procedure for lesions involving the
inferior surface of the cribriform plate ,the roof of the
ethmoid & frontal sinus.
Multidisciplinary skull base approach has improved the
• Superior extension: frontal lobes
• Lateral extension: cavernous sinus
• Posterior extension: prevertebral fascia
• Bilateral optic nerve involvement
• Distant Metastasis
Reconstruction after surgery is done with
microvascular free flap & maxillofacial obturator
Addition of RT to surgery improve 5-years survival (44%) when
compared to RT alone (23%) or surgery alone.
Definitive :medically inoperable or who refuse radical surgery or early lesions
Pre- and postoperative radiation may result in similar control rates.
But post-operative RT preferred:
increases the infection rate and the risk of postoperative wound complications.
Preoperative radiation may obscure the initial extent of disease=surgery can not
remove the microscopic extensions of the tumor.
• Postoperative radiation therapy is started 4 to 6 weeks after surgery.
2D CONVENTIONAL: 3field tecnique
Patient lies in a supine cast
with the head in
Tongue bite is used to
depress tongue &
lower alveolus away
from the target volume.
• Field Margins:
a three-field technique for maxillary antrum: 1 anterior and 2 lateral
superior border: above the crista galli to encompass the ethmoids.
in the absence of orbital invasion, at the lower edge of
the cornea to cover the orbital floor.
inferior border: 1 cm below the floor of the sinus.
medial border: 1 to 2 cm (or more if necessary) across the midline
cover contralateral ethmoidal extension.
lateral border: 1 cm beyond the apex of the sinus or falling off the skin.
superior border: follows the floor of anterior cranial fossa.
anterior border: behind the lat canthus parallel to the slope of face.
posterior border: covers the pterygoid plates.
When ther is no gross involvement of the orbit,
the cornea, lens & lacrimal gland are shielded
from the anterior field
If there is disease in the orbit, cornea is spared
by cutting out the cast and treating with the eyes open
It is angled 5-10 degree posteriorly so that the exit beam avoids
the opposite eye
Optic chiasma & hypothalamus are shielded from the lateral field
Anterior beam is weighed as 2:1 to that of lateral beam
Dose prescription:65Gy/32# or 55Gy/20#
2. two lateral portal
3. Intraorbital electron portal to make up the dose to post nasal
cavity, ethmoid sinus & medial orbit
A CT scan is performed with 3 mm slices from
2cm superior to the superior orbital ridge to the
hyoid bone (but extended to include the low
neck if neck nodes are to be treated).
TARGET VOLUME DELINEATION
The CTV should encompass
• all initial sites of disease(presurgery GTV),
• The mucosa of adjacent compartments of the sinonasal
• a 10 mm margin at least from initial sites of GTV where no
good bony barrier to invasion exists
(e.g. masticator space, cribriform plate and infraorbital fissure)
• Bony orbit if involved
For most tumours, the CTV will include the ipsilateral maxillary
sinus and bilateral nasal cavity and the ethmoid sinuses.
The CTV is expanded isotropically (usually by 3–5 mm)to form
Where a craniofacial excision has been carried out, the CTV should
extend 10 mm superior to the cribriform plate or 10 mm superior to
Initial sites of disease, whichever is greater
If the primary was close to or invading the nasopharynx, the adjacent
Ipsilateral retropharyngeal nodes should be included in the CTV.
When cervical node radiotherapy is indicated, the intraparotid nodes,
level Ib and superior level II nodes can be included in the CTV.
Elective neck nodal radiation is not recommended
ORGAN AT RISK
1.lenses,2. lacrimal glands (in the superolateral
orbit and upper eyelid), 3.optic nerves and
chiasm, 4.spinal cord, 5.brainstem and
OAR & possible complications of RT
Lens <10 Gy (cataracts)
Lacrimal gland <30–40 Gy (dry eye syndrome)
Retina <45 Gy (blindness)
Optic chiasm and nerves <54 Gy at standard fractionation.
Brain <60 Gy (necrosis)
Mandible <60 Gy (osteoradionecrosis)
Parotid mean dose <26 Gy (xerostomia)
Pituitary and hypothalamus mean dose <40 Gy.
A non-coplanar arrangement
of three to five sagittal midline
beams with right and left
lateral beams avoids entry or exit of
beams through the eyes and
provides a uniform dose distribution
IMRT has been shown to be useful in
reducing long-term toxicity by
reducing the dose to salivary glands,
temporal lobes, auditory structures,
and optic structures
Definitive RT: 70Gy , 2G/# over 7 wks
60 Gy in 30 daily fractions given in 6 weeks.
66 Gy in 33 daily fractions if possible where
there is residual disease.
36 Gy in 6 fractions of 6 Gy treating once weekly.
Treatment delivery and patient care
Patients are seen weekly during treatment in a
• Exercises to reduce trismus
• Prophylactic feeding tubes should be considered
• ophthalmic review .Lubricating eye ointments
• If there is a pre-existing facial nerve palsy, the eyelid
should be taped shut at night to avoid a dry eye.
• Pituitary function tests should be carried out annually
during follow-up to evaluate late radiotherapy effects
to the pituitary gland.
Role of chemotherapy
• Neoadjuvant chemotherapy is sometimes offered in
order to reduce tumor volume, which may permit
removal of tumor with a less morbid resection or
facilitate radiotherapy planning if shrinkage pulls
away tumor from critical structures.
• chemotherapy may be given concurrent with
radiotherapy in the management of inoperable
tumors on the basis of improved results in more
frequent head and neck carcinomas.
H&P, labs every 3 months for first
Every 4 months for second year,
Every 6 months for third year, then annually.
Imaging of the H&N at 3 months post treatment,
then as indicated