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Carcinoma Maxillary sinus
Carcinoma of the maxillary sinus is rare, constituting 3-5% of head and neck cancers. The maxillary sinus is the most common site. Anatomy of the maxilla includes processes, surfaces, and articulations with other bones. Maxillary sinus boundaries include the roof, medial wall, floor, and buttresses. Ohngren's line divides lesions into suprastructure and infrastructure types. Spread can occur via routes like the pterygomaxillary space. Risk factors include wood dust and HPV. Pathology is usually squamous cell carcinoma. Symptoms include oral, nasal, auditory, and facial issues. Diagnosis involves imaging like CT and MRI. Management involves surgery with or without radiation depending on
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Carcinoma Maxillary sinus
- 1. Carcinoma of maxillarysinus Prof S.Subbiah et al
- 2. Introduction • Carcinoma ofthe paranasal sinus are rare - 0.2–0.8% of all cancer • Constitute 3–5% of the malignant tumors in the head and neck region • The maxillary sinus - most frequent site Prof S.Subbiah et al
- 3. Anatomy of maxilla largestof facial bones • Pyramidal shaped • Base is medial- formed by lateral wall of nasal cavity • Apex- lateral – extends into zygomatic process • Body – formed by paranasal sinus-largest of all paranasal sinus Prof S.Subbiah et al
- 4. • 4 processes alveolar palatine zygomatic palatine ProfS.Subbiah et al
- 5. • 4 surfaces anterior posterior(infratemporal) orbital nasal Prof S.Subbiah et al
- 6. Anterior surface • Nasalnotch • Infra-orbital foramen • Canine fossa – site of origin of levator anguli oris muscle Prof S.Subbiah et al
- 7. Posterior surface • maxillarytuberosity with alveolar foramina • origin of a few fibers of the medial pterygoid muscle. Prof S.Subbiah et al
- 8. Orbital surface • infra-orbitalgroove leading into the infra-orbital canal • infraorbital nerve and blood vessels, Prof S.Subbiah et al
- 9. The Maxilla articulates with: TheFrontal bone The Ethmoid bone The Nasal bone The Zygomatic The Lacrimal The Inferior Nasal Concha The Palatine The Vomer The Maxilla Prof S.Subbiah et al
- 10. Boundaries of maxillarysinus • Roof: inferior wall of orbit • Medial wall: lateral wall of the nasal cavity and part of the lacrimal system • Floor: anterior portion of the hard palate and alveolar ridge • Buttresses: 2 horizontal and 3 vertical buttresses provide projection & height Prof S.Subbiah et al
- 11. Ohngren’s line • .Thesuperior wall- orbit • Posterior wall - the pterygoid plates, pterygoid space, and infratemporal fossa. • Ohngren (1933) - involvement of these superior and posterior areas signifies a poor prognosis . • imaginary line extending from the medial canthus through the angle of the mandible. • Lesions posteriorsuperior – suprastructure • Lesions anteriorinferior to this line-infrastructure Prof S.Subbiah et al
- 12. Supra structure Infrastructure Latesymptoms Early symptoms Advanced disease – unresectable Amenable to surgery Cure is less likeley Good chance of local control Prof S.Subbiah et al
- 13. Routes of spread Suprastructure Pterygomaxillary space , infratemporal fossa via posterior wall Middle cranial fossa via orbital roof Anterior cranial fossa via ethmoidal air cells Infrastructure Floor of mouth to oral cavity Nasal cavity via medial wall Soft tissues of cheek via anterior wall Regional lymph node spread < 10 % Prof S.Subbiah et al
- 14. ETIOLOGY • exposure tosoft wood - Japanese furniture industry (Nishimuraet al., 2009). • chronic sinusitis • cigarette smoking • chlorophenol, formaldehyde, textile dust, • inverted papilloma (IP)- 10% -presence of HPV(Batsakis and Suarez, 2001) Prof S.Subbiah et al
- 15. Pathology Squamous cell carcinoma (80 %) Tobocco use and nickel exposure Minor salivary gland tumour (10-15 %) Adenoid cystic carcinoma – most common Wood dust exposure Esthesioneuroblastoma Sinonasal undifferentiated carcinoma Melanomas Sarcomas , lymphomas Prof S.Subbiah et al
- 16. Natural history ofdisease • locally advanced at diagnosis -symptoms are nonspecific • localized for a long time • invade adjacent structures after sometime • The most effective barrier against tumors spread -periosteum that is particularly more resistant in two critical areas: The skull base and orbit Prof S.Subbiah et al
- 17. SIGNS AND SYMPTOMS oral •paininvolving the maxillary dentition, • trismus, •palatal and alveolar ridge fullness • frank erosion into the oral cavity. nasal • persistent sinusitis, • unilateral nasal obstruction, • nasal discharge • epistaxis auditory • hearing impairment secondary to serous otitis media due to nasopharyngeal extension. Facial • include infraorbital nerve hyperaesthesia, pain and facial asymmetry. intracranial • headache, personality changes(frontal lobe involvement) Prof S.Subbiah et al
- 18. DIAGNOSIS • Panoramic radiography- Destructionof maxillary sinus walls, especially the inferior antral wall, - • CT - soft tissue masses in the maxillary sinus cavity bony destruction. • MRI- evaluation of the posterior cranial fossa, orbit and perineural/perivascular dissemination differentiation between retained secretions and neoplastic tissue Prof S.Subbiah et al
- 19. The ostiomeatal unit/complex. The anatomical boundaries of the OMU/ C the uncinate process (U), middle turbinate (MT), inferior turbinate (IT) the most prominent anterior ethmoid air cell: bulla ethmoidalis (BE Prof S.Subbiah et al
- 20. Normal axial anatomyat the mid maxillary sinus level IOF:infraorbital foramen; LP: lateral pterygoid; PPF: pterygopalatine fossa. Prof S.Subbiah et al
- 21. Normal axial anatomyat the superior margin of the maxillary sinus Inferiorly, the inferior orbital fissure (dotted red oval) is contiguous with the Pterygopalatine fossa and posteriorly with the foramen rotundum (dotted white arrows) Prof S.Subbiah et al
- 22. Normal anatomy throughthe pterygopalatine fossa Prof S.Subbiah et al
- 23. The infratemporal fossalies peripheral to the lateral antral wall and is an important deep fascial space which can be involved by spread of infection or tumour Prof S.Subbiah et al
- 24. Differential diagnosis include •sinonasal undifferentiated carcinoma, nasopharyngeal carcinoma, lymphoma, esthesioneuroblastoma, • primary sinonasal melanoma • adenocarcinoma of minor salivary gland • metastatic disease Prof S.Subbiah et al
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- 27. Management of maxillarysinus carcinoma • Operable tumors – combined modality - surgery + radiation • Incidence of lymph node metastases -10% • Recommend neck dissection or elective neck radiation therapy - node positive • Pre- op radiation therapy - stage II and stage III tumors Prof S.Subbiah et al
- 28. Management of maxillarysinus tumours (NCCN guidelines) T1-2 NO RESECTION MARGIN NEGATIVE FOLLOW UP PERINEURAL INVASION RADIATION / SYSTEMIC THERAPY MARGIN POSITIVE RE- RESECTION Prof S.Subbiah et al
- 29. T1 – T4a,N+ Resection + neck dissection Adverse features Yes RT or consider systemic therapy no Only RT to primary & neck T1 – T4a, N+ Resection + neck dissection Adverse features Yes RT or consider systemic therapy no Only RT to primary & neck Prof S.Subbiah et al
- 30. T4b, N0-3 Clinical trialPS 0-1 Concurrent Chemoradiation PS 2 RT or concurrent chemoradiation PS 3 Palliative RT or single agent CT or best supportive care Prof S.Subbiah et al
- 31. Contraindications for surgery •invasion of pterygoid muscles and soft tissues in masticator space around temporomandibular joint and pterygomaxillary fossa • Invasion of skull base with destruction of posterolateral wall and lateral walls of sphenoid sinus • Brain invasion • Invasion of cavernous sinus • Cranial nerve paralysis (CN ii, iii, iv, v,vi) • Inavsion of carotid artery Prof S.Subbiah et al
- 32. Classification of maxillectomydefects • Santamaria and Cordeiro (MSKCC classification)-assess the surface area to volume requirement the need for the palatal closure the need for orbital reconstruction. • Brown’s (Liverpool classification )- based on mid face defect Terminology: "limited" (LM) maxillectomy -remove one wall of the antrum. "subtotal" (SM-remove at least two walls, including the palate. "total" - complete resection of the maxilla. Prof S.Subbiah et al
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- 34. Cordeiro classification Compares themaxilla with a hexahedrium. Disadvantage : doesn’t take into account bilateral defects Prof S.Subbiah et al
- 35. • Type Idefects (limited maxillectomy) - resection of one or two walls of the maxilla,excluding the palate. • anterior wall is partially removed with either the medial wall or the orbital floor resection of anterior and medial walls of maxilla Radial forearm fasciocutaneous flap - skin islands to resurface anterior cheek and medial nasal lining Prof S.Subbiah et al
- 36. Resection of lowerfive walls of maxilla, including the palate, but sparing the orbital floor (roof of maxilla) Radial forearm osteocutaneous flap strut of vascularized bone to reconstruct the anterior maxillary arch deficit sandwiched between two skin islands that replace palatal and nasal lining. Type II (subtotal maxillectomy) defect (the classic hemimaxillectomy or “infrastructural maxillectomy.)” Prof S.Subbiah et al
- 37. • Type IIIadefect- resection of all six walls of the maxilla, including the floor of orbit and hard palate. • The orbital contents have been preserved . • Resected specimen demonstrates the orbital floor, vertical maxillary buttresses, and palatal resection • Rectus abdominis free flap with orbital floor reconstruction Prof S.Subbiah et al
- 38. Patients who arenot free-flap candidates - reconstruct with split calvarial bone grafts, covered with the temporalis muscle, transposed anteriorly. The zygomatic arch should be osteotomized and removed temporarily to increase excursion of the temporalis muscle. Prof S.Subbiah et al
- 39. TYPE IIIB MAXILLECTOMY resectionof all six walls of the maxilla, including the floor of the orbit as well as orbital contents . resection of external eyelid, cheek skin, and orbital contents, in combination with entire maxilla and palate A three-skin-island rectus abdominis myocutaneous flap Orbital floor reconstruction – alloplasts- titanium mesh autologous tissues- free cartilage or bone grafts or osteocutaneous free microvascular flap Prof S.Subbiah et al
- 40. resection of upperfive walls of maxilla, including the orbital contents but sparing the palate Type IV (orbitomaxillectomy) defect Prof S.Subbiah et al
- 41. Browns classification Horizontal classification: aPalatal defect only, not involving the dental alveolus. b Palatal defect less than or equal to half unilateral. c Palatal defect less than or equal to half bilateral or transverse anterior. d Palatal defect greater than half maxillectomy Prof S.Subbiah et al
- 42. Vertical classification: I Maxillectomynot causing an oronasal fistula. II Maxillectomy not involving the orbit. III Maxillectomy involving the orbital adnexae with orbital retention. IV Maxillectomy with orbital enucleation or exenteration. V Maxillectomy with orbitomaxillary defect. VI Maxillectomy with nasomaxillary defect. Loss of the vertical component causes more of an aesthetic problem Prof S.Subbiah et al
- 43. Orbital Involvement • Carcinomaof the maxillary sinus commonest to invade the orbit (Dukes Elder et.al) • Three stages of orbital invasion (Iannetti17 et al) Grade I- erosion or destruction of the medial orbital wall Grade II- extraconal invasion of the periorbital fat Grade III- invasion of the medial rectus muscle, optic nerve, ocular bulb, or the skin overlying the eyelid. only grade III orbital invasion warrants orbital clearance or exenteration. Prof S.Subbiah et al
- 44. Approaches for maxillectomy •lateral rhinotomy- extending anteriorly to nasal bone or soft tissue or the lateral nasal wall • Open Medial Maxillectomy- lateral wall of the nasal cavity or the medial wall of the maxillary antrum • A transoral partial maxillectomy- tumors of the “infrastructure” of the maxilla, including tumors of the upper gum, hard palate, or floor of the maxillary antrum • Sublabial degloving approach-larger tumors of the anteroinferior aspect of the nasal cavity and the infrastructure of the maxilla • open craniofacial approach -involve the skull base Prof S.Subbiah et al
- 45. • Classic Weber–Ferguson-Diffenbach 1) excellent exposure 2)unacceptable scar 3)distortion of facial contour and expression 4) ectropion 5) alteration of shape of nasal vestibule Prof S.Subbiah et al
- 46. • Starts frommidline upper lip • Philtrum • Columella • Around vestibule and nasal ala • Nasolabial crease and medial canthus Prof S.Subbiah et al
- 47. Modified Weber-Ferguson incision •A-lynch extension; • B- subciliary extension; • C- infraorbital extension. D – Borle’s extension – ALLOWS HAREVEST OF TEMPORALIS FLAP Prof S.Subbiah et al
- 48. Conceptual Approach toReconstruction of Midface/ Maxillary Defects extent of resection of the maxillary bone- key building block to the structure of the midface. • Address the bony defect first- followed by soft-tissue, skin, palate, and cheek lining deficits. • Finally, critical functional structures – palate, oral commissure, nasal airway, and eyelids. Prof S.Subbiah et al
- 49. • The anterior(cheek), superior (orbital floor), and inferior (palatal) walls most commonly need to be reconstructed for the following reasons. • Bone replacement (floor of the orbit) – 1) maintain position of the ocular globe. 2)maxillary arch to provide anterior projection of the midface 3)obliterate any communication between the mouth and the nose and the nasopharynx and anterior cranial base to prevent ascending infections, • Palatal reconstruction - to enhance articulation and deglutition, • lacrimal apparatus • The space between the restored anterior, superior, and inferior walls of the maxilla can usually be filled with soft tissue (muscle/fat), and nasal lining may or may not be necessarily restored. Prof S.Subbiah et al
- 50. . • If thecavity is not reconstructed (no free microvascular flap)- 1) the inner aspect should be lined with a skin graft or acellular dermis. 2) promote rapid healing 3) prevent contraction of the surgical cavity –prevent subsequent collapse of the mid face. 4)The scar band that develops at the interface of the skin graft and the remaining buccal mucosa often aids to secure the prosthesis. Prof S.Subbiah et al
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- 52. Prosthesis after maxillectomy OBTURATORMAXILLOFACIAL PROSTHESIS CAD / CAM PROSTHESIS ( computer aided design / computer assisted manufacture Prof S.Subbiah et al
- 53. Postoperative rehabilitation • Preoperativelydesigned surgical obturator with clasps- fitted after the bolster is removed postoperative day 5th to 7th day. • Holes drilled in the posterior aspect - allow sutures to be placed in the soft palate to the splint- reduces oro-nasal reflux and facilitates the early return to a normal diet. • final prosthesis - after the incisions are healed and the edema has resolved (usually after the adjuvant treatment) Prof S.Subbiah et al
- 54. Definitive obturator prosthesis-only 3 months to 1 year after the resection surgery. Dimensional changes due to remodeling and scarring of the defect's contours last approximately 1 year ( soft tissue >bone tissue remodeling) • Maxillary defect < a quarter of the hard palate- the obturator gives excellent functional results Prof S.Subbiah et al
- 55. POST OPEARATIVE COMPLICATIONS •Resorption of orbital fat and wound contracture I enophthalmos diplopia restricted range of motion. cataract -Postoperative radiation therapy • Trismus- Soft tissue fibrosis • Lacrimal duct obstruction- dacryocystorhinostomy prevents it Prof S.Subbiah et al
- 56. Role of definitivechemoradiation Prof S.Subbiah et al
- 57. • Eighteen patientswith inoperable MSC with neck lymph node metastasis • 70 Gy in 35 fractions +tri-weekly systemic administration of cisplatin at 100 mg per square meter of body surface area • the 2-year LC, PFS and OS rates for all patients were 34, 31 and 46%, respectively Prof S.Subbiah et al
- 58. Recurrence • After surgery- radiation therapy or craniofacial resection with postoperative radiation therapy. • After radiation therapy -craniofacial resection if indicated. • Chemotherapy - does not respond • Clinical trials Prof S.Subbiah et al
- 59. Prognosis • Advanced stage-dismal prognosis- 5-year overall survival rates of 35–49% • A meta-analysis revealed that disease specific survival after five years is significantly higher for patients treated with surgery plus adjuvant radiotherapy (RT) (66%) than for patients treated with RT alone (46%) Prof S.Subbiah et al
- 60. PROGNOSIS • Orbital involvement-significant reduction in survival • skull base and orbital involvement - only factors significantly associated with disease-specific survival (Gullaneet al., 1983) 5-year survival - 17% vs 49% when there was no invasion . • no survival benefit - by orbital clearance 5 year survival- 11% despite complete extirpation of orbital contents (Carrilloet al., 2003) Prof S.Subbiah et al
- 61. Take home message •Suprastructure lesions present late and have poor prognosis • Orbital involvement is T3 disease and has poor prognosis and reduced survival • Lymph nodal metastasis is rare and nodal dissection is indicated only in node positive cases • Only grade 3 orbital invasion requires orbital exenteration Prof S.Subbiah et al
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