This document provides information about malignant tumours of the maxillary sinus, including epidemiology, etiology, classification, clinical presentation, spread, staging, and treatment. Some key points: - Squamous cell carcinoma and adenocarcinoma are the most common types. Risk factors include occupational exposures like wood dust. - Tumours often initially present with vague symptoms but can later invade adjacent structures. Spread is usually to lymph nodes, bones, brain, liver, or lungs. - Staging uses the AJCC TNM system and evaluates tumour size, extension sites, lymph node involvement, and distant metastasis. Late-stage tumours have spread widely. - Prognosis depends on stage,

1. MALIGNANT TUMOURS OF
MAXILLARY SINUS
Dr vivekanand A,BMCRI
1

2. CONTENTS
• INTRODUCTION
• EPIDEMIOLOGY
• ETIOLOGY
• CLASSIFICATION
• CLINICAL PRESENTATION
• SPREAD OF TUMOUR
• STAGING
• EVALUATION
• TREATMENT
• PROGNOSIS
2

3. INTRODUCTION
One of the most challenging problems in head and neck cancer
 Rare
 Area of greatest histological diversity
 Initialy develops as innocuous symptoms
 Often present with significant invasion of adjacent vital structures
 High morbidity and poor prognosis
3

4. EPIDEMIOLOGY
• 0.2-0.8% of all malignancies
• Incidence of 0.5-1 per 100,000 per year
• 3% of all tumours of head and neck
• 3% of upper aerodigestive tract neoplasms
• Fifth and sixth decades
• Male predominance
4

5. SITE OF ORIGIN
SITE ACC TO COMPREHENSIVE
MANAGMNT OF SKULL BASE
TUMOURS(IN %)
CUMMINGS(IN %)
MAXILLARY SINUS 60 50-70
NASAL CAVITY 22 15-30
ETHMOID 15 10-20
FRONTAL AND SPHENOID 3 LESS THAN 5
PREVALENCE
5

6. MOST COMMON LESIONS IN DESCENDING
ORDER
• Squamous cell carcinoma
• Adenocarcinoma
• Sarcoma
• Esthesioneuroblastoma
• Adenoid cystic carcinoma
• Melanoma
• Undifferentiated
• Mucoepidermoid
• lymphoma
6

7. ETIOLOGY
• Occupational-mainly due to inhalation of carcinogens
• Hard wood exposure increases the relative risk by 70 fold particularly ethmoids
• Soft wood exposure increases the risk of squamous cell carcinoma
• Nickel exposure increases the risk for SCC by 250 times
• 0ther factors-smoking,aflatoxins,formaldehyde,chromium,mustard gas,polycyclic
hydrocarbons,thorotrast
7

8. occupation Suspected carcinogen histology
Wood workers Dust >5 micromtr,
tar,aldehydes,chromium
Adeno-hardwood
SCC-softwood
leather Dust,tar,tannins,aldehydes adeno
Chrome pigment Calcium chromate
Zinc potassium chromate
adeno
Isopropyl alcohol Isopropyl oil adeno
textile Dyes and wood dust Melanoma and adeno
8

9. CLASSIFICATION
• WHO CLASSIFICATION
• HISTOLOGICAL CLASSIFICATIONS
• Most common epithelial subtypes-SCC,Adenoid cystic and Adeno carcinoma
• Most common non epithelial includes-lymphoma,esthesioneuroblastoma and
undifferentiated
9

10. WH0 10

11. HISTOLOGICAL CLASSIFICATION
1. EPITHELIAL
EPIDERMOID-SCC (spindle cell,verrucous,transitional)
NON EPIDERMOID-adenoid cystic,adeno,mucoepidermoid,acinic cell
2. Neuroectodermal-malignant melanoma,olfactory neuroblastoma,neuroendocrine
carcinoma,SNUC,ewing’s
3.Odontogenic-ameloblastoma
4.Mesenchymal-fibrosarcoma,liposarcoma,malignant fibrous histiocytoma,alveolar soft part
sarcoma
5.Vascular-angiosarcoma,kaposi’s sarcoma,glomangiopericytoma
6.Muscular-leiomyosarcoma,rhabdomyosarcoma
7.Cartilagenous-chondrosarcoma
8.Osseous-osteosarcoma
9.lymhoreticular-NHL,burkitts,NK cell lymphoma,plasmocytoma
10.Metastasis
11

12. SQUAMOUS CELL CARCINOMA
• Most common-58-73%
• M/C -maxillary sinus >ethmoid >fronto sphenoid
• Risk factors-inverted papilloma,thorotrast,nickel
• Presents at advanced stage-80% with stage III or IV
• Tumours from nasal cavity are keratinizing usually and from PNS non keratinizng
• Most are poorly differentiated 70%,un differentiated 10-20%
• Undifferentiated may mimick SNUC and melanoma
12

13. • Macroscopocally- exophytic,fungating or papillary ,friable ,haemorrhagic ,necrotic or
indurated and demarcative or infiltrative
• Microscopically-keratinizng can be well,moderately or poorly differntiated
-shows squamous differentiation as extra or intracellular keratin
 Cells are opposed to one another in a ‘mosaic tile’ arrangement
 Tumour cells may be in nests, masses or small groups of individual cells
 Desmoplastic stromal reaction is often evident
Non keratinizing SCC -cylinfrical cell carcinoma
 Characterized by plexiform or ribbon like growth pattern
 Maturation is lacking with evident atypia
 Invades underlying tissues with smooth well delineated smooth border
13

14. 14

15. SCC FROM INVERTED PAPILLOMA
• SCC in IP frequently occur concomitantly or as metachronous SCC
• Regional or distant metastasis is uncommon
• Radiotion with or without surgery resulted in a survival rate of 85%
• Surgery with post operative radiation has improved local control rate and cure rates
from less than 50% to 60%
• Ref:-treatment outcomes in the management of IP,Lawson et al,laryngoscope
2003;113:1548-1545
15

16. ADENOCARCINOMA
• Epidemiological association with wood working
• Latency period of approx 40 years
• Two types- intestinal and seromucinous
INTESTINAL SEROMUCINOUS
Identical to Colonic adenocarcinoma respiratory
site Ethmoidal sinus and
nasal cavity
Ethmoid and maxillary
sinus
histology Resembles intestine,may
show signet ring or
mucinous
Back to back cuboidal
lined glands and cords
16

17. • Macroscopically-necrotic friable some times gelatinous.
Microscopically
-Barne classification-papillary,colonic,solid,mucinous,mixed
-kleinasser-papillary tubular cylinder,alveolar goblet,signet,transitional
HISTOLOGICAL TYPES
Papillary- papillary architecture with occasional tubular glands,minimal atypia
Colonic-tubulo glandular,nuclear pleomorphism and atypia
Solid-loss of differentiation,solid or trabecular growth with isolated tubule formation
17

18. 18

19. ADENOID CYSTIC CARCINOMA
• Incidence peak in 5th and 6th decade
• Equal incidence in men and women
• Histological types-tubular,cribriform and solid
• Tends to infiltrate perineuraly and adjacent structures
• Hemategenous spread is common-high rate of lung metastasis
• Baseline CT chest
• High rate of local recurrence in spite of appropriate surgery and irradiation
19

20. 20

21. SNUC
• Rare tumour,5th -6th decade,M=F,
• Highly aggressive
• Macroscopicaly-large >3cm,infiltrate adjacent areas with bone erosion
• Microscopically-
No glandular or squamous differentiation,3 types
Western type-cells with pink cytoplasm
Undifferentiated NPC type-cells with large round water clear nuclei and lymphocyte
infiltrates
Large cell type-identical to lung type,cells with pleomorphic nucleiand prominent
eosinophilic with or without giant cell formation
21

22. 22

23. CHONDROSARCOMA
• 3rd to 4th decade,M=F
• Maignant tumour of hyaline cartilage
• Macroscopically-lobulated pale glistening masses with cystic changes
-chalky white calcification foci
• Microscopicaly-lobulated,round to oval shaped cells with blue chondroid matrix
with myxoid changes
• Frequently immunoreactive for CD99
23

24. 24

25. CHORDOMA
• Derived from remnants of notochord
• Frequently in sacral areas
• Rarely from spheno occipital or vertebral regions
Three variants-
• Conventional
• Chondroid
• Dedifferentiated
• Piecemeal surgical resection
25

26. ESTHESIONEUROBLASTOMA
• Arises from olfactory epithelium
• Neither occupational or other aetiology nor genetic factors identified
• Slight male predominant with bimodal peak 2nd-3rd and 6th -7th decade
• Most common location-at the level of cribriform plate
• Diagnosis is often delayed
• Macroscopically-polypoid reddish grey mass that bleeds easily
• Microscopicaly-limited to submucosa,growing in circumscribed lobules or nests separated by
richly vascularised fibrous stroma
-surrounded by neurofibrillary matrix
Rosettes-Homer Wright type(pseudorosette) <30%
Flexner Wintersteiner type (true rosette) <5%
26

27. 27

28. MELANOMA
• 3.6%,female predominance,elderly
• Nasal cavity and septum
• High hematogenous spread-lungs and brain
• Macroscopicaly-bulky polypoidal lesions that tends to ulcerate
• Microscopicaly-may have different characteristics such as small spindle
cells,epithelioid or pleomorphic cells
-melanin pigment in two third of cases
High recurrence rate
28

29. 29

30. LYMPHOMAS
• <10%,more in males,6th to 8th decade
• Most are primary
• NHL most common variety
• 53% limited to nasal cavity,M/c sinus involved-maxillary
• Other varities-NK cell
-anaplastic large cell
-burkitt(m/c in children)
- follicular lymphoma
-extra nodal marginal zone B lymphoma
-MALT
30

31. 31

32. HAEMANGIOPERICYTOMA
• Rare,develop from pericytes with in outer capillary wall
• Associated with steroid therapy,coincidental trauma,hypertension and malignancy
• Macroscopicaly-red grey firm polypoid lesions
• Rarely metastasize
• Relatively radioresistant
• Recurrence rate upto 60%
32

33. 33

34. OHNGREN’S LINE
Suprastructure: poor
Prognosis
Infrastructure: good
prognosis
34

35. LEDERMAN’S CLASSIFICATION
Ethmoid, sphenoid, frontal
sinuses & olfactory area of
nose.
Maxillary & respiratory
part of nose.
Alveolar process
35

36. CLINICAL PRESENTATION
• MAXILLARY SINUS TUMOURS
 Naasal blockage,bleeding,hyposmia
 Mass,ulceration
 Middle ear effusion
 Glabellar mass
 Paraesthesia
 Loosening of teeth or dentures
 Malignant oroantral fistula
 Proptosis
 diplopia
36

37. • ETHMOID SINUSES TUMOURS
Same as of maxillary sinuses tumours
Can cross to contralateral side
Mucous retention
Proptosis
Chemosis
Visual loss,diplopia
Personality changes
37

38. SPREAD OF TUMOURS
• MAXILLARY SINUS
38

39. • ETHMOIDAL SINUS
39

40. • FRONTAL SINUSES
40

41. • SPHENOID SINUSES
41

42. SITE ANTERIORLY POSTERIORLY MEDIALY LATERALY SUPERIORLY INFERIOR
LY
FRONTAL skin Anterior cranial
fossa,frontal
lobe
ethmoid
ETHMOID skin Spenoid,nasoph
arynx,clivus,pitui
tary
Cribriform
plate
orbit Anterior cranial
fossa,frontal lobe
Nasal
cavity
MAXILLARY Cheek,skin Pterygopalatine
and infra
temporal
fossa,temporal
lobe,middle
cranial fossa
Nasal
cavity
Cheek,skin orbit palate
SPHENOID Ethmoidal
sinus
Clivus,pituitary
gland,posterior
fossa
Cavernous
sinus,middle
cranial fossa
Pituitary,hypotha
lamus
nasophary
nx
NASAL
CAVITY
skin Spenoid
sinus,nasophary
nx
Maxillary
sinus
Anterior cranial
fossa,frontal
lobes
palate
42

43. LYMPHATIC SPREAD
• Lymphatic spread is seen in 25-30% of cases
• If tumor extension into skin of face, nasal
• cavity, NPX > ↑ed incidence of LN
 Submandibular and subdigastric nodes
 Contralateral metastasis extremely rare
43

44. DISTANT METASTASIS
• More common with adenocarcinoma (18%)> SCC(10%)
• COMMON SITES-bone,brain,liver,lung and skin
44

45. STAGING
• AJCC TNM SYSTEM
• Only for maxillary and ethmoid sinuses and nasal cavity
45

46. MAXILLARY SINUS
• TX-Primary tumour cannot be assessed
• T0-no evidence of primary tumour
• Tis-carcinoma in situ
• T1-tumour limited to antral mucosa with no bone erosion or destruction
• T2-tumour with erosion or destruction of infrastructure including hard
Palate and / or the middle nasal meatus
 T3-tumour invades any of the following:-skin of the cheek,posterior wall
Of maxillary sinus,floor or medial wall of orbit,ant ethmoid sinus
 T4-tumour invades orbital contents and/or any of the following
Cribriform plate,posterior ethmoid or sphenoidal sinuses,nasopharynx,palate
Pterygomaxillary or temporal fossa or base of the skull
46

47. NASAL CAVITY & ETHMOID SINUS
 Tx - Primary tm cannot be assessed
 To - no evidence of primary tm
 Tis - carcinoma in situ
 T1 - Tm restricted to any one subsite with or without bony
 invasion
 T2 - invading two subsite in a single region or extending to
involve an adjacent region within the nasoethmoidal complex
 T3 - invade medial wall/ floor of orbit, maxillary sinus,palate/
cribiform plate
 T4a - invade ant orbital contents, skin of nose /cheek, ant cranial
fossa, pterygoid plates,sphenoid/ frontal sinus
 T4b - orbital apex, dura, brain,mid cranial fossa, cr nerves,
nasopharynx/ clivus
47

48.  Nx - regional nodal status cannot be assessed,
 No - No regional lymph node metastasis
 N1 - single I/L clinically +ve lymph node ≤ 3cm
 N2 - metastasis in ipsilateral, bilateral, contralateral node
N2a - single I/L +ve LN >3cm <6cm
N2b - multiple, I/L +ve LN <6cm
N2c - B/L or C/L LN <6cm
 N3 - any LN > 6cm
48

49.  Mx - distant metastasis cannot be assessed
 Mo - No distant metastasis
 M1 -distant metastasis multiple, ipsilateral clinically positive
node <6cm
49

50.  stage I - T1N0M0
 stage II – T2N0M0
 stage III – T3N0M0 OR T1-T3N1M0
 stage IV :
IVA -T4N0-1M0
any TN2M0
IVB any TN3M0
IVC any T any N, M1
50

51. KADISH STAGING FOR
ESTHESIONEUROBLASTOMA
GROUP DEFNITION
KADISH A CONFINED TO NASAL CAVITY
KADISH B EXTENDS TO PARANASAL SINUSES
KADISH C EXTENDS BEYOND NASAL CAVITY AND PARANASL SINUSES
KADISH D LYMPHNODE OR DISTANT METASTASIS
51

52. • DULGUEROV STAGING FOR ESTHESIONEUROBLASTOMA
• T1-tumour involving the nasal cavity and/or paranasal sinuses
(except sphenoid),sparing the most superior ethmoidal cells
 T2-tumour involving the nasal cavity and/or paranasal sinuses
(including sphenoid),with extension to or erosion of cribriform plate
 T3-tumour extending into the orbit or protruding into the anterior cranial
Fossa,without dural invasion
 T4-tumour involving the brain
 No- no cervical lymph node metastasis
 N1-any form of cervical lymph node metastasis
 M0-no metastasis
 M1-distant metastasis present
52

53. 53

54. 54

55. CLINICAL EVALUATION
• Endoscopy
• Imaging
• Biopsy
• immunohistochemistry
55

56. CT SCAN
• Advantages
Bony detail
Detects calcification,cartilage or bone with in the tumour
Planning reconstruction
Preliminary detail about intra cranial and intra orbital spread
85% accuracy
56

57. • Key areas include the bony orbital walls,
• cribriform plate, fovea ethmoidalis,
• posterior wall of the maxillary sinus,
• pterygopalatine fossa, the
• sphenoid sinus, and the posterior table
• of the frontal sinus
57

58. • Limitations
Periorbital involvement
Difficult to differentiate between: Tumor vs. Inflammation vs. secretions
58

59. MRI
 94% accuracy
• • Inflammatory tissue & secretions:
• intense T2
• • Tumor: Intermediate T1 & T2,
• Enhancement with Gadolinium
• • MRI is excellent for determining
• perineural spread, involvement of
• the dura, or involvement
• intracranially.
59

60. PET CT
• Increased 18FDG by sinonasal inflammation limits its use
• To detect distant metastasis
60

61. BIOPSY
• For confirmation of diagnosis
• Can be tran nasal,endoscopic maxillary antrostomy or sphenoidotomy,CT guided needle
biopsy
• Biopsy via Caldwell-Luc approach is not recommended because of the potential to seed the
gingivobuccal sulcus and cheek skin with tumor
• Rule out encephalocele or vascular tumour before biopsy
• Tissues for IHC
61

62. IHC
 Pathological diagnosis sometimes difficult
 To know the cells of origin or kind of tumour
62

63. tumour CK LCA NSE ACTIN SNP S100 VIMENT
IN
HMB45 CD99
SCC +
ADENO
+
ESTHESIONEUROBL
ASTOMA + + +
MELANOMA
+/- +/- + + +
SNUC
+ +/-
FIBROSARCOMA
+
HAEMANGIO
+/- +
LYMPHOMA
+
PNET
+/- +/- +/- + +
63

64. TREATMENT
• FOR CURE- surgical resection followed by adjuvant radiation or chemoradiation
• For palliative-local debulking with adjuvant radiation
64

65. • Multidisciplinary expertise
• Surgical planning
-evaluate bony and soft tissue structures to be
resected
-designing the optimal approach for better
exposure
-reconstruction and rehabilitation
65

66. MAXILLARY SINUS-TREATMENT
OPTIONS
 Surgery
• • Radiotherapy
• - definitive
• - pre op RT
• - post op RT
• • Combined modality ( Sx + RT)
• • Chemotherapy
• - Neo adjuvant
• - Concomitant
66

67. SURGICAL APPROACHES
• Aim-to achieve complete tumour resction with negative margin
• Open and endoscopic approaches
67

68. UNRESECTABILITY
• Superior extension: Frontal lobes or gross brain invasion
• Lateral extension: Cavernous sinus,invovment of carotid arteries
• Posterior extension: Prevertebral fascia,gross involvement of pterygoid
• Bilateral optic nerve involvement
• Distant Metastasis
Treated by primary chemoradiation
68

69. OPEN PROCEDURES
• Caldwell luc
• Maxillectomy-medial/subtotal/total with or without orbital exenteration
• Lateral rhinotomy
• Mid facial degloving
• Anterior craniofacial resection
69

70. ANAESTHESIA
• Under GA, reversed trendelenburg position with 15-200 head elevation
• Nasal mucosal vasoconstriction with 2-4ml,of Moffat’s solution
• Incision site infiltrated with 2%lignocaine and adrenaline 1;80,000
• Incase of craniofacial resection,patient should be started with antiepileptics 48hrs
prior
• Broad spectrum antibiotic
70

71. MIDFACIAL DEGLOVING
• Popularized by cassen et al in 1970s and price in 1980s
• Excellent access to middle third of the face
• Used alone or combined with coronal scalp incision for craniofacial resection
71

72. INDICATIONS
Nasal cavity,maxillary tumors with bilateral involvement,pterygopalatine and
infratemporal fossa
Most suited for inferiorly located tumors with minimal ethmoidal involvement
CONTRAINDICATION
Limits of resection
Posteriorly-posterior wall of sphenoid,pterygoid plate and muscles
Superiorly skull base
Lateraly-coronoid process of mdible
72

73. • INCISION
 A bilateral sublabial incision from maxillary
Tuberosity to tuberosity down to bone
 Routine rhinoplasty intercartilagenous incision
73

74. TECHNIQUE
 The procedure is started with complete transfixion incision, which is connected to
bilateral intercartilagenous incisions.
 Elevation of soft tissue from the nasal dorsum is performed through the
intercartilagenous space.
 The soft tissue elevation over dorsum of nose is continued over the anterior wall of
maxilla on both sides.
 Elevation of soft tissue should also continue over the glabella and frontal bone.
74

75. • Supero laterally the elevation should extend up to the medial canthal region.
The intercartilagenous incision is extended laterally and caudally across the
floor of the vestibule to be connected with the transfixation incision.
 This results in a full circumvestibular incision on both sides.
 At the pyriform aperture region sublabial incision is connected to intranasal
incisions.

75

76. § periosteal elevators are used to elevate the soft tissue over the anterior walls
of both maxilla up to the level of the orbital rim taking care to protect the infraorbital
vessels and nerve.
• § The entire midfacial skin is stripped from the dorsum of the nose and anterior
wall of maxilla.
• § This flap includes the lower lateral cartilages, columella with its medial crura.
76

77.  The elevation is continued till the level of glabella superiorly and medial canthus
laterally.
• The bony nasal pyramid and the attached upper lateral cartilages are exposed
completely.
• Two rubber drains are passed through the nose and upper lip and are used to retract
the midfacial flap along with the upper lip.
• Once in every 15 minutes one of the drain should be released to allow blood supply
to the middle portion of the upper lip.
77

78. 78

79. COMPLICATIONS
Immediate-hemorrhage
-facial bruising
-infraorbital paraesthesia
Late -vestibular stenosis
-oro antral fistula
-epiphora
-septal perforation
79

80. MEDIAL MAXILLECTOMY
• INDICATION
Lesions that involve upto the entire lateral nasal wall but do
not extent into orbit,anterior cranial fossa,lateral maxilla or
alveolus
 A complete medial maxillectomy-encompasses middle and
inferior turbinates,contents with in ethmoid and maxillary
sinuses
80

81. The operation may be considered in 3 stages:
• soft tissue dissection/bone exposure
• bone resection
• closure/reconstruction.
• It is important to complete the soft tissue dissection and bone exposure before
doing any bone work so as to avoid excessive blood loss.
81

82. SOFT TISSUE DISSECTION
Done via midfacial degloving or lateral rhinotomy approach
midfacial degloving approach avoids facial scars and is suited to resections that do
not extend above the orbital floor
 when the resection requires removal of the medial wall of the orbit and the
ethmoids, lateral rhinotomy provides better access.
Soft tissue of the face are elevated off the maxilla,till lateraly upto infraorbital
foramen
Identify medial palpebral ligament,anterior lacrimal crest,lacrimal sac in lacrimal
foss,posterior lacrimal crest
Elevate lacrimal sac from the fossa
82

83. • Expose medial and inferior orbit
• Frontoethmoidal suture line is identified-anterior and posterior ethmoid artery
ligated,clipped or bipolar cauterised
• Strip along the floor of the orbit in extra periosteal plane
• Free soft tissue from bone up to anterior free margin of nasal apertures
83

84. 84

85. • BONE RESECTION
• An antrostomy in the anterior face of maxilla uptpo orbital rim
• Inspect the antrum and plan subsequent bone cuts
85

86. 1.Through infraorbital rim
2.Connecting antrostomy with nasal vestibuli
3.Across frontal process of maxilla
4.Along orbital floor
5.Along floor of nose
6.Through lacrimal bone,lamina papyracea and
anterior ethmoids
7.Vertical posterior osteotome through posterior
ethmoids,antrum along posterior wall and
pterygopalatine plate
86

87. 87

88. 88

89. • The medial maxillectomy specimen is then removed by gently levering it inferiorly
and laterally with the Mayo scissors while completing the posterior osteotomy,
• in the process fracturing through the apex of the orbital floor and the posterior
ethmoids cells, and remaining lateral to and preserving the middle turbinate.
89

90. • • The specimen is inspected to determine the adequacy
of the tumour resection.
• • An external ethmoidectomy may safely be completed
up to the cribriform plate.
• • The ethmoids are carefully inspected to determine
whether an external frontoethmoidectomy +/-
sphenoidectomy is required, and for evidence of a CSF
leak
90

91. RECONSTRUCTION
 Haemostasis is achieved with cautery, bone wax and or topical haemostatics.
 The objectives of closure are to minimise enophthalmos, diplopia, epiphora and an unsightly
scar.
 Suture any tears in the periorbita to avoid herniation of orbital fat. The lacrimal sac is slit
open along its longitudinal axis and the edges are sutured to the surrounding tissues to
avoid epiphora.
 If an extensive resection of the orbital floor has been done, then consideration should be
given to reconstructing the floor with fascia / bone / titanium mesh.
 The skin is carefully repaired to optimise the cosmetic results.
 Patients are instructed about nasal douching and are recalled for nasal toilette.
91

92. SUB TOTAL AND TOTAL
MAXILLECTOMY• Infrastructural maxillectomy-medial maxillectomy with removal of dentition,alveolar
ridge and hard palate
• Subtotal-entire maxilla is removed
• Total-subtotal +orbital floor
• Approach is modified weber ferguson with subciliary extension
92

93. 93

94. 94

95. • When tumour invoves bony orbital wall not contents-maxillectomy that removes
orbital rim en bloc with rest of maxilla
• Orbital exenteration-invasion through orbital periosteum into the periorbita
95

96. LATERAL RHINOTOMY
• Gives excellent access to nasal cavity through which medial maxillectomy can be
done
• Can extend superiorly or inferiorly if required
• Ascribed to moure in 1902
96

97. • INDICATION-
• Any malignant tumour affecting the nasal septum,lateral wall and extending into
sphenoid,ethmoid and maxillary sinuses and up to anterior skull base
• CONTRAINDICATION-
Tumours extended beyond these areas
97

98. • INCISION
Runs from level of medial canthus,midway between the medial canthus and the nasal
bridge in the nasomaxillary groove curving around the lower ala into nasal cavity
98

99. • Through the incision orbital periosteum dissected from lamina and nasolacrimal
duct mobilized
• Anterior and posterio ethmoidal artery
• En bloc or piecemeal removal of lateral nasal wall including pyriform aperture,nasal
bones,frontal process of maxilla,anterior maxillary wall,the medial orbital floor and
rim, ethmoids lamina papyrracea and lacrimal fossa
• If extended superiorly-sphenoids and frontals
• Orbital periosteum resected if required
99

100. • Whitehead varnish packing if necessary
• Incision closed
• Care must be exercised at alar margin to get good approximation
100

101. • COMPLICATIONS
• Early-haemorrhage,orbital edema,CSF leak,meningitis
• Late-epiphora,diplopia,cosmetic(alar lift vestibular stenosis), frontal
paraesthesia,Sinus obstruction,infection,mucocele
101

102. CRANIOFACIAL RESECTION
• Gold standard for tumours affecting the anterior skull base
• CONTRAINDICATIONS
Extensive frontal lobe or middle cranial fossa involvement
Certain histologies where extent of surgery does not influence outcome
Distant metastasis
102

103. • INCISION
• Extended lateral rhinotomy
• In young patients coronal flap with a midfacial degloving variation
103

104.  Bicoronal scalp skin incision a few centimeters post hairline.
 The supraorbital, supratrochlear and superficial temporal vessels are well identified
and preserved in the base of the flap.
 Adequate elevation of posterior scalp flap deep to galeal plane to allow generous-
length pericranial flap for skull base repair;
 Anterior scalp flap pericranial flap elevated up to supraorbital ridges to maintain
blood supply of flap.
 Minimum osteotomy may be needed to release supraorbital vessels providing
extrapericranial flap length and bone exposure;
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105. • Anteriorly based U-shaped pericranial flap elevated;
• • Small frontal craniotomy;
• • Frontal bone plate is preserved;
• • The tumor can be approached from the inferior aspect via one of many transfacial
approaches;
• • Management of the orbit as appropriate;
• • The nasolacrimal drainage needs to be dealt with to avoid any afterward epiphora;
• • Skull base and dural defect should be repaired
• • The entire nasal cavity is then packed snugly with Whitehead’s varnish to provide a support
to the galeal flap superiorly and the medial orbital periosteum laterally.
• Nasal packs are to be kept for 2 weeks or more as needed
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106. 106

107. COMPLICATIONS
Immediate-convulsion,hemorrhage,air embolism
Intermediate-CVA,pulm embolism,meningitis,aerocele
Late-
hemorrhage,frontal abscess,bonenecrosis/fistula,epilepsy,epiphora,diplopia
Cellulitis,pituitary deficeincy
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108. ENDOSCOPIC RESECTION
ANATOMIC LIMITS
Soft tissue involvement or skin of the face and forehead
Frontal sinus/bone involvement
Dural involvement lateral to orbit
Significant brain invasion >2cm
Internal carotid artery encasement
Involvement of mandible
Invasion to extraocular muscles or optic nerve,cavernous sinus
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109. TYPES
1. Endoscopic partial or medail maxillectomy
2. Transcribriform cranial resection
3. Coronal plane resection to pterygopalatine or infratemporal fossa
4. Orbital extensions
5. Endoscopic nasopharyngectomy
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110. EBRT
• Supine position
• • Immobilisation
• • Mouthbite
• • Planning
• - maxilla
• - adj. nasal cavity
• - ethmoid sinuses
• - NPx
• - pterygopalatine fossa
• - portion of orbit
• • Techniques
• - Anterolateral wedge pair
• tech
• - 3 field tech
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111. • Dose prescribed at depth of 5 cm
• • EBRT dose
• - Pre operative : 45-50 Gy over 5 wks
• - Post operative : 55-60 Gy over 5.5 – 6 wks
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112. CHEMOTHERAPY
• ROLE
• For palliation
• Induction approach to reduce tumour burden
• Certain histological types-SNUC,lymphoma,rhabdomyosarcoma
• DRUGS-Cisplatin
-5 Flurouracil
-Carboplatin
-Docetaxel
-Gemcitabine
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113. • KNEGT’S REGIMEN
• For adenocarcinoma of ethmoid
• Surgical debulking
• Tumour bed packed with 5 FU
• Necrotomy
• 5 year survival 87%
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114. MANAGEMENT OF ORBIT
BIOPSY/IMAGING
CRANIOFACIAL RESECTION
LAMINA PAPYRACEA ERODED INTACT
ADJACENT TO PERIOSTEUM
TUMOUR THROUGH PERIOSTEUM RESECTION/FROZEN SEC
CLEAR
ORBITAL CLEARANCE RECURRENCE
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115. STAGEWISE TREATMENT
115

116. 116

117. RECONSTRUCTION
• Optimizing functional rehabilitation in terms of speech,swallow and sight
• Maxillectomy and orbital defects with facial and dental prostheses
• Microvascular free flap reconstruction
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118. BROWN AND SHAW MIDFACE AND
MAXILLARY CLASSIFICATION
Consists of
• Vertical component
• Horizontal component
118

119. • 1. Not causing oroantral fistula
• 2.not involving orbit
• 3.involving orbital adnexa with orbir retension
• 4.orbital enucleation or extenteration
• 5.Orbitomaxillary defect
• 6.Nasomaxillary defect
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120. • A.palatal defect only,not involving dental alveolus
• B. Less than or equal to half unilateral
• C.less than or equal to half bilateral transverse anterior
• D.greater than half maxillectomy
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121. • Class I to IIB defects-obturation,reconstruction,faciocutaneous radial forearm flap
• Class III- soft tissue rectus abdominis reconstruction with neovascularised bone(iliac
crest),Deep circumflex iliac artery flaps,Thoracodorsal angular arterty flaps
• Class IV- DCIA flaps,TDAA flaps
• Class V- temperoparietal or temporalis flap with orbital prosthesis
• Class VI-0steocutaneous radial forearm flap and vascularised bone
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122. SKULL BASE DEFECTS
• Region 1-arises from sinuses and orbitand extend into
anterior cranial fossa
• Region II-originate in the lateral skull base and involve the
infratemporal and pterygopalatine fossa and extend to
middle cranial fossa
• Region III-originate at the ear,parotid or temporal bone and
extend intracranialy to posterior fossa
122

123. 123

124. PROGNOSIS
• Factors affecting
• Anatomical
• Histological
• Tumour stage
124

125. Anatomical factors 5 year survival in %
Nasal cavity 77
Maxillary sinus 62
Ethmoid sinus 48
Above Ohngren’s line worse
125

126. histology 5 year survival in %
OAN 88
Adenocarcinoma 68
SCC 51
SNUC 44
Melanoma 18
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127. TUMOUR STAGE 5 year survival in %
T1 91
T2 64
T3 72
T4 49
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128. TO SEE WHAT IS INFRONT OF ONE’S
NOSE,NEEDS A CONSTANT
STRUGGLE
GEORGE ORWELL
THANK YOU
128