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1. SINONASAL TUMORS
Dr Raju kafle
3rd year resident
ORL- HNS Dept, NMCTH
1

2. INTRODUCTION
• Uncommon tumors , less than 1% of all
neoplasm
• little symptoms initially : misdiagnosed
commonly as rhinosinusitis
• Leads to delay in diagnosis : average of 6
months
• By this time tumors
• already erodes bone , sensory nerves
• It causes facial pain and sensory
deficit
• Also extension into orbit, brain and
infratemporal fossa
2

3. 3

4. EPIDEMIOLOGY
• Incidence : 0.5-1/100,000 per year
• 0.2-0.8% of all malignancies
• 3% of upper aerodigestive tract neoplasms
• Age : 5th and 6th decades of life, M:F= 2:1
• 40% of sinonasal malignancies: inhalation of carcinogenic compounds
• 50% arises from lateral nasal wall
4

5. AETIOLOGY
 Most common cause
• Exposure to Nickel : 250 folds high chance of
sinonasal SCC
• Exposure to wood dust ( occupational hazard)
• Soft woods : SCC
• Hard woods : 70 times increased risk of
Adenocarcinoma
Hard woods: from trees that shed
leaves annually and slow growing
• Rosewood ( sisau)
• Shorea robusta ( saal)
• Oak ( katush)
• Hickory (okhar tree)
Soft woods: from trees that are
evergreen and donot shed leaves
• Pine trees ( sallo )
• Cedar ( devdaar )
• Juniper ( Dhupi)
5

6.  Less common cause
• Smoking : synergistic with wood dust
• Other chemicals:
• chromium , polycyclic hydrocarbons
• mustard gas
• Aflatoxins
• Thorotrast (paints used in watch dials)
• Boot, shoe and textile workers
• Isopropyl oil
• Radiation
• HPV may be a cofactor
6

7. Classification
7

8.  SQUAMOUS PAPILLOMA
Benign epithelial tumor , exophytic growth
• low-risk HPV : types 6 and 11
• M:F=10:1, 3rd -5th decade of life
• It can arise from the vestibule and lower part of
nasal septum.
• These papillomas may be single /multiple and
pedunculated /sessile.
Treatment:
• local excision with cauterization of the base – to
prevent recurrence.
• Other option: cryosurgery or laser (pulse dye
laser)
HE stain: finger like projection
outwards form mucosal
8

9.  INVERTED PAPILLOMA
(Ringertz or Schneiderian papilloma or Transitional cell papilloma or malignant papilloma of
nose or villiform papilloma, cynlindrical cell papilloma, papillary sinusitis, soft papilloma )
• 2nd most common benign neoplasm (after osteoma)
• Locally aggressive sinonasal tumour
• Upto 4% of all nasal neoplasms
• Common in males between 50-60 years of life
• M:F ratio 2-3 : 1
• Usually unilateral involvement
• Malignant transformation (EGFR mutation) : 5-15% of cases (synchronous
>>metachronous) 9

10. Etiology:
• Occupational exposure to organic solvents (hydrocarbons, amines, esters, ethers, ketones )
• HPV (debatable, 22% - 66% incidence by lawson et al)
• Others : chronic inflammation, allergy
• Alcohol and smoking : no association
• However smoking confers 12 folds risk of malignant transformation and recurrences
• Sites:
• predominant : lateral wall and maxillary sinus ( in region of fontanelle : most
common site of origin) >>> ethmoid sinus and septum
• Rare: frontal sinus, sphenoid sinus
10

11. Clinical features
• U/L nasal obstruction
• Watery nasal discharge
• Unilateral sinusitis due to mechanical obstruction of sinus drainage
• Headache and facial pain
• Anosmia
• Advanced lesion involving the orbit : S/o malignant transformation
• Epiphora
• Proptosis
• Diplopia
• Numbness of cheek and altered speech
Most common presentation
11

12. Nasal endoscopy
12

13. Computed tomography
Coronal CT :
• homogeneous soft tissue density opacification
• sclerotic bony spur, where the lesion originates
• Bony destruction of lateral wall
Mass in ethmoid and maxillary sinus : African
continent sign
13

14. Magnetic resonance imaging
• T2 weighted MRI with gadolinium
enhancement: best modality
1. Differentiate b/w :
 Tumors : decreased signal intensity
 Secretions: increased signal intensity
2. Typical of IP : cerebriform-columnar
pattern best seen
 If lost : suggestive of malignant
transformation
3. Intracranial , intraorbital extensions
14

15. Punch biopsy and HPE
15

16. Treatment:
1. Endoscopic endonasal surgery : gold standard treatment
Contraindication
• Concommitant presence of malignancy
• Massive involvement of frontal sinus mucosa
• Orbital involvement
2. medial maxillectomy and en bloc ethmoidectomy by
lateral rhinotomy or midfacial degloving
3. Caldwell luc surgery
4. Tu Na surgery (cummings 7th edi)
• marked tendency to recur
after surgical removal.
Recurrence rate :
80% after intranasal
removal
60% after Caldwell luc
30% after medial
maxillectomy
16

17.  OSTEOMAS
• Most common benign tumor of sinonasal tract
• Osteoblastic tumor of cortical and cancellous bone
• Childhood , slow growth
• Common in frontal sinus (80% of cases) >ethmoid > maxillary
> sphenoid sinus( very rare)
• Silent and incidental finding on plain radiographs and CT scan
• Fu and perzin classification : ivory type, mature/spongiform type
and mixed type 17

18. Ethmoid osteoma: ground-glass appearance
typically seen in the spongiosum variant
Frontal osteoma
• High homogeneous density,
resembling cortical bone, is
characteristic of the ivory variant. 18

19. • Macroscopic : hard , white multilobulated mass
• Microscopic : according to fu and perzin histological subtypes
Treatment
Many are asymptomatic , require removal if interfere the sinus drainage by
• Endoscopic transnasal surgery : preferred technique
• Traditional external techniques:
• frontoethmoidectomy , midfacial degloving , lateral rhinotomy , Caldwell
luc , bicoronal osteoplastic frontal sinusotomy
19

20.  Fibrous dysplasia
• Expansile tumor
• normal medullary bone is replaced by abnormal
proliferation of fibrous tissue
• C/F: painless slow growing, infancy or childhood
• maxilla > frontal > sphenoid > ethmoid
• CT scan: ground - glass appearance with regions of
osteolysis & calcification
• Management : Endoscopic transnasal surgery
Fig. 50.17 Axial computed tomography scan
showing fibrous dysplasia.
20

21.  Ossifying fibroma
• Histologically it looks similar to fibrous dysplasia , young adults.
• But is true benign tumor (vs fibrous dysplasia: genetic developmental
anomaly, absence of capsule, more immature bone , no osteoblastic activity )
• Radiology: The sclerotic bony margin can be seen.
• Treatment: It can be shelled out easily
21

22.  LOBULAR CAPILLARY HAEMANGIOMA
(bleeding polypus )
• Rapidly growing lesion
• Proliferation of capillaries arranged in lobules and separated by a loose connective
tissue stroma, often infiltrated by inflammatory cells
• 10% in the nasal cavity.
• Age : 10 months to 72 years, peak incidence : 5th decade of life.
• No gender predilection has been observed
• Cause : Trauma, hormonal factors (such as puberty, pregnancy, and contraceptive
use), underlying microscopic arteriovenous malformations, etc
22

23. Symptoms:
• epistaxis (75%)
• nasal obstruction (36%)
• and pain (3%).
• Typical presentation: red to purple mass, not
larger than 1 cm
• Very rarely : fills nasal cavity entirely
• Biopsy : definitive treatment once AF is
excluded
• Treatment : radical resection by endoscopic
nasal surgery
23

24.  Schwannoma
• Neurogenic tumor arising from schwann cells of sheath of myelinated nerves.
• It is an isolated encapsulated tumor.
• 25-45% in head and neck region , 4% in sinonasal tract
• Age: 14-81 years ( average :40 years)
• Slight male predominance
In Sinonasal malignancy :
• most frequently from ophthalmic and maxillary division of trigeminal nerves
• rarely from sympathetic fibers of carotid plexus and parasympathetic fibers of
pterygopalatine ganglion
Clinical symptoms: headache, facial pain, nasal obstruction, diplopia/proptosis,
epistaxis, anosmia, and Horner syndrome
24

25. Coronal T2-weighted magnetic resonance
image
• An expansile, hyperintense mass on the left
vidian canal
• Bone resorption of the base of the pterygoid
25

26. • Macroscopic : well delinated , globular , firm to rubbery yellow tan mass
• Microscopic : non encapsulated , composed of cellular Antoni A areas with
verocay bodies alternating with hypocellular myxoid Antoni B areas
• Immuno reactive for S 100 protein
Treatment
• Radical surgery is the treatment of choice for sinonasal schwannoma by
endoscopic transnasal surgery
• In selected cases (small, asymptomatic tumors and unfit or old patients)
• a wait and see policy
• Due to extreme rarity of malignant transformation
26

27. SINONASAL MALIGNANCY
27

28.  Site of cancer
• Maxillary sinus (55%)
• Nasal cavity (35%)
• Ethmoid sinuses(9%)
• Frontal and sphenoidal (1%)
 Pattern of tumor spread
• Local invasion
• Regional spread
• Distant metastasis
-18% patients with adenocarcinoma
-10% with SCC
-Common sites : bone, brain , liver, lung and skin
28

29. Local invasion : breaching of wall
• First : sinonasal ca consumes sinus cavity before
eroding bony walls
• Periosteum , perichondrium and dura : acts as
temporary barrier
• Thin bone of fovea ethmoidalis, cribriform and
lamina : not a strong barrier
Examples of breaching:
• Bone of anterior maxilla and orbital floor : very
thin and easily eroded
• Maxillary ca : 0nly 25% are contained within sinus,
usually breaches lateral wall
• Ethmoid ca : can breach lateral wall into the orbit
29

30. local invasion : routes
Mainly in maxillary
carcinoma
Inferior orbital
fissure : to orbit
Infratemporal and
pterygopalatine
fossa
30

31. 31

32. Regional spread
• Anterior nose : lymphatic vessels of face
• Maxillary sinus and ethmoid sinus: SMG
• Sphenoid sinus : retropharyngeal lymph node
32

33. TNM STAGING: MAXILLARY CARCINOMA
• T1: limited to antral mucosa, no erosion of bone
• T2: bone erosion extending to hard palate and/or middle meatus
• T3: invades posterior antral wall, skin, floor or medial wall of orbit, ethmoid sinus
• T4a: invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal
fossa, cribriform plate , sphenoid or frontal sinuses
• T4b: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than
maxillary division of V2, nasopharynx or clivus
33

34. TNM STAGING: ETHMOID CARCINOMA
• T1: tumor confined to ethmoid with or without bone erosion
• T2: extends into nasal cavity
• T3: extends into anterior orbit and/or maxillary sinus
• T4a: invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal
fossa, cribriform plate , sphenoid or frontal sinuses
• T4b: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary
division of V2, nasopharynx or clivus
34

35. TNM STAGING: NASAL CAVITY TUMORS
• T1: tumor involves one subsite
• T2: two subsites or ethmoid
• T3: anterior orbit and/or maxillary sinus
• T4a: invades anterior orbital contents, skin of cheek, pterygoid plates,
infratemporal fossa, cribriform plate , sphenoid or frontal sinuses
• T4b: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than
maxillary division of V2, nasopharynx or clivus
35

36. Ohngren's Classification
Ohngren's line
• Supra structural growth: poorer prognosis
• Infra structural growths: better prognosis
36

37. Lederman’s Classification
2 horizontal lines of Sebileau, divides
• Suprastructure: ethmoid, sphenoid & frontal
sinuses, olfactory area of nose
• Mesostructure: maxillary sinus & respiratory
part of nose
• Infrastructure: alveolar process
37

38. SCC
• SCC is the most common sinonasal malignancy ( 80% )
• Highest incidence in 7th decade of life, male preponderance.
• Most SCCs arise from the lateral wall of the nasal cavity with 50% developing on the
turbinates.
• Approximately 85% of SCCs are well differentiated tumours.
• Papillary and exophytic histological patterns are also recognized.
Macroscopically
• Mostly are fungating, friable and keratinizing , some are polypoidal
38

39. Adenocarcinoma
• Adenocarcinoma accounts for 9% of sinonasal malignancies.
• Like SCC, 6th-7th decade of life, male predilection
• Involves upper nasal cavity and ethmoid sinuses.
• slow growth rate and rarely metastasize.
• histological subtype
• papillary, sessile, mucoid, neuroendocrine, intestinal and undifferentiated.
• Papillary adenocarcinomas are the least aggressive form.
• The intestinal variety is most often associated with woodwork-induced tumours.
• Sessile and mucoid adenocarcinomas have the worst prognosis
39

40. Adenoid cystic carcinoma
• A little less than 5% of sinonasal malignancies are ACCs.
• As elsewhere ACCs tend to grow slowly but inexorably with early
perineurial and vascular spread.
• The maxillary sinus is the most commonly affected site
• Due to slow growth: long history of facial pain that can defy diagnosis
for many months to years
40

41. Olfactory neuroblastoma (aesthesioneuroblastoma)
• OAN arises from basal cells within the olfactory neuroepithelium.
• less than 5% of all sinonasal malignancies.
• bimodal distribution with peaks at 20 and 50 years of age.
• Unlike most sinonasal malignancies it is more common in women than men.
• neuroendocrine tumour capable of causing paraneoplastic syndromes by secreting
peptides.
• Patients with OAN causing Cushing’s syndrome, inappropriate antidiuretic hormone
secretion or hypertension produced by vasoactive peptides have been reported in the
literature.
41

42. • OAN is one of a group of ‘small round blue cell tumours’ and needs to be differentiated
from sinonasal undifferentiated carcinoma (SNUC), neuroendocrine tumour, small cell
carcinoma, rhabdomyosarcoma and lymphoma.
• Expert histopathological review is therefore recommended.
• OAN typically expresses neuroendocrine markers (neurone specic enolase,
synaptophysin and chromogranin) and is negative for keratins.
• S-100 may show positivity around the periphery of the tumour only, helping to
differentiate OAN from sinonasal melanoma.
• Negativity for vimentin, actin and desmin excludes rhabdomyosarcoma
42

43. Sinonasal undifferentiated carcinoma SNUC
• was described relatively recently by Frierson et al.
• It is otherwise known as anaplastic carcinoma and can be hard to
distinguish from high-grade OAN.
• It is a highly aggressive and invasive tumour
• commonly containing areas of necrosis
• But ,paradoxically it often produces few symptoms despite its
extensive nature
43

44. Melanoma
• Melanoma accounts for 3.6% of all sinonasal malignancies.
• It is more common in women than men and tends to affect the elderly.
• The nasal cavity and the septum are usually the sites of origin.
• Appearances vary from a polypoid mass to an area of ulceration.
• While some are pigmented, others are not.
• Immunohistochemistry shows positivity for S100 and HMB-45.
• Sinonasal melanoma metastasizes less frequently to regional cervical lymph
nodes than melanoma that develops elsewhere, but more often to the lungs and
brain
44

45. Haemangiopericytomas
• rare neoplasms develop from pericytes within the outer capillary wall.
• less than 5% of all sarcomas.
• In head and neck 20% develops in nasal cavity and sinuses.
• associated with steroid therapy, coincidental trauma, hypertension and pregnancy.
• Macroscopically : red-grey, polypoid lesions.
• Rarely metastasize.
Treatment
• Complete surgical excision is necessary as they are relatively radioresistant.
• There is a 10–60% recurrence rate
45

46. rhabdomyosarcoma
46

47. CLINICAL PRESENTATION
47

48. Maxillary carcinoma
Medial spread
• Mimic maxillary sinusitis
• Nasal stuffiness
• Blood stained nasal discharge
• Epiphora
• Unilateral friable nasal mass
Anterior spread
• Cheek swelling
• Facial anaesthesia
48

49. 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
49

50. Late clinical features
Posterior spread:
• Pterygoid muscle involvement  trismus
Intracranial spread via:
• Ethmoids, cribriform plate or foramen lacerum
Lymphatic spread:
• Neck node metastases in late stages
Systemic spread: Lungs, bone, abdominal viscera
50

51. Ethmoid ca
• Medially into nasal cavity: nasal blockage, bleeding and hyposmia
• Inferolaterally into maxilla : mucus retention
• Medially into orbit : proptosis, chemosis, diplopia, visual loss and epiphora
• Superiorly into anterior cranial fossa : personality changes
51

52. Nasal cavity tumors
• Confined to cavity : nasal blockage, bleeding and hyposmia
• Inferiorly into palate : mass
• Posteriorly into nasopharynx : middle ear effusion
• Anterosuperiorly into the nasal bone : glabellar mass
• Externally into skin : mass / ulcerations
• Superiorly into anterior cranial fossa : headache, personality changes
52

53. Sphenoid and frontal sinus
• Rarely of primary malignant tumor
• Generally involved by local spread or due to involvement of surrounding bone
• Frontal sinus tumor : swelling in forehead ( m/c presentation)
• Sphenoid tumors : orbital symptoms (m/c : visual loss )
53

54. Clinical evaluation
 Endoscopy
Mandatory in anyone suspected of malignancy
Polypoidal and ulcerative growth
54

55. Imaging
• Combination of both CT and MRI : for accurate evaluation and staging
• CT : detail of bone erosion and potential involvement of skull base
• MRI /gadolinium enhanced
-fine tumor detail , including flow voids suggesting intense vascularity
-dural or cerebral infiltration
-Assessment of orbital invasion
• T2- weighted:
• inflammation and secretions- hyperintense
• tumors and mucosal thickening - intermediate
• Arteriography :
• if preoperative embolization is considered for vascular tumors like
hemangiopericytoma
• FDG-PET/CT:
• to exclude distant metastasis ( m/c in melanoma)
55

56. Biopsy
• Mandatory part of tumour evaluation.
• Bleeding tumor : adequate facilities to arrest any hemorrhage during attempt
• Biopsy perfomed under GA , reduces the rate of non diagnostic samples and
provides oppurnity to sample from within sinus itself
• No biopsy through Caldwell Luc approach : to prevent tumor seeding
56

57. Treatment
• Surgery alone
• Surgery + radiotherapy
• Chemotherapy: in case of poorly differentiated disseminated sinonasal CA, olfactory
neuroblastoma, rhabdomyosarcoma, lymphoma.
• Radiotherapy : before or after surgery
• Topical chemotherapy : 5-FU twice weekly packing for 4 weeks along with repeated
debulking in case of SCC and adenocarcinoma
• Role of elective neck dissection : not recommended , still controversial ( stell maran 5th
edi)
57

58. Surgery for maxillary tumors
• Partial maxillectomy :
-Medial maxillectomy
-Palatal resection with adjacent alveolus – tumors of hard palate
• Total maxillectomy :
-Total removal of upper jaw (bony box containing the tumor)
• Extended maxillectomy :
-When tumor extends beyond the upper jaw
-if involves the skull base CFR is used.
58

59. Total maxillectomy
59

60. Anesthesia
• Topical anaesthesia of the nasal mucosa with Moffet’s solution
• hypotensive general anaesthesia
• prefer a nasal tube placed in the contralateral nostril
• If the cranial cavity is opened, brain shrinkage is helpful
• best achieved by hyperventilation to lower the end-tidal pCO2 to about 24 mmHg -- induces
decreased cerebral blood flow and brain shrinkage.
• If the anterior fossa is opened, the patient should be loaded with phenytoin at the
time of induction and maintained on this prophylactically for 3 months
60

61. Surgical Approaches
Soft tissue appraoches:
1) Lateral rhinotomy (Moure)
2) Weber-Fergusson incision
3) Midfacial degloving
4) Extended lateral rhinotomy incision
61

62. • Maxilla is best exposed by weber-ferugson incision
• Transverse limb : started from 1cm lateral to outer
canthus , should be placed subciliary 3mm below the
eyelash
• In the medial canthal region , incision curved at obtuse
angle
• Incision continues down along nasomaxillary groove –
alar region –columella
• Then incision along the crest of philtrum and lip slit
done using two incisions
• Then the facial skin flap is raised in submuscular plane
and all soft tissue incision gently dissected free of bone
• Then the osteotomies is done
62

63. Osteotomies
• The maxilla is freed from the skull by osteotomies through
the frontal process of the maxilla.
• The body of the zygoma, the midline of the palate and the
pterygoid plates need to be freed posteriorly.
• The palatal osteotomy is placed in the floor of the nasal
cavity
• The pterygoid plates are best separated from the maxilla and
subsequently dissected free from the muscles.
• The final two osteotomies are made medially through the
ethmoid cells and frontal process of the maxilla after dividing
the lacrimal sac;
• laterally, the osteotomy is made through the body of the
zygoma,
• laterally placed tumours: osteotomy is made in the lateral orbital wall
below Whitnall’s tubercle and through the zygomatic arch
63

64. • The remaining soft tissue remnants are then removed using mayo scissors
• Bleeding from internal maxillary artery is controlled by packing , ligaclip
applications , diathermy or hemostatic matrices , often in combinations
64

65. Completion of resection
• Following removal of maxilla , further tissue removal is necessary to promote drainage
from remaining sinuses
• If obvious involvement of orbital periosteum then orbital extenteration is generally
indicated
• Support of globe is complex : so all medial and inferior orbital walls can be removed
without anopthalmus
• However , if whitnaills tubercle laterally if removed , results in lack of support of eye :
then transpose temporalis muscle medially
• Bleeding from the ophthalmic artery is stopped by applying local pressure or bipolar
coagulation
65

66. Rehabilitation
• For good cosmetic and functional outcome
• Cavity should be immediately fitted with an obturator to cover the palate
• Primary prosthesis is changed after 14 days and appropriate adjustment
made.
• This process is repeated several times over subsequent weeks until cavity
has healed and final prosthesis made .
66

67. Partial /Medial maxillectomy
• Done for clearence of lateral wall of nose +
ethmoid sinus
• Lateral rhinotomy approach : good access to the
nasal cavities, the ethmoids, nasopharynx,
sphenoid and the pterygopalatine fossa
• For more extensive lesion : combined with
anterior craniofacial approach
67

68. • Incision: Upper end start just above the level of the
medial canthus and continued along lateral border
of nose to upper alar margin
• The orbital periosteum is elevated and extended
laterally over the maxilla to the infraorbital nerve.
68

69. Osteotomy
• The first is through the anterior wall of the maxilla just
medial to the inferior orbital foramen curving medially
into the nasal cavity.
• Further osteotomies along the lower border of the lateral
nasal wall in the inferior meatus, and across the floor of
the orbit towards the foramen of the anterior ethmoidal
artery.
• Finally, an upper osteotomy is continued forward through
the frontal process of the maxilla and nasal bone then
down to the pyriform aperture.
• This frees the whole block of the lateral nasal wall and
ethmoid complex, apart from their posterior attachments
just in front of the optic and sphenoplatine foramen
69

70. • The view obtained following the removal of this
main block of tissue is excellent
• Then the resection is extended into the sphenoid and
frontal sinuses or alternatively into the
pterygopalatine fossa
• At the completion of the procedure, the operative
cavity is packed with a Whitehead’s varnish pack for
seven to ten days
70

71. Other maxillectomies
• Infrastructure maxillectomy : lower part of
maxilla and hard palate removed with some of
tooth , keeping orbital wall intact
• Suprastructure maxillectomy : upper part of
maxilla and orbital floor is removed keeping hard
palate intact
71

72. Subtotal maxillectomy
• Any maxillary resection that involves the
removal of at least two walls of maxilla ,
including the floor of the antrum ( hard palate) ,
keeping posterior wall intact
72

73. Other surgical procedure
73

74. Craniofacial resection
74

75. • Since its introduction in the 1970s, craniofacial resection has become the ‘gold standard’
for tumours affecting the anterior skull base
INDICATIONS
• Malignant tumours which require surgical resection, involving the anterior skull base.
CONTRAINDICATIONS
• Extensive frontal lobe and/or middle cranial fossa involvement or bilateral orbital
invasion
• Certain histologies ex. mucosal malignant melanoma where extent of surgery does not
influence outcome
• Those where surgery is not appropriate, sinonasal undifferentiated carcinoma, lymphoma,
plasmacytoma.
• Distant metastasis
75

76. Craniofacial resection
76

77. 77

78. POSTOPERATIVE CARE
• Patients are kept in a neutral position for the first 2 or 3 days
• and then gently elevated, usually getting out of bed on the fifth day.
• Neurological observations continue for at least 24 hours.
• Fluid intake is initially restricted to match the inevitable diuresis experienced in the first
24–36 hours.
• The urinary catheter is removed on the second or third day and facial sutures after 5–7
days.
• All patients experience some degree of cerebrospinal rhinorrhoea initially so broad-
spectrum antibiotics are continued until the nasal packing is removed under a general
anaesthetic at 10–12 days.
• The anticonvulsant is continued for 6 weeks following the operation and patients must
douche the nose long term.
78

79. COMPLICATIONS
• Immediate: convulsions , haemorrhage , air embolism
• Intermediate:confusion, pulmonary embolism, meningitis
• long term: haemorrhage, frontal abscess/encephalitis, bone necrosis/fistula,
cerebrospinal fluid leak, epilepsy, epiphora , diplopia , sinusitis/mucocele,
cellulitis
79

80. Midfacial degloving approach
INDICATIONS
• Selected malignant tumours affecting the nasal cavity, maxilla, ethmoids, sphenoid,
pterygopalatine and infratemporal fossae.
• A bilateral maxillectomy can be performed via this approach if required.
CONTRAINDICATIONS
• The limits of resection are posteriorly the posterior wall of the sphenoid, pterygoid plates
and muscles, superiorly the skull base and laterally the coronoid process of the mandible.
80

81. • Intercartilaginous incisions are made extending into a
transfixion incision .
• The circumferential incisions are joined across the floor of
the nose just anterior to the pryriform aperture.
81

82. 82

83. COMPLICATIONS
• generally rare
• immediate/early: – haemorrhage – facial bruising – infraorbital
paraesthesia
• late: – vestibular stenosis – oro-antral fistula – epiphora – septal
perforation – upward tip rotation
83

84. Lateral rhinotomy approach
INDICATIONS
• Any malignant tumour affecting the nasal septum, lateral wall and extending
into ethmoid, sphenoid, maxillary sinuses and up to the anterior skull base
CONTRAINDICATIONS
• Malignant tumours which have spread beyond these areas when an extended
procedure is required, i.e. craniofacial, maxillectomies
84

85. 85

86. COMPLICATIONS
• early: – haemorrhage – orbital oedema – cerebrospinal fluid leak /
meningitis
• late: – epiphora – diplopia – cosmetic – webbing, alar lift, vestibular
stenosis – facial paraesthesia – frontal sinus obstruction, infection,
mucocele
86

87. Management of the orbit
• Attempts to preserve the orbital contents and reduce mutilation often result in orbital
recurrence.
Indications
• Involvement of orbital muscles, globe or orbital apex are involved
• The lids provide good skin cover of the defect and can also be used to cover implants,
which can be placed at the time of the surgery
87

88. 88

89. Prognosis
89

90. References
• Scott brown 8th edition
• Scott brown 7th edition
• Stell and maran 5th edition
• Jatin shah head and neck oncology 6th edition
• Open atlas of head and neck surgery , university of capetown
2020
90

91. 91