Detailed discussion on tumors and other pathologies of paranasal sinus and their management. Surgical anatomy and approaches are also discussed. Complications of PNS surgeries are discussed briefly

1. Presented by: Dr Dibya Falgoon Sarkar

2.  Paranasal sinuses
• Introduction
• Development
• Anatomy
• Physiology
• Examination and investigations
 Paranasal sinus pathologies
• Classification
• Description
• Complications
• Treatment

3. • Paranasal sinuses are the mucosa
lined air spaces present within the
bones of the face & skull.
• There are four bilaterally paired
paranasal sinuses:
- Frontal sinus
- Maxillary sinus
- Ethmoidal sinus
- Sphenoidal sinus
• Named after the bones in
which they are located

4. 1. Frontal sinus
2. Ethmoidal sinus
3. Sphenoidal sinus
4. Maxillary sinus

5. • Humidifying and warming the inspired air.
• Imparts resonance to voice
• Increases surface area for absorption of noxious
gases and trapping of particles in inspired air
•Lightens the skull
•Helps in absorbing the shock of blows to the face &
thereby limiting the extent of facial injury from
trauma.
•Serves as an accessory olfactory organ by evenly
distributing the inspired air.
•Contributes to facial growth

6. Sinuses begin their
development at the 3rd
month of intrauterine life
as outpouchings of the
mucous membranes of
the nasal meatuses and
sphenoethmoidal recess
The early PNS expand
into the walls of the nasal
fossa by the growth of
mucous membranes into
the maxillary, sphenoid,
ethmoid and frontal
bones
Pneumatization follows.
Sinuses enlarge variably
but always retain their
original communication
with the nasal cavity
through ostia

8. • Largest of all the paranasal sinuses.
• Also known as the “antrum cave of
Highmore”– English physician
described an infection of sinus in
1651.
• First sinus to develop
• Pyramidal shaped - base toward the
lateral wall of nose and apex
directed laterally into the zygomatic
process
• Capacity approx. 15ml

9. Superior wall
• This wall forms both- roof of sinus & floor of the
orbit.
• It is thinnest wall & mostly flat slopes slightly
anteriorly and laterally.
• The Infraorbital canal runs along this wall and
crosses from back to front- accentuates the fragility
of wall
• This wall is frequently involved in orbital and
maxillary trauma.
 Anterolateral wall
• Thickness is 2-5mm.Thinnest portion over canine
fossa
• Related to facial artery and vein
• Labial levator muscles & inferior portion of
orbicularis oculi is attached to this wall above the
infra-orbital foramen.
• These attachments direct the spread of infection
from maxillary teeth.
• This wall also contains the anterior & middle
superior alveolar nerves.
• Any surgical procedure through this wall may
jeopardise the nerve supply to these teeth.

10. Floor of the maxillary sinus
• It is approximately 1.5 cm below
the floor of nasal cavity.
• It corresponds to the line drawn
laterally from ala of the nose.
Posterolateral wall
• Posterior superior alveolar nerves
and vessels sometimes present in
close contact with the sinus
mucosa.
• In such instances , acute sinusitis
is accompanied by pain in
multiple maxillary posterior teeth.
• Immediately posterior to this wall,
vital structures include:
-maxillary nerve & maxillary artery
- nerve of pterygoid canal
- sphenopalatine ganglion.

11. Ostium of maxillary sinus
• Communication between maxillary sinus
and nasal cavity.
• Average length: 5.5mm
• Located superior to the floor of the sinus.
• Opens into posterior part of hiatus
semilunaris in the middle meatus
• Arterial supply:
- Facial artery
- Infraorbital artery
- Greater palatine artery.
• Venous drainage:
- Facial vein
- Infraorbital vein
 Nerve supply:
 Infraorbital nerve
 Anterior , Middle &
Posterior superior
alveolar nerves
 Lymphatics:
 Submandibular lymph
nodes

12. • The frontal sinuses are rudimentary
or absent at birth.
• They are developed between 7th &
8th year of life but reach the full
size only after puberty.
• Situated between the inner and
outer tables of frontal bone
• Absent on one (15 %) or both sides
(5 %)
• Drainage pathway – naso- frontal
duct- frontal recess - situated at its
floor
• Drains into middle meatus (62%) or
ethmoid infundibulum (38%).

13. • The inner table is much thinner than the outer table. As a result the
chances of fracture of the inner table are more frequent ,even
without the fracture of outer table.
 Arterial supply:
- supraorbital artery
- anterior ethmoidal artery
 Venous drainage:
Anastomotic vein in the
supraorbital notch
connecting the supraorbital
& superior ophthalmic
veins.
 Lymphatic drainage:
Submandibular nodes.
 Nerve supply:
Supraorbital nerve

14. • Formation begins at 4th month of fetal life
• Thin-walled air cavities in the lateral masses
of ethmoid bone, between nose and the
eyes.
• Anterior ethmoidal air cells
-3- 11 drain into either the
ethmoidal infundibulum or
the frontonasal duct.
• Bullar cells (middle
ethmoidal air cells) -usually
<3 - open in ethmoidal
infundibulum.
• Posterior group :- Up to 7 -
usually drain by a single
orifice into the superior
meatus

15. Ethmoidal bulla:
• This is the most constant landmark
for surgery. It lies above the
infundibulum and it's lateral/inferior
surface and the superior edge of the
uncinate process forms the hiatus
semilunaris.
• The anterior ethmoid artery usually
decends across the roof of this cell.
 Arterial supply:
- Sphenopalatine artery
- Anterior and posterior
ethmoidal arteries
 Venous drainage:
Corresponding veins
 Lymphatic drainage:
• Anterior and middle groups
drain in the
submandibular nodes .
• Posterior group drains into
retropharyngeal nodes.
 Nerve supply: Anterior and
posterior ethmoidal nerves
Orbital branches of
pterygopalatine ganglion.

16. • They are the most anterior ethmoidal air cells.
• Its size influence the patency of the frontal recess
and the anterior middle meatus.
• Haller cells: Also called infraorbital ethmoid cells.
• Present in approx. 20 % patients.
• Clinical significance –
1. Become infected , with potential extension into
orbit.
2. Narrows the maxillary ostium.
• These are posterior ethmoidal cells extending into
the sphenoid bone, either adjacent to or impinging
upon the optic nerve.
• When these Onodi cells abut or surround the optic
nerve, the nerve is at risk when surgical excision of
these cells is performed.

17. • Body of sphenoid - behind the nose,
in the centre of the skull.
• Rarely symmetrical and separated by
a thin bony septum.
• Ostium of the sphenoid sinus is
situated in the upper part of its
anterior wall and drains into
sphenoethmoidal recess.
• Average size – 2 x 2 x 2 cm.
• According to Congdon sphenoid
pneumatization can be as follows:
1. Conchal – 5 %
2. Presellar – 23 %
3. Postsellar – 67%
• Arterial supply- Posterior ethmoidal
artery.
• Nerve supply- Posterior ethmoidal
nerves
• Lymphatic drainage-
Retropharyngeal nodes

18. • History and systemic clinical examination:
• Check general signs of health
• Systemic medical history, history of allergies, drug use and abuse
• Occupation history
• Examination of neck for lumps or swollen lymph nodes
• Palpation:
• PNS may be palpated directly to elicit any tenderness
• Tenderness over maxillary and frontal bones may indicate inflammatory
condition
• Step-off deformity indicates facial bone fracture in trauma cases
• Paresthesia is seen over midface region in injury to infraorbital nerve

19. 1. Anterior rhinoscopy:
• Examination of nose with a nasal
speculum to check for abnormal
areas, useful in evaluation of
nasal obstruction.
• Colour of nasal mucosa and its
vascularity
• Position of septum is noted for
deviation or dislocation, as well
as septal spurs, haematoma or
perforations
• Inferior & middle turbinates seen
2. Posterior rhinoscopy:
• Assessed using a mouth mirror
and headlight in the nasopharynx
• Technique sensitive

20. • Low specificity and sensitivity
• Helpful in absence of endoscopy
• Decreased light transmission when
compared with normal side
suggests of significant fluid
collection or marked mucosal
edema
Transillumination

21. • Endoscopic examination/
Rhinoscopy:
Nasoscope/rhinoscope is a thin,
tube-like instrument with a light
and a lens for viewing.
• A special tool on the nasoscope
may be used to remove samples
of tissue. The tissues samples are
viewed under a microscope by a
pathologist.
• Helps in visualization of
inaccessible areas like middle
meatal cleft.

22. 1. Maxillary sinus:
• Water’s view (PNS view) x-ray and CT scan are ideal for
maxillary sinus visualization.
• X-ray beam angled at 45 degree to orbitomeatal line
2. Frontal sinus:
• CT scan is helpful in trauma cases as we can appreciate both
inner and outer tables in the axial view
• PNS view x-ray is helpful to detect fluid accumulation in
sinusitis cases
3. Ethmoidal sinus: Axial views of CT scan are helpful in
detecting fractures of the ethmoid bone.
4. Sphenoid sinus: Best viewed in sagittal and axial sections of
CT scan.
“Limited CT Evaluation” – slice 3-4 mm

23. Maxillary sinus & Ethmoid air sinus
Axial CT scans

24. Frontal sinus
CT scan axial
PNS view radiograph

25. Sphenoid sinus
Axial CT Sagittal CT

26. • MRI: Excellent soft tissue definition -
evaluation of neoplastic disease.
• MRI (magnetic resonance imaging) with
gadolinium: Gadolinium is injected into
a vein. The gadolinium collects around
the cancer cells so they show up
brighter in the picture.

27. • Developmental variations and anomalies
• Inflammatory/infectious diseases
• Cysts
• Tumours – benign & malignant
• Other surgically relevant conditions

28. • Paradoxical curvature of
middle turbinate:
• Normally the convexity of the
middle turbinate is directed
medially toward the nasal
septum.
• When the convexity is directed
laterally, it is termed a
paradoxical middle turbinate .
• Most authors agree that the
paradoxical middle turbinate
can be a contributing factor to
sinusitis.

29. • Variation of the ethmoidal roof
anatomy
• The ethmoid roof is of critical
importance for two reasons:
1. most vulnerable to iatrogenic
cerebrospinal fluid leaks.
2. anterior ethmoid artery is vulnerable
to injury.
• The depth of the olfactory fossa is
determined by the height of the lateral
lamella of the cribriform plate.
• In 1962, Keros classified the depth of
the olfactory fossa into three types, that
is,
a) Keros type I: <3 mm
b) Keros type II: 4-7 mm
c) Keros type III: 8-16 mm - most
vulnerable to iatrogenic injury.

30. • Variations of uncinate process
• The uncinate process may be
medialized, lateralized, or
pneumatized/bent.
• Medialization occurs with giant
bulla ethmoidalis.
• Lateralization of the uncinate
process may obstruct the
infundibulum.
• Pneumatization (uncinate bulla)
can rarely cause obstruction of
the infundibulum.

31. • Sinusitis is the inflammatory condition of
the mucous membrane lining of the
sinuses. It may progress to pus formation.
• Causes :
• Rhinogenous – infection spreads from the
nasal cavity. It is the most common way
for infection and such sinusitis is the
complication of the flu.
• Odontogenic – infection spreads from
upper teeth. This way is typical only for
maxillary sinus. The pathologic process
may spreads from upper 4,5,6 teeth apex
to the inferior wall of the maxillary sinus
• Traumatic
• Hematogenic
• Allergic

32. 1. Initial phase: reversible
2. Ostium obstruction phase
3. Bacterial phase
4. Chronic phase
Osteomeatal
complex obstruction
Decreased
ventilation of the
sinuses
Decreased drainage
of the sinuses
pO2 decrease,
pCO2 increase,
mucous stasis
Inflammation and
viscous mucous,
ciliary movement
slowing
Ciliary damage
along with increase
in number of
anaerobic organisms

33. • According to duration:
1. Acute : infection lasting 4 weeks, symptoms resolve completely
resolved in < 30 days.
2. Subacute :infection lasting between 4 to 12 weeks, yet resolves
completely.
3. Recurrent: ≥ 4 discrete acute episodes per year, each completely
resolved in < 30 days but recurring in cycles, with at least 10 days
between complete resolution of symptoms and initiation of a new
episode
4. Chronic: symptoms lasting more than 12 weeks.

34. • According to pathogen:
1. Bacterial: Hospital-acquired acute
infections are more often bacterial,
typically involving Staphylococcus aureus,
Klebsiella pneumoniae, Pseudomonas
aeruginosa
2. Viral: In immunocompetent patients - in
the community is almost always viral (eg,
rhinovirus, influenza, parainfluenza).
antibiotics given for:
• Mild to moderate sinus symptoms persisting
for ≥ 10 days
• Severe symptoms (eg, fever ≥ 39°, severe
pain) for ≥ 3 to 4 days
• Worsening sinus symptoms after initially
improving from a typical
• viral URI ("double sickening" or biphasic
illness)

35. 3. Fungal: Usually seen in
immunocompromised patients because
of poorly controlled diabetes,
neutropenia, or HIV infection.
It is clinically of 2 types:
A)Non-invasive fungal sinusitis:
• Saprophytic fungal
infestation/colonization
• Allergic fungal rhinosinusitis (AFRS)
• Saprophytic fungus balls (mycetoma)
B)Invasive fungal sinusitis –
• Chronic invasive fungal sinusitis
• Granulomatous invasive fungal sinusitis
• Acute (fulminant) invasive fungal
sinusitis

36. • Risk factors:
1. Obstruction to drainage: most important
2. Defect of self-cleaning mechanism of the mucous membrane of sinus –
infections causing immobility of the cilia, Increased viscosity of secretions,
Immotile cilia syndrome, Prolonged exposure to cigarette smoke
3. Medications: First generation antihistamines (non sedating do not affect),
Anticholinergics, Aspirin, Anesthetic agents, Benzodiazepines
4. Immunodeficiency: Immunoglobulin deficiency (IgA, IgG), diabetes, HIV
infection
5. Other factors: prolonged ICU stays, severe burns, cystic fibrosis, and ciliary
dyskinesia.
According to number of
sinuses involved:
Hemisinusitis - all
sinuses on one side
Polysinusitis - several
sinuses, but not all, are
involved
Pansinusitis - all, are
involved

37. 1.Nasal congestion and discharge
2. Sore throat and postnasal drip
3. Pain or pressure.
4. Oedema of facial tissues.
5. Bad breath or loss of smell
(hyposmia/anosmia).
6. Systemic symptoms: Malaise may be
present. Fever and chills suggest an
extension of the infection beyond the
sinuses, rise in temperature, bad appetite,
sleep disturbances, changes of the blood
(leukocytosis), Productive cough (especially
at night)
7. Complications – ocular, neurological, local

38. • Diagnosis is mainly clinical
• CT scan and cultures - mainly for chronic, refractory, or atypical
cases.
• Clinical diagnostic criteria include
a) 2 major factors
b) 1 major and 2 minor factors or presence of pus in nasal cavity.
Major factors Minor factors
Facial pain/pressure Headache
Facial congestion/fullness Maxillary dental pain
Nasal drainage/discharge Halitosis
Postnasal drip Cough
Fever (acute sinusitis only)
Purulence in nasal cavity on examination
Hyposmia

39. Treatment options measures to enhance
drainage:
1. Heat therapy: Steam inhalation and hot
beverages
2. Topical vasoconstrictors/ Nasal decongestants:
Topical nasal sprays (limit use to 3-7 days) -
Phenylephrine, Oxymetazoline.
Corticosteroids: Corticosteroid nasal sprays can
help relieve symptoms but typically take at least
10 days to be effective
3. Systemic vasoconstrictors: Systemic
vasoconstrictors, such as pseudoephedrine 30 mg
4. Nasal irrigation
5. Antihistaminics: recommended if allergy
present.
6. Hydration
7. Antibiotics: Amoxicillin 500 mg tid for 10-14
days - First line
Nasal irrigation

40. 8. Mucoactive drugs: main purpose - increase the ability to expectorate
sputum and/or decrease mucus hypersecretion.
1. Expectorants: hypertonic saline, iodine containing compounds,
guaifenesin
2. Mucoregulators: anticholinergic drugs, glucocorticoids, macrolide
antibiotics
3. Mucolytics: classic mucolytic (N-Acetyl Cysteine), peptide mucolytic
4. Mucokinetics: bronchodilators, ambroxol
a) Nebulization: best form of physiotherapy.
b) Laser therapy: used directly over the sinuses to reduce inflammation
c) Ultrasound therapy: sound waves are conducted through a
hypoallergenic gel to reduce inflammation and loosen the accumulated
mucous.
d) Short-wave diathermy
e) Rinoflow therapy: new option, basically micronized endotracheal
wash. Used in sinusitis, rhinitis, pharyngitis, laryngitis and secretory otitis
media.

41. Indications:
• Sinusitis unresponsive to antibiotic therapy
• Necrotic sinusitis
• Orbital complications (abscess and phlegmon of orbit)
• Intracranial complications (meningitis, brain abscess)
• Rhinogenic sepsis
• Odontogenic sinusitis combined with maxillary osteomyelitis.
Approaches:
1. Removal of etiology (eg: removal of the infected teeth)
2. Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical
treatment of sinusitis and nasal polyps, including bacterial, fungal, recurrent
acute, and chronic sinus problems.
3. Caldwell-luc procedure/ Denker’s procedure
4. Intranasal antrostomy
5. Radical surgeries

42. • Oro-antral communication: it is an abnormal connection between oral and
Antral cavities.
• Oro-antral fistula: long standing oro-antral communication when left open,
epithelializes to form a patent fistula between the two cavities.
• Types:
1. Alveolosinusal
2. Palato-sinusal
3. Vestibulo-sinusal
• Causes:
• Extraction – maxillary posterior teeth
• Cysts, tumors
• Osteomyelitis
• Radiation therapy
• Trauma
• Implant denture
Oro-antral Fistula

43. • Some patients are asymptomatic
• Unpleasant tasting discharge and odor
• Reflux of fluids and foods into the nose from mouth
• Difficulty in smoking and blowing air
• Development of chronic sinusitis in infected cases
• Valsalva manoeuvre
• Mirror fog test
• Cotton wisp test
• Nasal regurgitation of fluid
• Radiographs: Sinus floor discontinuity,
sinus opacity, focal alveolar atrophy.

44.  Immediate treatment: Primary purpose is
closure of defect and prevention of sinusitis
through:
• Suturing across the defect with/without
periodontal pack, warm saline rinses,
antibiotic and antihistaminic therapy with
decongestants.
• Depending on defect size:
1. Size < 5mm: non-invasive intervention
(spontaneous closure by blood clot)
2. Size 2-6mm: Collagen plug in the socket
with figure of 8 suturing
3. Size > 6mm and > 48 hours: surgical
closure : small defects – local flaps; large
defects – regional/distant flaps
Obturators: immunocompromised patients

45.  In long-standing OAF we must evaluate the patient for maxillary
sinusitis and treat it before closing the defect surgically
The fistulous tract must be excised prior to surgical closure

46. • Most common and
oldest surgical
technique
• Developed by Rehrman
• Disadvantage: Reduces
depth of buccal
vestibule
• Overall success rate
approx. 87.2%

47. • Full thickness flap
• Based on the greater palatine artery
• Advantages:
a) No reduction of vestibular depth
b) Lesser chance of flap breakdown
c) Anteriorly based flaps are ideal for
closure of tuberosity defects
• Disadvantage: Exposed palatal bone
takes long time to heal

48. • First described by Egyedi in 1977
• Helpful in small to medium sized defects
• Pedicled flap
• Complication can be avoided:
i. Graft should not be in tension
ii. Patient should be on a liquid diet
Anatomy of BFP:
It has 4 processes- buccal,
pterygoid, pterygopalatine,
superficial and deep temporal
Blood supply: Deep & superficial
temporal artery, facial artery

49. • Based on lingual artery and its branches
• Tongue flaps are useful :
i. When both buccal and palatal flaps have
failed
ii. Defect size is > 1.5cm
• Types of tongue flaps:
a) Anteriorly based- Defects of hard palate,
buccal mucosa
b) Posteriorly based- Defects of soft palate
• Disadvantages:
i. Second surgery is required for flap division
ii. Swallowing and speech difficulty
• Some investigators placed the patients in IMF to
reduced flap tearing

50. Gold foil

51. • By George Walter( USA, 1983) and Henri Luc
(France,1989)
• Technique to gain access to the maxillary antrum
through canine fossa of maxilla
• Indications:
Removal of tooth fragments, chronic sinusitis,
neoplasms, cysts
Controlling maxillary antrum bleed/ haematomas
Treating orbital floor fractures
Nasal Antrostomy
• Artificial ostium is made to the max. sinus with an
opening in inferior meatus
• Principle: Opening at a lower level improves
drainage
• Types : Middle meatal (child), inferior meatal,
sublabial

52. Presented by: Dr Dibya Falgoon Sarkar

53. PNS Cysts
Intrinsic cysts
Mucocele
Serous cysts
Cholesteatoma
Extrinsic cysts
Dentigerous
cysts
Radicular cyst Neurogenic cysts
Meningocele
Encephalocele
Fissural cysts
Nasopalatine
duct cyst
Globulumaxillar
cyst
Median palatal
cyst
Pierse et al Oral & Maxillofacial Surgery Clinics 2012

54. Mucous retention cyst Mucous extravasation cyst (Mucocele)
Most common and donot produce bone destruction Produces bone destruction
Results from obstruction of glands in the sinus lining Results from accumulation of mucous in an
obstructed sinus cavity
Site: Floor of Maxillary sinus Site predilection: Frontal & Ethmoidal sinus
Radiographically visible as a dome-shaped,
homogenous mass
Radiographically Pressure erosion seen surrounding
sinus walls. Initially sinus is opacified
• Treatment: Surgical excision along with the supplying gland
• Excellent prognosis, low recurrence

55. Neurogenic cysts of PNS
• Non-neoplastic lesions
• Two types : Meningocele &
encephalocele
• Both are results of congenital
herniation of intracranial meningeal
and neural tissue
• Encephalocele is more common and
contains primitive neural tissue
• Meningocele contains arachnoid and
dural tissue and CSF
• Radiographically seen as bony
dehiscences in base of skull or cranial
vault associated with a soft tissue
extension in nose and PNS
• Treatment : Surgical enucleation
Encephalocele in fronto-
ethmoidal sinus

57. Sinonasal
tumours
Benign tumours
Epithelial tumors
Sinonasal
papilloma
Mesenchymal
tumors
Osteoma
Angiofibroma
Haemangioma
Malignant
tumours
Epithelial
tumours
Squamous cell
carcinoma
Adenoid cystic
Carcinoma
Adenocarcinoma
Mesenchymal
tumours
Olfactory
neuroblastoama
Sarcomas

58. • Early : asymptomatic .
• Oral symptoms: Toothache , trismus, alveolar ridge fullness, erosion ,
malocclusion .
• Nasal findings: Obstruction, epistaxis, rhinorrhea , post nasal
discharge , anosmia, nasal mass or polyposis, mass in the medical
canthus, broadening of nasal dorsum .
• Ocular findings: Epiphora, diplopia, proptosis
• Facial signs: Paraesthesia, asymmetry
• Maxillary sinus involvement: Mass in palate or upper alveolus .
mass in upper gingivobuccal sulcus, malocclusion or loose teeth.
• Advanced :
Trismus, Orbital : Periorbital swelling , proptosis, epiphora ,
impaired ocular mobility

59. • Benign, localized proliferations of the
respiratory mucosa
• 10-25% of all paranasal tumors
• Cause: Some clinicians believe that these
are actually reactive hyperplasia
secondary to stimulants like allergens,
bacteria or HPV virus( type 6,11),
tobacco smoking
• Types :
1) Fungiform
2) Inverted
3) Cylindrical

60. Fungiform papilloma Inverted papilloma Cylindrical papilloma
Distribution Similar to oral
papillomas; 18-50% all
PNS papillomas
Most common, premalignant <7% of PNS papillomas
HPV Almost all variants are
HPV positve
HPV 6,11,16 & 18 Low frequency of HPV
association
Age/sex 20-50 years; M>F > 20 years; M>F 20-50 years; M>F
Clinical
features
Unilateral nasal
obstruction, epistaxis,
pink nodule
Unilateral nasal obstruction,
epistaxis, pink nodule, bone
erosion, locally aggressive
Unilateral nasal obstruction,
epistaxis, robust red multi
nodular
Treatment Complete surgical
excision, no malignant
transformation
Aggressive surgical excision,
Greatest potential for
malignant transformation and
destruction
Aggressive surgical excision

61. • Most common benign, mesenchymal tumor
of PNS
• Arises from junction of membranous &
endochondral bone in frontoethmoidal
suture region
• May have intracranial/ orbital extensions
• Histological subtypes: hard cortical & soft
cancellous
• Surgical excision
• Low recurrence
Osteoma
Hard cortical osteoma Soft cancellous
osteoma
Lobulated densities
obstructing sinus
Less dense, may be
mistaken with a soft
tissue sinus mass

62. • Usually an extension of juvenile
angiofibroma of nasopharynx
• Often extends into sphenoid and
ethmoidal sinuses
• Have a vertical spreading pattern
• Imaging: Appears as an enhancing
lesion in MRI
• Carotid angiography and CECT are
helpful as angiofibromas contain a
hypertrophied internal maxillary
artery
• Conservative surgical excision

63. • Rare mucosal neoplasm
• Neural crest origin
• Often exhibits immunological
symbiosis with the host
• Radical procedures are
contraindicated
• Treatment by endoscopic resection
• Role of radiotherapy is debatable

64. • Arise from the nasal cavity (septum/
alveolus)
• Multifocal, frequent recurrence
• Spreads superiorly into skull base
• Age range: both young and old
• Treatment: Craniofacial resection
• Not radiosensitive

65. • Classically arises from olfactory epithelium in the upper nasal vault
• The presence of a mass in the upper nasal cavity with associated skull base
erosion is typical.
• Bimodal peak in the second/third and sixth/seventh decades.
• Cervical metastases have been described in up to 23%.
• These are routinely resected in craniofacial approaches
• Endoscopic resection is being increasingly offered for this tumour particularly
when it arises from the middle and superior turbinates.
• Should always be combined with radiotherapy.
Stage I confined to primary site
Stage II presence of nodal
metastasis
Stage III presence of distant
metastasis

66. • 3% of all the head and neck
malignancies
• Incidence: Maxillary sinus (70%),
Ethmoid (20%), frontal (3%),
Sphenoid(1%)
• M > F ( 2 : 1 )
• Age – 6th & 7th decades
• Risk factors :
1. Wood workers
2. Leather manufacturers
3. Smoking & alcohol
• Damage from smoking and
alcohol plays a less damaging
role
Case of Small cell neuroendocrine
carcinoma of Left maxillary sinus

67. • About 30 per cent of patients with this
condition are woodworkers.
• These tumours usually arise in the
middle meatus and spread into the
ethmoidal sinuses
• Adenocarcinoma is generally rather
radio resistant but combined therapy is
usually offered.
• Many patients require a craniofacial but
in selected cases have been treated
successfully by an endoscopic resection
• Use of topical 5- flurouracil and surgical
debulking has been advocated

68. • Propensity to spread along perineural lymphatics which compromises
attempts at excision.
• Known to produce blood-borne metastases, classically to the lung while
lymphatic spread is rare.
• Treatment is generally combined surgery and radiotherapy

69. Clinical features:
1. Maxillary sinus ca
• Accounts for 80% of all PNS cancers
• Facial swelling, pain, paraesthesia of cheek
• Epistaxis, nasal discharge, obstruction
• Ill fitting dentures, alveolar/palatal mass
• Proptosis, diplopia, impaired vision, orbital pain
2. Ethmoid sinus ca
• Headache
• Referred pain to nasal, retrobulbar region
• Subcutaneous mass at inner canthus, diplopia & proptosis
• Nasal obstruction, discharge,

70. 1. Tumors from maxillary sinus:
• Posterior wall > Infratemporal fossa
• Superior wall > Infraorbital canal > Orbit
• Inferiorly > Roots of upper premolars & molars > Oral cavity / Palate
2. Tumors invading ethmoid bone:
• Via lamina papyracea of ethmoid bone
• Via emissary veins present anterior to the crista galli which eventually connects
to the sagittal sinus
• Via olfactory fibres through the cribriform plate
3. Tumors invading the orbit can spread via:
• Superior orbital fissures > Cavernous sinus
• Inferior orbital fissures > Pterygopalatine fossa & infratemporal fossa
• Orbital apex > Middle cranial fossa
4. Tumors from nasal septum:
• Superiorly: Into extranasal structures
• Inferiorly: Into upper lip & gingivobuccal sulcus

71. Diagnostic work up for PNS carcinoma
patients:
• Routine blood examination
• Histopathology
• Chest X-ray for Adenoid cystic carcinoma
• CT/MRI
• Dental evaluation
• Baseline ophthalmologic examination
• Baseline speech & swallowing assessment
• Fibre optic endoscopic examination & biopsy
Lymphatic spread of PNS carcinoma:
• Usually sparse-10% incidence of cervical lymph
node metastasis
• First echelon: Upper jugular/ submandibular nodes
• Contralateral metastasis: extremely rare
• Tumors of nasal septum, columella and nasal
vestibule show bilateral metastases
Lymphatic drainage of sinuses

73. AJCC
stage
Stage
grouping
Stage description
0 Tis
N0
M0
The tumor is only in the top layer of cells lining the inside of the
maxillary sinus and has not grown any deeper (Tis).
The cancer has not spread to nearby lymph nodes (N0) or to distant
parts of the body (M0).
I T1
N0
M0
The tumor has grown deeper, but it is only in the tissue lining the sinus
(the mucosa) and does not grow into the bone. (T1).
The cancer has not spread to nearby lymph nodes (N0) or to distant
parts of the body (M0).
II T2
N0
M0
The tumor has begun to grow into some of the bones of the sinus,
other than into the bone of the back part of the sinus (T2).
The cancer has not spread to nearby lymph nodes (N0) or to distant
parts of the body (M0).

74. AJCC
stage
Stage
grouping
Stage description
III T3
N0
M0
The tumor has grown into the bone at the back of the sinus (called the posterior wall) or
into the ethmoid sinus, the tissues under the skin, or the side or bottom of the eye
socket (T3).
The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body
(M0).
OR
T1 to
T3
N1
M0
The tumor might or might not have grown into structures just outside the maxillary sinus
(T1 to T3).
The cancer has spread to a single lymph node on the same side of the neck as the tumor,
which is no larger than 3 centimeters (cm) across (N1).
The cancer has not spread to distant parts of the body (M0).
IVA
T4a
N0 or
N1
M0
The tumor is growing into the skin of the cheek, the front part of the eye socket, the bone at
the top of the nose (cribriform plate), the sphenoid sinus, the frontal sinus, or certain parts
of the face (the pterygoid plates or the infratemporal fossa). This is also known
as moderately advanced local disease (T4a).
The cancer has not spread to nearby lymph nodes (N0), or it has spread to a single lymph
node on the same side of the neck as the tumor, which is no larger than 3 centimeters (cm)
across (N1).
The cancer has not spread to distant parts of the body (M0).

75. AJCC
stage
Stage
grouping
Stage description
IVB
T4b
Any N
M0
The tumor is growing into the throat behind the nasal cavity (the nasopharynx), the
back of the eye socket, the brain, the tissue covering the brain (the dura), some parts
of the base of the skull (middle cranial fossa or clivus), or certain cranial nerves. This
is also known as very advanced local disease (T4b).
The cancer might or might not have spread to nearby lymph nodes (any N). It has not
spread to distant parts of the body (M0).
OR
Any T
N3
M0
The tumor might or might not have grown into structures outside the maxillary sinus
(any T).
The cancer has spread to at least one lymph node that is larger than 6 cm across, OR it
has spread to a lymph node and then grown outside of the lymph node (N3).
It has not spread to distant parts of the body (M0).
IVC Any T
Any N
M1
The tumor might or might not have grown into structures outside the maxillary sinus,
and it might or might not have affected a vocal cord (any T).
The cancer might or might not have spread to nearby lymph nodes (any N).
The cancer has spread to distant parts of the body (M1)

77. • Nodal metastases is dependent upon histological subtype of the carcinoma
 Nodal metastases has as high as 28% in SCC, 25% in adenocarcinoma, 12%
for undifferentiated carcinoma and 10% for adenoid cystic carcinoma.
( According to Kaplan et al AJCC 1999)
• Maxilary sinus carcinomas involving hard palate shows a higher incidence of
cervical node metastases
(Castelnau et al Role of Elective Neck Management in Maxillary Sinus Squamous Cell
Carcinoma. Otolaryngol (Sunnyvale). 2016)
• Most powerful prognostic factor for overall survival is T- stage followed by
nodal involvement
(Wu TH, Huang JS, Wang HM, Wang CH et al Long-term survival after surgery of stage III-IV
maxillary sinus carcinomaChang Gung Med J. 2010)

78. According to Jatin Shah et al 2015
(Curr Opin Otolaryngol Head Neck Surg 2015)
• Treatment failure occurs in 62% of all cases of
maxillary sinus carcinoma
• Local recurrence is the most common cause
• Thus they concluded that :
1. Elective treatment of neck is justifiable only in
advanced staged (T3-4) maxillary sinus
carcinomas
2. Elective neck dissection can be performed if
we are planning for any vascular anastomosis
in the neck during flap reconstruction
3. If neck is not entered in a case cN0 T3-4
tumor we should irradiate the neck during
post op radiotherapy of primary site.
 IMRT is the most preferable modality of
radiotherapy
4. Elective neck dissection is not recommended
in T1-2 tumors of sinus

79. Incisions Midfacial degloving
approach
Weber –Fergusson approach Lateral rhinotomy approach
Intra/extraoral Intraoral Extraoral Extraoral
Access Indicated in pathologies
of frontal, ethmoidal,
maxillary sinus and
infratemporal fossa
Transoral approach for
pathologies of maxilla, not
suitable for skull base /
ethmoid lesions
Indicated for approach to
maxillary, sphenoid and
ethmoidal sinuses
Advantages Excellent esthetics Easier and provides wide
area of exposure
Easier approach, scar lies
in the folds of facial skin
Disadvantages Technique sensitive Heals by scar formation, Limited access

82. Borle’s extension- When
temporalis flap is planned for
maxillectomy defect
reconstruction
Lynch extension- To
expose the ethmoidal
sinus
Dieffenbach extension-
When total maxillectomy is
being planned

83. Palatal incisaion is given 3mm lateral to
midline so that a mucoperiosteal flap is
formed which can cover the raw bony
edge
Osteotomies through zygoma, floor of
orbit, frontal process of maxilla &
pyriform aperture

84. • The incision is made around the base of the nose (or
entering the nostril floor for a better esthetical result)
and along the facial nasal groove (In the border of both
esthetic units).
• The dissection goes deep to the subperiosteal plane of
the frontal process of the maxilla.
• Below the nasal bone the incision is deepened through
the nasal mucosa.
• A unilateral nasomaxillary osteotomy is made
with a small osteotome, and the two osteotomy
lines are joined at the level of the naso frontal
junction.
• The septum is cut and freed from the mobilized
segment according to the resection plan

85. • Originally described by
Tessier
• Excellent approach for
accessing the pathologies
of frontal and ethmoidal
sinuses.
• Major risks of this approach
include injury to the
temporal and zygomatic
branches of the facial
nerve, temporal hollowing,
scalp hematoma, parietal
scalp pain, parasthesia or
anesthesia, infection, and
nasal orbital hypertrophy.

86. • First reported by Smith in 1954
• Has become a ‘gold standard’ for tumors affecting the anterior skull
base ( According to Stell & Maran)
• Principle: En bloc resection of the tumor including the ethmoidal
sinuses, superior nasal septum and floor of anterior cranial fossa.
• Laterally part of the bony orbit may also be included in anterolateral
resection.
• Indications: Malignant tumors requiring surgical resection and
involving the anterior skull base
• Contraindications:
1. Extensive frontal lobe involvement
2. Bilateral orbital invasion/ optic chiasm
3. Distant metastasis cases
4. Tumors with poor prognosis like malignant melanoma

87. • Incision: An extended lateral
rhinotomy incision is made on
the side of maximal tumor
involvement.

88. • IMMEDIATE:
– convulsions
– haemorrhage
– air embolism
• INTERMEDIATE:
– cerebrovascular accident
– confusion
– pulmonary embolism
– meningitis
• LONG TERM:
– haemorrhage
– frontal abscess/encephalitis
– bone necrosis/fistula
– cerebrospinal fluid leak
– epilepsy
– epiphora

89. Brown’s classification of Maxillectomy, 2010 (Lancet Oncol 2010; 11: 1001–08)
Vertical classification: I—maxillectomy not causing an oronasal fistula; II—not involving the orbit; III—involving the
orbital adnexae with orbital retention; IV—with orbital enucleation or exenteration; V—orbitomaxillary defect; VI—
nasomaxillary defect.
Horizontal classification: a—palatal defect only, not involving the dental alveolus; b—less than or equal to 1/2
unilateral; c—less than or equal to 1/2 bilateral or transverse anterior; d—greater than 1/2 maxillectomy. Letters refer to
the increasing complexity of the dentoalveolar and palatal defect, and qualify the vertical dimension.

90. Algorithm for Maxillary Reconstruction
(Brown JS, Richard Shaw; Lancet Oncol 2010; 11: 1001–08)
• Class I defects: Most reconstructive techniques reported for class I
defects are the fasciocutaneous radial forearm flap or obturators
• Class II defects:
1) If the defect is less than half of the lateral alveolus and palate
(class IIb), very good results can be achieved with either
obturation or reconstruction.
2) Zygomatic implants are also efficient in Class II defects
• Class III defects:
a) With class III defects, orbital support is lost as well as anterior
support of the cheek and dental arch. Very little role for a
prosthetics.
b) Vascularized bone grafts are ideal especially DCIA with internal
oblique flap.
• Class IV: Involve patients with stage IV disease and poor prognosis
• Class V: Reconstruction with temporalis flap is adequate
• Class VI: Nasomaxillary defects that involve the nasal bone with or
without skin require reconstruction. Osteocut. RFFP is ideal.

91. Summary of published methods of
reconstruction from 1998-2009, in number of
reported cases
Recommended methods by Brown et al.

92. Management algorithm of the PNS tumors
invading the orbit (Stell & Maran)

93. • Can be used in resection of PNS tumours
• May need combination with craniofacial
resection if:
1. Dural invasion
2. Infiltration of superior sagittal sinus
• Principles: Complete resection of the
tumour including a wide field of clearance of
adjacent mucosa, bone and cartilage
• Can be used to repair skull base bone and
dural defects
• Extent of surgery: A complete fronto-ethmo-
sphenoidectomy is undertaken with lateral
nasal wall removal
• Advantage: low morbidity and short hospital
stay
• Disadvantage: technique sensitive

94. • Extension through anterior cranial fossa
• Involvement of both optic nerve
• Posterior extension into sphenoid sinus
• Invasion of middle cranial fossa
• Inoperable neck node & distant metastasis
• Well differentiated adenocarcinoma
• Early maxillary tumors
• Olfactory neuroblastoma
• SCC arising from inverted papiloma