This document discusses sinonasal tumours, including: 1. It classifies sinonasal tumours by tissue of origin such as epithelial, neuroendocrine, soft tissue, bone, etc. and lists examples of benign and malignant lesions within each tissue. 2. It provides details on specific benign tumours such as inverted papilloma, haemangioma, and juvenile angiofibroma. 3. It also discusses malignant tumours of the sinonasal region like squamous cell carcinoma, adenocarcinoma, olfactory neuroblastoma and haemangiopericytoma.

1. SINONASAL TUMOUR
DR. SMRUTI RANJAN SAMAL
DEPARTMENT OF ENT
VIMSAR, BURLA

2. CLASSIFICATION OF SINONASAL TUMOR BY TISSUE OF ORIGIN
TISSUE OF ORIGIN BENIGN LEISON MALIGNANT LEISION
A. Epithelial 1. Inverted Papilloma 1. Squamous Cell Carcinoma
2. Oncocytic Papilloma 2. SNUC
3. Exophytic Papilloma 3. Lymphoepithelial Carcinoma
4. REHA 4. Adenocarcinoma
5. Salivary Gland Adenoma 5. Salivary Gland Carcinoma
6. Mucoepidermoid
7. Adenoid Cystic Carcinoma
B. Neuroendocrine 1. Carcinoid
C. Soft tissue 1. Myxoma, 2. Leiomyoma 1. Fibrosarcoma
3. Hemangioma,4. Schwanoma 2. Rhabdomyosarcoma
5.Meningioma,6. Neurofibroma 3. Angiosarcoma
7. Angiofibroma, 8. Hemangiopericytoma
D. Bone & Cartilage 1. Fibrous dysplasia 1. Chondrosarcoma
2. Osteoma, 3. Chondroma 2. Osteosarcoma, 3. Chordoma
4.Osteoblastoma, 5.Ameloblstoma
E. Haematological 1. Lymhoma
2. Langerhans cell Histiocytosis
F. Germ Cell Tumour 1. Dermoid Cyst 1. Teratoma
G. Neuroectodermal tumours 1. Esthesioneuroblastoma

3. Epidemiology:
1. 0.5% of all body cancers
2. 15% of all upper respiratory neoplasm
3. Maxillary Sinus is most common
4. 80-85% are Squamous Cell Carcinoma
5. Male : Female = 2:1
6. Age group: 45-65 years
7. Most common adult sinonasal malignancy: SCC
8. Most common paediatric : Rhabdomyosarcoma
9. Maxillary sinus > Nasal cavity > Ethmoid sinus

4. Risk Factors:
a. Hardwood dust ( Adenocarcinoma)
b. Softwood dust ( Squamous Carcinoma)
c. Nickel Refining, Chromium workers
d. Boot , shoe and textile workers
e. Mustard gas exposure
f. Human Papilloma Virus
g. Long standing Dentigerous Cyst
h. Exposure to radiation

5. Benign Neoplasm of Nasal Cavity
A. Squamous Papilloma :
 Verrucous lesions similar to skin wart.
 Involves nasal vestibule / lower nasal septum
 Single/ Multiple; Sesile / Pedunculated
 Tt: Cauterisation /Cryosurgery/ Laser
B. Papilloma of the Nose
 Male: Female = 3:1
 Age 30-50 year
 3 types: 1. Fungiform : 50% , nasal septum, HPV +ve
2. Cylindrical: 3% , lateral wall/sinuses
3. Inverted Papilloma:47%, lateral wall

6. Inverted Papilloma:( Schneiderian papilloma)
 4% of sinonasal tumours
 Unilateral, local invasion, M>F, 50-70yr
 Malignant potential 10 %( TCC, SCC)
 Recurrence rate: 70 %
 Microscopically proliferation of the covering epithelium and extensive
finger-like inversions into the underlying stroma of the epithelium.
 U/L Nasal obstruction with Rhinorrhoea, epistaxis
 D/D: AC polyp, AFRS, malignancy

7. Investigation
 Biopsy: definite diagnosis
 CT Scan: Hyper dense areas & calcification
coronal section – Cribriform Palm Tree Pattern
 MRI: Enhancing mass in middle meatus with extension into maxillary
and ethmoid sinus. Heterogeneous Convoluted Cerebriform
appearance
Krouse’s Staging
Stage 1: Tumour limited to nasal cavity
Stage 2: Tumour limited to ethmoidal sinuses & medial & superior
portion of maxillary sinus
Stage 3: Tumours involves lateral & inferior aspects of maxillary
sinus or extension into frontal or sphenoid sinuses
Stage 4: Tumour spreads outside the confine of the nose and
sinuses

8. Resection :
• Initially via Trans-nasal resection: 50-80% recurrence
Via endoscopic surgery:
Type I- IP involving MM, E, SM, SS or combination
Type-II – Endoscopic medial maxillectomy- Nasoethmoidal complex not involving
anterior or lateral wall of the maxillary sinus
Type –III – Endonasal Denker / Sturman-Canfield – Anterior compartment of
Maxillary sinus
• Medial Maxillectomy via Lateral Rhinotomy
 Gold Standard (only 10-20% recurrence)
 indication: Benign & Malignant neoplasm limited to nasal walls & medial
wall of maxilla
• Inferior Medial Maxillectomy
• Endoscopic Medial Maxillectomy
 Identify the origin of the papilloma
 Bony removal of this region

9. Haemangioma
A: Capillary Haemangioma:
 Bleeding polypus of the nasal septum
 Soft , dark red, pedunculated / sesile
 Epistaxis , Nasal obstruction
 Local excision
B. Cavernous Haemangioma
 Arises from the turbinate
 Epistaxis , Nasal obstruction
 Excision

10. Juvenile Angiofibroma:
• Highly vascular , benign but biologically aggressive tumour
with high incidence of persistence, recurrence.
• 0.5% of all head and neck tumour
• Exclusive to adolescent male ( 8-20 y)
• Most accepted theory ( Mild and Mauris hypothesis): JA
originates from sex steroid stimulated hammartomatous
tissue located in the turbinate cartilage
Histopathology:
 Firm , slightly spongy lobulated swelling
 Nodularity increases with age
 Lack true capsule
 Immature fibroblast in connective tissue stroma
 Vascularization most often in periphery

11.  Originates from the upper margin of Sphenopalatine
Foramen
 Large tumour present as bilobed dumb bell swelling- one
component filling nasopharynx; other extending into
pterygopalatine and infratemporal fossa
 Blood Supply:
 Internal maxillary artery
 Ascending pharyngeal artery
 Vidian artery
 Vertebral artery
• Spread : Medial: nasopharynx & nasal cavity
Lateral: pterygopalatine>infratemporal fossa>cheek
Posterior: medial pterygoid>lateral pterygoid
Anterior : Orbit through infra-orbit fissure
Superior : nasal cavity> sphenoid sinus

12. Clinical Features:
• Progressive nasal obstruction
• Recurrent severe epistaxis-profuse, painless, unprovoked
• Facial deformity: frog face-proptosis+ nasal bridge broad
• Eye sign: proptosis, diplopia, lacrimation, eyelid swelling
• Neck mass- nasopharynx>infratemporal fossa
• ET dysfunction
• Nasal intonation
• Facial pain and Headache
Investigations:
Nasal endoscopy, CT, MRI, MRA, DSA

14. Tumour site Approach
Fisch stage 1, 2 & some 3 Endoscopic transnasal
Extending to nasal cavity &
maxillary sinus
Midfacial degloving
Extending to nasal cavity ,
maxillary sinus &Orbit
Lateral rhinotomy
Nasal cavity , sinuses, erosion
of posterior wall of sinuses
Weber Ferguson incision
Ethmoid-sphenoid complex
involving anterior skull base
Bicoronal incision and Anterior
Craniofacial Resection
Fisch stage 3, 4 Lateral skull base approach with
post operative radiotherapy
Major extension into
infratemporal fossa
Midline mandibulotomy with
trans palatine exposure

15. Transnasal Endoscopic Approach

16. Advantage
 Incision avoided
 Less haemorrhage
 Osteotomies avoided
 Decreased duration of hospitalization
 Minimal morbidity
Preoperative devascularisation
 Local chemical sclerosing agent- 2% phenol, lithium salicylate
 Cryosurgery using liquid nitrogen
 Electrocoagulation
 Estrogen therapy, Non-steroidal androgen receptor blocker
Postoperative residual disease
 External beam radiotherapy- 3000-3500cGy over 3weeks
 Chemothearpy – Doxorubicin, Dacarbazine, Vincristine
 Gamma knife , Cyber Knife

17. Chordoma:
 Ethmoid , nasal cavity, nasal septum
 Smooth , lobulated, firm
 Surgical excision
Intranasal Meningoencephalocole
 Herniation of brain tissues & meninges : Foramen caecum or Cribiform
plate
 Smooth polyp in upper part of nose between the septum and middle
turbinate
 Infants & young children
 Increases size on crying or straining
 Tt; Frontal Craniotomy, severing the stalk
from brain & repair dural & bony defect

18. Glioma;
o 30% are intranasal , 10% are both intra & extranasal
o Intranasal glioma presents as Firm Polyp
o Mostly infant & children
Nasal Dermoid:
o Widening of upper part of nasal septum with splaying
nasal bone & hypertelorism
o A pit or sinus in the midline of nasal
dorsum with hair protruding from
the opening

19. Malignant neoplasm- Nasal Cavity
 Primary carcinoma per se rare- may be extension of maxillary or
ethmoid carcinoma
A. Squamous Cell Carcinoma:
 Vestibular : arises from lateral wall of nasal vestibule extend to
columella, nasal floor, lip. Metastasis to Parotid
 Septal : arises from mucocutaneous junction & causes burning &
soreness in nose. “ nose-picker’s cancer”
 Lateral wall: extend into ethmoid or maxillary sinus. Presents as
polypoid mass.
 Nasal obstruction, epistaxis, pain , cervical lymphadenopathy
 Tt : Wide excision with 1 cm healthy margin
Radiotherapy

20. B. Adenocarcinoma & Adenoid cystic carcinoma
 Arises from glands of mucous membrane or minor salivary glands.
 Histologically: Low grade: mix of tubular & cribriform pattern
cribriform pattern – Swiss Cheese pattern arranged in a tubular structure
High grade: solid areas of malignant cells
 Upper part of the lateral wall of nasal cavity
 Types: Papillary, Sessile, Alveolar-mucoid
 Surgical resection
C. Malignant melanoma
 Mean age : 50 years
 Both sexes are equally affected
 Presents as slaty-gray / bluish-black polypoidal mass
 Anterior nasal septum/MT/IT
 Tumour spread by lymphatic & blood stream
 Tt : Wide surgical excision

21. D.Olfactory Neuroblastoma( Ethesioneuroblastoma)
 Tumour of olfactory placode – neural element of cribiform plate
 Both sex at 20-40yr age group
 Presents as cherry red, polypoidal mass in upper third of nasal cavity-
nasal obstruction , epistaxis , hyposmia
 Cervical node metastasis, multicentre
 Local invasion, Systemic spread
 Biopsy: Definite diagnosis
 CT Scan: Dumbbell mass –
intracranial fossa & upper nasal cavity
Bone destruction , speckled calcification
 Surgical excision followed by radiotherapy
 Preoperative chemotherapy- Vincristine ,Cyclophosphamide

22. E. Haemangiopericytoma
 Tumour of vascular origin
 Age group: 60-70 year
 Polypoidal mass , bleeds on touch
 Arises from Zimmermann
Pericyte cells of capillaries
 Tt: Radiotherapy Wide surgical
Excision. 50% recurrence. 10%(M)
Metastasis to lung, liver, bone

23. Malignant Neoplasm of PNS
 Maxillary sinus m.c. site
 Early clinical features:
 Nasal Stuffiness
 Blood stained nasal discharge
 Facial paraesthesia or pain
 Epiphora
 Late clinical feature:
 Medial spread: u/l nasal obstruction, u/l purulent nasal discharge,
epistaxis, friable, nasal mass
 Anterior spread: cheek swelling, invasion of facial skin
 Inferior spread: expansion of alveolus with dental pain, loosening of
teeth, poor fitting of dentures, swelling in hard palate or alveolus
 Superior spread: Proptosis, diplopia, ocular pain
 Posterior spread: Pterygoid muscle involvement- Trismus
 Intracranial spread: Ethmoid, cribriform or foramen lacerum
 Lymphatic spread: neck node metastasis
 Systemic spread: Lungs, bone

25. Diagnosis
 Diagnostic Nasal Endoscopy
 X-ray PNS: expansion & destruction of
bony wall
 CT scan Nose & PNS: with contrast
 Biopsy
Ohngren’s Classification
Ohngren’s line:
 Imaginary plane extending b/n medial canthus of eye & angle of
mandible.
 Supra structural growth: poor prognosis
 Infra structural growth: better prognosis

26. Lederman’s Classification:
 2 horizontal lines pass through floors of orbits & maxillary sinus:
 Supra structure, Mesostructure, Infrastructure

28. Treatment :
T1 and T2 : Surgery or Irradiation
T3 and T4 : Combined modalities
Inoperable tumour : Chemo radiation
Intra-arterial infusion of 5-Fluorouracil or Cisplatin

29. SURGICAL OPTIONS
A. Total Maxillectomy
 Weber – Ferguson incision
 Malignancy limited to maxilla
B. Radical Maxillectomy with Orbital exenteration
 Involvement of orbital fat
C. Anterior Cranio-facial resection
 Extended lateral rhinotomy incision
 Involvement of cribriform plate , frontal sinus

30. MAXILLECTOMY
TUMORS CONFINED TO LATERAL NASAL WALL
TUMOURS CONFINED TO UPPER ALVEOLUS OR HARD PALATE
TUMORS LIMITED TO ROOF OF THE MAXILLARY SINUS
AND/OR ETHMOID SINUS WITH OR WITHOUT ORBITAL
INVOLVEMENT
TUMOURS CONFINED TO UPPER ALVEOLUS OR HARD PALATE
WITH LIMITED INVOLVEMENT OF LOWER HALF OF MAXILLARY
SINUS/NASAL CAVITY; POSTERIOR EXTENSION( PTERYGOID
PLATE)
INVOLVES REMOVAL OF THE HARD PALATE & THE ORBITAL
FLOOR ALONG WITH THE ENTIRE MAAXILLA ON ONE SIDE OF
THE FACE

31. WEBER FERGUSSON INCISION
Line drawn through the vermillion border along with filtrum of the
lip , extending around the base of the nose & along the facial nasal
groove.

32. Modifications in Weber Fergusson Incision
 Lynch extension
 Borle’s extension
 Dieffenbach extension

33. Surgical Steps:
Step .1: Incision

34. Step.2: Flap Elevation
Step.3: Dissecting The Periorbita

35. Step. 4: Osteotomies
 First Bone Cut(1) Malar prominence.Cut is made anterior(1a) or posterior
( 1b1 and 1b2) to the malar prominence acc. to tumour extent.
 Second Bone Cut: (2) Palate is transected with Gigli saw through the nose
into the mouth at the junction of hard & soft palate
 Third Bone Cut (3): separate naso-maxillary suture extended superiorly to
the level of 2-3mm inferior to a line paralleling the ant. & post.ethmoid vessel
 Fourth Bone Cut(4): chisel is turned posteriorly into ethmoid labyrinth to the
depth of PEA & turns inf. to Inferior Orbital fissure
 Fifth Bone Cut(5) : Mandible is depressed , pterygoid plates amputated from
skull base/ posterior sinus wall

36. Step.5: Delivering the Maxilla
Maxilla is delivered by antero-inferior traction.
Step.6: Reconstruction & Wound Closure
Reconstruction includes: 1. Dacryocystorhinostomy (DCR)
With lacrimal sac marsupialization
2. Orbital floor reconstruction – titanium mesh/free cartilage/bone graft/
osteocutaneous free micro vascular flaps
ORBITAL EXENTERATION
Tumour invading orbital soft tissues ( lid, lacrimal apparatus, globe,
muscle or fat)
1. Incision
2. Dissecting the Periorbita
3. Transection of Orbital Apex Tissue Bundle
4. Final closure

37. INCISION Dissecting the Periorbita
Transection of Orbital Apex
Tissue Bundle
Final closure. A. Front view, B. saggital
view

38. Anterior Craniofacial Resection
 Tumoursinvolving anteriorskull base
 Allows wideexposureofthe complexanatomicalstructuresatthe baseofskull permittingmonobloc
tumourresection
 Classical cfr : transfacial/ transnasal and trans cranial approach
 Modified cfr : endoscopic assisted cfr in place of transfacial approach

39. MIDFACIAL DEGLOVING
Advantage – 1. very good exposure
2. bilateral exposure
3. less post operative complication
4. can be combined with CFR
5. cosmetic results
Tumours resectable:
1. Inverted papilloma
2. Squamous cell carcinoma
3. Angiofibroma
4. Haemangioma
5. Plasmacytoma
6. Ameloblastoma

40. 3 steps
A. Bilateral maxillary vestibular approach & Sub periosteal dissection- by
bilateral sub labial incision from maxilary tuberosity to tuberosity

41. B. Circular endonasal incision using
 Inter-cartilaginous incision (A)
 Transfixion incision (B)
 Incision of the nasal floor along the piriform aperture

42. C. Degloving of the nose, nasal radix & ethmoid region
Area exposed: Nasal cavity, nasopharynx , maxillary
antrum , ethmoid, sphenoid, skull base .

43. Transoral ( Caldwell-Luc Incision)
 Sublabial approach – small limited infrastructural
malignancy- upper alveolar ridge, anterior nasal cavity
& hard palate

44. ENDOSCOPIC MEDIAL MAXILLECTOMY
Step1: Debulking of the tumour

45. Step2 : Removal of the Uncinate & identification of natural
ostium
Step 3: Identification of Hasner Valve

46. Step 4: Subtotal Inferior Turbinectomy
Step 5 : Creation of a Nasal Floor Mucosal Flap

47. Step 6 : Mega –antrostomy
Step 7: Exposure of the Anterior, Inferior or Lateral
Maxillary sinus ( when necessary)

48. Step 8: Removal of the Tumour Pedicle
Postoperative Considerations
 Irrigation with saline solution
 Serial in office debridement
 Patient should be instructed to massage the NLD in postoperative
period
 Long term surveillance for recurrence