sinonasal malignancy :diagnosis to management

1. SINONASAL
MALIGNANCY
By Dr. Abdulrahman
Yaqoub
PGY1 ORL-HNS
Reviewed By Dr. Hadi
Mokarbish

2. OBJECTIVE
Case Presentation ​
Introduction
​Clinical Features
Classification
​Work Up
Management ​

3. CASE
PRESENTATION
A 21 years old female presented to ENT clinic with
right side nasal obstruction with nasal discharge for 2
years
HOW WILL YOU APPROACH THIS PATIENT ?
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4. H/E
The patient complained of a right side
nasal obstruction with nasal discharge,
headache, hyposmia, and recurrent nasal
bleeding for 2 years .
On examination, there was a right sided
nasal polypoidal mass, red in color ,not
bleeding on touch .
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What is the most appropriate next step
?

6. DIFFERENTIAL
DIAGNOSIS
Inflammatory :
CRSwNP
Foreign body granuloma
Granulomatous disease
Benign Neoplasm :
Inverted papilloma
Osteoma
Chondroma
Fibrous dysplasia
Gliomas
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7. DIFFERENTIAL
DIAGNOSIS
Malignant neoplasm :
Squamous cell carcinoma
Adenocarcinoma
Malignant
Melanoma
Infection :
Bacterial or fungal Sinusitis
Trauma
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8. MANAGEMENT
CT PNS
PNS MRI ( if needed )
Medical management for nasal symptoms
Booked for FESS
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9. 9
PNS CT scan was done

10. 10
PNS CT scan was done

11. CONT.
CT scan showed total opacification of
right sphenoid sinus with polypoidal mass
occupying the right nasal cavity and
retention cyst in the right maxillary sinus.
What is next step ?
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12. MRI 12

13. MRI 13

14. MRI
• An MRI for Paranasal sinuses was
obtained . the findings were a right
posterior nasal soft tissue mass
isointensity signal on T2, hypointense
in T1, shows enhancement in
postcontrast images,
• The right sphenoethmoidal and recess
filled with hypointense signal lesion in
T2
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15. MANAGEMENT
The patient underwent endoscopic sinus
surgery where she had the right nasal
mass excised, then wide sphenoidotomy
,anterior and posterior ethmoidectomy
,and middle meatus antrostomy were
performed. The nasal mass was sent for
histopathological study.
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16. MANAGEMENT
The patient had uneventful postoperative
period and discharged in a good
condition with fellow up in OPD. After
receiving the histopathology report, the
decision was to have a second look and
to obtain clear margins of the tumor.
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17. MANAGEMENT
she was admitted for second endoscopic
sinus surgery for clear margins and the
completion of the tumor
during the surgery, all suspected mucosa
in the right side were excised including
pterygoid base and multiple biopsies for
clear margins were performed. The
histopathological report confirmed the
complete excision of the tumor with clear
margins.
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18. MANAGEMENT
The histological result secretory
carcinoma ( SC ), previously called
mammary analogue secretory carcinoma
( MASC ).
The Patient had smooth post-operative
period and was discharged in a good
condition.
Metastatic work-up were negative for any
metastasis.
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19. MANAGEMENT
The patient case was discussed in the
tumor board and the decision was that
there were no further management
needed and she need only surveillance
follow up for close monitoring for any
recurrence. She is currently on regular
follow-up with no signs of recurrence
clinically or radiologically.
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20. MANAGEMENT 20

21. PNS SC, MASC
Mammary gland analogue Secretory
carcinoma is a newly discovered kind of
salivary gland carcinoma. This disease is
rare and can affect children and
adolescents
Although the majority of SCs affect the
major salivary glands, yet about 30% of
them can develop in minor salivary
glands, and mostly in the oral cavity. SCs
in the sinonasal tract appear to be rare,
however, there have been some recorded
cases
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22. PNS SC, MASC
SCs are slow-growing tumors that are
discovered incidentally during a physical
examination.
The most common Presentation of MASC
is a slowly growing painless nodule.
Pain, skin infiltration, ulceration, cervical
lymphadenopathy, and facial nerve
involvement are some of the other
reported symptoms
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23. PNS SC, MASC
Imaging has only been described in a
small number of cases, thus, relying on
imaging as a diagnostic modality has not
been well reported.
To date, the only definitive approach to
diagnose MASC is excisional biopsy of
the mass followed by further histological
investigation.
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24. PNS SC, MASC
Surgical excision is the most common
treatment for SC.
Despite the lack of evidence on
treatments and outcomes, SC appears to
be a low-grade malignant tumor with a
good prognosis.
However, in a significant number of
cases, recurrences and local tumor
metastases have previously been
reported.
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25. INCIDENCE
• 3% of aero digestive malignancies
• 1% of all malignancies
• Males : females = 2 : 1.
• Sixth to seventh decades
• The maxillary sinus is most commonly involved
with tumor, followed by the nasal cavity, the
ethmoids, and then the frontal and sphenoid
sinuses.
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26. ANATOMY

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Maxillary Antrum :
Superior: Orbit, Ethmoid
Posterior: Pterygoids,
Infratemporal fossa
Ethmoid Sinus:
Superior: Fovea,
Cribriform
Medial: lamina Papyracea

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Sphenoid Sinus
Superior: Optic nerve,
Pituitary
Lateral: ICA, cavernous
Inferior: Nasopharynx
Frontal Sinus:
Inferior: Orbit
Posterior: Anterior cranial
fossa

29. LYMPHATIC
DRAINAGE
The anterior nose has the same lymphatic
drainage as the external nose. These tend to
spread to the sub-mental or level I area.
The posterior nose tends to drain to the retro
pharyngeal nodes. As well as the lateral pharyngeal
nodes, which eventually drain into the level II.
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30. RISK FACTORS 30

31. CLINICAL PICTURES 31

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33. CLASSIFICATION 33
1- Histological Classification
 Malignant Epithelial Sinonasal Malignancy
 SCC
 Adenocarcinoma
 ACC
 Melanoma
 Olfactory Neuroblastoma
 SNUC
 Small cell carcinoma

34. CLASSIFICATION 34
1- Histological Classification
 Malignant Non Epithelial Sinonasal
Malignancy
 Rhabdomyosarcoma
 Neurogenic Sarcoma
 Hemangiopericytoma
 Leiomyosarcoma
 Fibrosarcoma
 Osteogenic sarcomas and
Chondrosarcomas
 Lymphomas
 Metastatic Tumor
 Chordoma

35. CLASSIFICATION 35
1- Anatomical Classification
 Maxillary Sinus Ca
 Nasal Cavity Ca
 Ethmoid Sinus Ca
 Frontal Sinus Ca
 Sphenoid Sinus Ca

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58. DIAGNOSTIC WORKUP
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Physical Examination
Nasal Endoscopy
Biopsy
Imaging ( CT, MRI )

59. COMPUTED TOMOGRAPHY
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 Effective in delineating calcification and evaluating the
pattern of bone invasion
 Difficult to differentiate between tumor vs secretion vs
inflammation
MRI
 Excellent for determining perineural spread, involvement of
dura or involvement intracranially
 Inflammatory tissue and secretion are intense in T2, while
tumors are intermediate in T1 & T2, enhancement by
gadolinium

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Manageme
nt

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Manageme
nt
Surgical resection is the primary treatment modality
for cancers involving the maxillary or ethmoid
sinuses.
Resection is often limited by tumor involvement of
the base of skull which can result in damage to
critical structures such as brain, and the cranial
nerves.
Unresectability :
o Extension to frontal lobes.
o Invasion of pre vertebral fascia.
o Bilateral optic nerve involvement.
o Cavernous sinus extension.

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Manageme
nt
The goal of surgery for nasal cavity and paranasal
sinus tumors is to achieve en bloc resection of all
involved bone and soft tissue with clear margins
while maximizing the cosmetic and functional
outcome.
Surgical Approaches :
o Medial Maxillectomy Lateral Rhinotomy
o Mid-Face Degloving
o Total Maxillectomy
o Orbital Exenteration
o Inferior Maxillectomy

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Manageme
nt

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Manageme
nt

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Manageme
nt

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Manageme
nt

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Manageme
nt

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Manageme
nt

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Manageme
nt
• Indication of Orbital Exenteration :
 Involvement of the orbital apex
 Involvement of the extra ocular muscles
 Involvement of the bulbar conjunctiva or sclera
 Lid involvement beyond a reasonable hope for
reconstruction
 Non-resectable full thickness invasion through the
periorbita into the retrobulbar fat

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Manageme
nt

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Manageme
nt

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Manageme
nt

79. THANK YOU