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  1. 1. DISEASES OF THE NOSE AND PARANASAL SINUSES RYAN DUNCAN, MD PGY-4 RESIDENT OTOLARYNGOLOGY-HEAD AND NECK SURGERY February 6, 2006
  2. 2. NASAL ANATOMY
  3. 3. NASAL ANATOMY
  4. 4. NASAL ANATOMY
  5. 5. Ethmoid Maxilla Palatine Lacrimal Pterygoid plate of Sphenoid Nasal Inferior Turbinate Bony Structure
  6. 7. 7 bones 4 paired sinuses 4 turbinates 3 meati Drainage system Nervous supply Vascular supply Related structures Sinus Anatomy Overview
  7. 8. Arterial Supply External Carotid Maxillary A. Sphenopalatine Internal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear
  8. 10. Innervation
  9. 11. VIRAL RHINITIS <ul><li>Inflammation and swelling of the mucous membranes of the nose usually caused by rhinovirus (common cold) </li></ul><ul><li>Symptoms consist of runny nose, congestion, post-nasal drip, cough, and a low-grade fever </li></ul><ul><li>Diagnosis made by history; adjunct tests usually not necessary </li></ul>
  10. 12. VIRAL RHINITIS <ul><li>Complications may prolong illness </li></ul><ul><li>often triggers asthma attacks </li></ul><ul><li>Secondary infections: congestion in nose/ear blocks normal drainage allowing bacteria to grow  sinusitis, otitis media </li></ul>
  11. 13. VIRAL RHINITIS-TREATMENT <ul><li>No vaccines available </li></ul><ul><li>Echinacea, Vit C, Zinc effectiveness not confirmed </li></ul><ul><li>Currently available antiviral drugs not effective </li></ul><ul><li>Symptomatic treatment with antihistamines, decongestants, cough preparations </li></ul>
  12. 14. Function of Paranasal Sinuses <ul><li>Humidifying and warming inspired air </li></ul><ul><li>Regulation of intranasal pressure </li></ul><ul><li>Increasing surface area for olfaction </li></ul><ul><li>Lightening the skull </li></ul><ul><li>Resonance </li></ul><ul><li>Absorbing shock </li></ul><ul><li>Contribute to facial growth </li></ul><ul><li>generate 1 L mucus/day </li></ul>
  13. 15. Rhinosinusitis <ul><li>Introduction </li></ul><ul><li>37 million Americans suffer from “sinusitis” </li></ul><ul><li>25 million office visits in 1994-incidence increasing </li></ul><ul><li>Over $200 million spent on prescriptions for cold products; over half is for products containing antihistamines </li></ul><ul><li>97 % of patients who see a physician with “cold symptoms” receive a prescription </li></ul>
  14. 16. Rhinosinusitis <ul><li>Defining “Sinusitis” </li></ul><ul><li>Acute rhinosinusitis (ARS) </li></ul><ul><li>Subacute rhinosinusitis (SARS) </li></ul><ul><li>Chronic rhinosinusitis (CRS) </li></ul><ul><li>Recurrent acute rhinosinusitis (RARS) </li></ul><ul><li>Acute superimposed upon chronic rhinosinusitis (ARS/CRS) </li></ul>
  15. 17. Rhinosinusitis <ul><li>Major Symptoms </li></ul><ul><li>Facial pain/pressure </li></ul><ul><li>Facial congestion </li></ul><ul><li>Nasal obstruction </li></ul><ul><li>Purulent PND </li></ul><ul><li>Altered sense of smell </li></ul><ul><li>Fever (ARS) </li></ul><ul><li>Minor Symptoms </li></ul><ul><li>Headache </li></ul><ul><li>Fever (all non-acute) </li></ul><ul><li>Halitosis </li></ul><ul><li>Fatigue </li></ul><ul><li>Dental pain </li></ul><ul><li>Cough </li></ul><ul><li>Ear pain/pressure </li></ul>
  16. 18. Rhinosinusitis <ul><li>Acute Rhinosinusitis </li></ul><ul><li>Duration < 4 weeks </li></ul><ul><li>> 2 major or 1 major and 2 minor factors or purulence seen on examination </li></ul><ul><li>Subacute Rhinosinusitis </li></ul><ul><li>Duration-4-12 weeks </li></ul>
  17. 19. Middle turbinate MSO Septum
  18. 20. Rhinosinusitis <ul><li>Chronic Rhinosinusitis </li></ul><ul><li>Duration- > 12 weeks </li></ul><ul><li>Recurrent Acute Rhinosinusitis </li></ul><ul><li>> 4 episodes/yr. of ARS with symptoms lasting > 7 days with no intervening signs and symptoms of CRS </li></ul><ul><li>Acute Exacerbation of Chronic Rhinosinusitis </li></ul><ul><li>Sudden worsening of CRS </li></ul>
  19. 21. Septum MT remnant MSO CRS -”Empty nose”-Pseudomonas, Staph. aureus
  20. 22. Rhinosinusitis <ul><li>Diagnosis </li></ul><ul><li>Physical examination-anterior rhinoscopy vs. nasal endoscopy </li></ul><ul><ul><li>Edema </li></ul></ul><ul><ul><li>Hyperemia </li></ul></ul><ul><ul><li>Purulence </li></ul></ul><ul><ul><li>Polyps </li></ul></ul>
  21. 23. Rhinosinusitis <ul><li>Diagnosis </li></ul><ul><li>Plain radiography of the paranasal sinuses </li></ul><ul><li>Magnetic resonance imaging </li></ul><ul><li>Computerized tomography (non-contrast) </li></ul><ul><ul><li>Screening CT </li></ul></ul><ul><ul><li>Standard CT </li></ul></ul><ul><ul><li>Timing of CT </li></ul></ul><ul><li>Other tests </li></ul>
  22. 24. Rhinosinusitis <ul><li>Management </li></ul><ul><li>Goals </li></ul><ul><ul><li>Elimination of infection </li></ul></ul><ul><ul><li>Restoration of ventilation and drainage </li></ul></ul>
  23. 25. Rhinosinusitis <ul><li>Surgical Management </li></ul><ul><li>Prior to 1985, most surgery via external approach with emphasis on maximum tissue removal </li></ul><ul><li>With introduction of functional endoscopic sinus surgery (FESS) in 1985, emphasis is on maximum tissue preservation </li></ul>
  24. 26. Rhinosinusitis <ul><li>Surgical Management </li></ul><ul><li>ARS-no role for surgery except for management of complications </li></ul><ul><li>CRS-indicated for medically refractory disease; 80-98 % improvement, revision rate < 10 %, major complications <0.3 % </li></ul><ul><li>RARS-focused surgery often helpful </li></ul>
  25. 27. Techniques of Functional Endoscopic Sinus Surgery Uncinectomy LNW MT MT LNW
  26. 28. Techniques of Functional Endoscopic Sinus Surgery 0 degree telescope 45 degree telescope Maxillary Antrostomy MSO Accessory ostium
  27. 29. Rhinosinusitis <ul><li>Surgical Management </li></ul><ul><li>Computer assisted surgery (CAS) of the anterior skull base and paranasal sinuses has been commercially available since 1996 </li></ul><ul><li>CAS has allowed us to safely expand minimally invasive endoscopic transnasal techniques </li></ul>
  28. 31. Rhinosinusitis <ul><li>Conclusion </li></ul><ul><li>“Sinusitis” is a complicated disease </li></ul><ul><li>Defining categories is beneficial </li></ul><ul><li>Management options are varied </li></ul><ul><li>Surgical therapy plays a role for a well-defined, small population of patients </li></ul>
  29. 32. EPISTAXIS (nosebleeds)
  30. 33. Why bleeding from the nose ? <ul><li>Vascular organ secondary to incredible heating/humidification requirements </li></ul><ul><li>Vasculature runs just under mucosa (not squamous) </li></ul><ul><li>Arterial to venous anastamoses </li></ul><ul><li>ICA and ECA blood flow </li></ul>
  31. 34. EPISTAXIS <ul><li>External Carotid Artery </li></ul><ul><li>-Sphenopalatine artery </li></ul><ul><li>-Greater palatine artery </li></ul><ul><li>-Ascending pharyngeal artery </li></ul><ul><li>-Posterior nasal artery </li></ul><ul><li>-Superior Labial artery </li></ul><ul><li>Internal Carotid Artery </li></ul><ul><li>-Anterior Ethmoid artery </li></ul><ul><li>-Posterior Ethmoid artery </li></ul>
  32. 35. Kesselbach’s Plexus/Little’s Area: -Anterior Ethmoid (Opth) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX ) Woodruff’s Plexus: -Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)
  33. 37. Anterior vs. Posterior <ul><li>Maxillary sinus ostium </li></ul><ul><li>Anterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severe </li></ul><ul><li>Posterior: older population, usually from Woodruff’s plexus, more serious. </li></ul>
  34. 38. Etiology <ul><li>Local factors </li></ul><ul><ul><li>Vascular </li></ul></ul><ul><ul><li>Infectious/Inflammatory </li></ul></ul><ul><ul><li>Trauma (most common) </li></ul></ul><ul><ul><li>Iatrogenic </li></ul></ul><ul><ul><li>Neoplasm </li></ul></ul><ul><ul><li>Dessication </li></ul></ul><ul><ul><li>Foreign Bodies/other </li></ul></ul>
  35. 39. Etiology <ul><li>Systemic factors </li></ul><ul><ul><li>Vascular </li></ul></ul><ul><ul><li>Infection/Inflammation </li></ul></ul><ul><ul><li>Coagulopathy </li></ul></ul>
  36. 40. Local Factors -- Vascular <ul><li>ICA Aneurysms </li></ul><ul><ul><li>extradural </li></ul></ul><ul><ul><li>cavernous sinus </li></ul></ul>
  37. 41. Local Factors - Infection/Inflammation <ul><li>Rhinitis/Sinusitis </li></ul><ul><ul><li>Allergic </li></ul></ul><ul><ul><li>Bacterial </li></ul></ul><ul><ul><li>Fungal </li></ul></ul><ul><ul><li>Viral </li></ul></ul>
  38. 42. Local Factors - Trauma <ul><li>Nose picking </li></ul><ul><li>Nose blowing/sneezing </li></ul><ul><li>Nasal fracture </li></ul><ul><li>Nasogastric/nasotracheal intubation </li></ul><ul><li>Trauma to sinuses, orbits, middle ear, base of skull </li></ul><ul><li>Barotrauma </li></ul>
  39. 43. Nasal Fracture with Septal Hematoma
  40. 44. Local Factors - Iatrogenic nasal injury <ul><li>Functional endoscopic sinus surgery </li></ul><ul><li>Rhinoplasty </li></ul><ul><li>Nasal reconstruction </li></ul>
  41. 45. Local Factors - Neoplasm <ul><li>Juvenile nasopharyngeal angiofibroma </li></ul><ul><li>Inverted papilloma </li></ul><ul><li>SCCA </li></ul><ul><li>Adenocarcinoma </li></ul><ul><li>Melanoma </li></ul><ul><li>Esthesioneuroblastoma </li></ul><ul><li>Lymphoma </li></ul>
  42. 47. Local Factors – Dessication <ul><li>Cold, dry air—more common in wintertime </li></ul><ul><li>Dry heat—Phoenix and Death valley </li></ul><ul><li>Nasal oxygen </li></ul><ul><li>Anatomic abnormalities </li></ul><ul><li>Atrophic rhinitis </li></ul>
  43. 48. Local Factors - Other <ul><li>Self-inflicted (pedi) vs. traumatic foreign bodies </li></ul><ul><li>Intranasal parasites </li></ul><ul><li>Septal perforation </li></ul><ul><li>Chemical (cocaine, nasal sprays, ammonia, etc.) </li></ul>
  44. 49. Systemic Factors -- Vascular <ul><li>Hypertension/Arteriosclerosis </li></ul><ul><li>Hereditary Hemorrhagic Telangectasias (OWR) </li></ul>
  45. 50. Epistaxis Osler-Weber- Rendu (HHT) R L
  46. 51. Systemic Factors – Infection/Inflammation <ul><li>Tuberculosis </li></ul><ul><li>Syphillis </li></ul><ul><li>Wegener’s Granulomatosis </li></ul><ul><li>Periarteritis nodosa </li></ul><ul><li>SLE </li></ul>
  47. 52. Systemic Factors – Coagulopathies <ul><li>Thrombocytopenia </li></ul><ul><li>Platelet dysfunction </li></ul><ul><ul><li>Systemic disease (Uremia) </li></ul></ul><ul><ul><li>drug-induced (Coumadin/NSAIDs/Herbal supplements) </li></ul></ul><ul><li>Clotting Factor Deficiencies </li></ul><ul><ul><li>Hemophilia </li></ul></ul><ul><ul><li>VonWillebrand’s disease </li></ul></ul><ul><ul><li>Hepatic failure </li></ul></ul><ul><li>Hematologic malignancies </li></ul>
  48. 53. Etiology and Age <ul><li>Children—foreign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o) </li></ul><ul><li>Adults—trauma, idiopathic </li></ul><ul><li>Middle age—tumors </li></ul><ul><li>Old age--hypertension </li></ul>
  49. 54. Initial Management <ul><li>ABC’s </li></ul><ul><li>Medical history/Medications </li></ul><ul><li>Vital signs—need IV? </li></ul><ul><li>Physical exam </li></ul><ul><ul><li>Anterior rhinoscopy </li></ul></ul><ul><ul><li>Endoscopic rhinoscopy </li></ul></ul><ul><li>Laboratory exam </li></ul><ul><li>Radiologic studies </li></ul>
  50. 55. suction good light anesthetic silver nitrate merocels gelfoam bacitracin endoscopes suction bovie/bipolar Afrin T.C.A. surgicel epistat bayonet forcepts vaseline gauze
  51. 56. Non-surgical treatments <ul><li>Control of hypertension </li></ul><ul><li>Correction of coagulopathies/thrombocytopenia </li></ul><ul><ul><li>FFP or whole blood/reversal of anticoagulant/platelets </li></ul></ul><ul><li>Pressure/Expulsion of clots </li></ul><ul><li>Topical decongestants/vasocontrictors </li></ul><ul><li>Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie) </li></ul><ul><li>Nasal packing (effective 80-90% of time) </li></ul><ul><li>Greater palatine foramen block </li></ul>
  52. 57. Non-surgical treatments – on d/c <ul><li>Humidity/emolients </li></ul><ul><li>Discontinue offending meds </li></ul><ul><li>Nasal saline sprays </li></ul><ul><li>Avoidance of nose picking/blowing </li></ul><ul><li>Sneeze with mouth open </li></ul><ul><li>Avoid straining/bedrest </li></ul>
  53. 58. Nasal packs <ul><li>Anterior nasal packs </li></ul><ul><ul><li>Traditional </li></ul></ul><ul><ul><li>Recent modifications </li></ul></ul><ul><li>Posterior nasal packs </li></ul><ul><ul><li>Traditional </li></ul></ul><ul><ul><li>Recent modifications </li></ul></ul><ul><li>Ant/Post nasal packing </li></ul>
  54. 59. TSS—Nugauze vs. Merocel Electron microscopy
  55. 60. Posterior Packs – Admission <ul><li>Elderly and those with other chronic diseases may need to be admitted to the ICU </li></ul><ul><li>Continuous cardiopulmonary monitoring </li></ul><ul><li>Antibiotics </li></ul><ul><li>Oxygen supplementation may be needed </li></ul><ul><li>Mild sedation/analgesia </li></ul><ul><li>IVF </li></ul>
  56. 61. Indications for surgery/embolization <ul><li>Continued bleeding despite nasal packing </li></ul><ul><li>Pt requires transfusion/admit hct of <38% (barlow) </li></ul><ul><li>Nasal anomaly precluding packing </li></ul><ul><li>Patient refusal/intolerance of packing </li></ul><ul><li>Posterior bleed vs. failed medical mgmt after >72hrs (wang vs. schaitkin) </li></ul>
  57. 62. Selective Angiography/embolization <ul><li>Helps identify location of bleeding </li></ul><ul><li>Embolization most effective in patients who </li></ul><ul><ul><li>Still bleeding after surgical arterial ligation </li></ul></ul><ul><ul><li>Bleeding site difficult to reach surgically </li></ul></ul><ul><ul><li>Comorbidities prohibit general anesthetic </li></ul></ul><ul><li>Effective only when bleeding is >.5 ml/min </li></ul><ul><li>90+% success rate, complication rate of 0.1% </li></ul><ul><li>Only able to embolize external carotid & branches </li></ul><ul><li>Complications: minor (18-45%)/major (0-2%) </li></ul><ul><li>Contraindicated in bad atherosclerosis, Ethmoid bleed </li></ul>
  58. 63. Surgical treatment <ul><li>Transmaxillary IMA ligation </li></ul><ul><li>Intraoral IMA ligation </li></ul><ul><li>Anterior/Posterior Ethmoidal ligation </li></ul><ul><li>Transnasal Sphenopalatine ligation </li></ul><ul><li>External carotid artery ligation </li></ul><ul><li>Septodermoplasty/Laser ablation </li></ul>
  59. 64. Transmaxillary IMA ligation <ul><li>Waters view </li></ul><ul><li>Caldwell-Luc </li></ul><ul><li>Electrocautery of posterior wall before removal </li></ul><ul><li>Microscopic dissection and ligation of IMA --descending palatine & sphenopalantine most important </li></ul><ul><li>Recurrence rate (failure rate) of 10-15% </li></ul><ul><li>Complication rate of 25-30% (oa fistula,dental, n) </li></ul>
  60. 66. Intraoral IMA ligation <ul><li>Posterior gingivobuccal incision beginning at second molar </li></ul><ul><li>Temporalis mm split and partially dissected </li></ul><ul><li>IMAX visualized, clipped and divided </li></ul><ul><li>Advantages: children/facial fractures </li></ul><ul><li>Disadvantages: more proximal ligation </li></ul><ul><li>Complications: trismus, damage to infraorbital n </li></ul>
  61. 67. Ant./Post. Ethmoidal ligation <ul><li>Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclear </li></ul><ul><li>Lynch incision </li></ul><ul><li>Fronto-ethmoid </li></ul><ul><li>suture line </li></ul><ul><li>12-24-6 </li></ul><ul><li>(14-18, 8-10, 4-6) </li></ul>
  62. 68. Transnasal Endoscopic Sphenopalatine Artery ligation <ul><li>Follow Middle Turbinate to posteriormost aspect </li></ul><ul><li>Vertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid. and inf. turbs) </li></ul><ul><li>Elevation of flap—ID neurovascular bundle at foramen </li></ul><ul><li>Ligation with titanium clip </li></ul><ul><li>Reapproximate flap </li></ul><ul><li>Complications –few, Failures—0-13% </li></ul>
  63. 69. Transnasal Spheno-palatine Artery ligation
  64. 70. ECA ligation <ul><li>Effectiveness </li></ul><ul><li>Anterior border of SCM </li></ul><ul><li>ID ECA/ICA </li></ul><ul><li>Ligation after clear that surrounding structures are safe. </li></ul>
  65. 71. Septodermoplasty/Laser <ul><li>Remove mucosa from anterior ½ septum, floor of nose, lateral wall </li></ul><ul><li>STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autografts </li></ul><ul><li>Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod disease </li></ul><ul><li>Still bleed, but not as bad </li></ul><ul><li>Definitive treatment (severe disease)—closure of nose </li></ul>
  66. 72. Statistically speaking,…. <ul><li>Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs. </li></ul><ul><li>Others compared all medical treatment to surgery and showed cost cut using medical management. </li></ul><ul><li>Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28% </li></ul><ul><li>Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equal </li></ul><ul><li>Failure rates: PP-30%, Sx-17%, Emb-4% </li></ul>
  67. 73. Neoplasms of Nose and Paranasal Sinuses <ul><li>Very rare 3% </li></ul><ul><li>Delay in diagnosis due to similarity to benign conditions </li></ul><ul><li>Nasal cavity </li></ul><ul><ul><li>½ benign </li></ul></ul><ul><ul><li>½ malignant </li></ul></ul><ul><li>Paranasal Sinuses </li></ul><ul><ul><li>Malignant </li></ul></ul>
  68. 74. Neoplasm <ul><li>Benign </li></ul><ul><ul><li>Schneiderian papilloma </li></ul></ul><ul><ul><ul><li>Squamous </li></ul></ul></ul><ul><ul><ul><li>Inverted-13 % incidence of malignant degeneration </li></ul></ul></ul><ul><ul><ul><li>Cylindrical </li></ul></ul></ul><ul><li>Malignant </li></ul><ul><ul><li>Squamous cell carcinoma </li></ul></ul><ul><ul><li>Salivary gland tumors </li></ul></ul><ul><ul><li>Neuroepithelial tumors </li></ul></ul>
  69. 77. MRI demonstrating right nasal mass with no intracranial involvement Nasal mass
  70. 78. Septum Nasal mass
  71. 79. Angiofibroma
  72. 82. Neoplasms of Nose and Paranasal Sinuses <ul><li>Multimodality treatment </li></ul><ul><li>Orbital Preservation </li></ul><ul><li>Minimally invasive surgical techniques </li></ul>
  73. 83. Epidemiology <ul><li>Predominately of older males </li></ul><ul><li>Exposure: </li></ul><ul><ul><li>Wood, nickel-refining processes </li></ul></ul><ul><ul><li>Industrial fumes, leather tanning </li></ul></ul><ul><li>Cigarette and Alcohol consumption </li></ul><ul><ul><li>No significant association has been shown </li></ul></ul>
  74. 84. Location <ul><li>Maxillary sinus </li></ul><ul><ul><li>70% </li></ul></ul><ul><li>Ethmoid sinus </li></ul><ul><ul><li>20% </li></ul></ul><ul><li>Sphenoid </li></ul><ul><ul><li>3% </li></ul></ul><ul><li>Frontal </li></ul><ul><ul><li>1% </li></ul></ul>
  75. 85. Presentation <ul><li>Oral symptoms: 25-35% </li></ul><ul><ul><li>Pain, trismus, alveolar ridge fullness, erosion </li></ul></ul><ul><li>Nasal findings: 50% </li></ul><ul><ul><li>Obstruction, epistaxis, rhinorrhea </li></ul></ul><ul><li>Ocular findings: 25% </li></ul><ul><ul><li>Epiphora, diplopia, proptosis </li></ul></ul><ul><li>Facial signs </li></ul><ul><ul><li>Paresthesias, asymmetry </li></ul></ul>
  76. 86. Radiography <ul><li>CT </li></ul><ul><ul><li>Bony erosion </li></ul></ul><ul><ul><li>Limitations with periorbita involvement </li></ul></ul><ul><li>MRI </li></ul><ul><ul><li>94 -98% correlation with surgical findings </li></ul></ul><ul><ul><li>Inflammation/retained secretions: low T1, high T2 </li></ul></ul><ul><ul><li>Hypercellular malignancy: low/intermediate on both </li></ul></ul><ul><ul><ul><li>Enhancement with Gadolinium </li></ul></ul></ul>
  77. 87. Benign Lesions <ul><li>Polyps </li></ul><ul><li>Papillomas </li></ul><ul><li>Osteomas </li></ul><ul><li>Fibrous Dysplasia </li></ul><ul><li>Neurogenic tumors </li></ul>
  78. 88. NASAL POLYPS <ul><li>Benign, semitransparent lesions </li></ul><ul><li>Arise from nasal mucosa </li></ul><ul><li>Caused by chronic inflammation </li></ul><ul><li>a/w asthma, CF, aspirin intolerance, CRS, Allergic Rhinitis </li></ul>
  79. 89. NASAL POLYPS <ul><li>Nasal Endoscopy </li></ul><ul><li>CT/MRI </li></ul><ul><li>Medical Tx: topical/systemic steroids </li></ul><ul><li>Surgical Tx: FESS with polypectomy </li></ul>
  80. 90. Papilloma <ul><li>Vestibular papillomas </li></ul><ul><li>Schneiderian papillomas derived from schneiderian mucosa (squamous) </li></ul><ul><ul><li>Fungiform: 50%, nasal septum </li></ul></ul><ul><ul><li>Cylindrical: 3%, lateral wall/sinuses </li></ul></ul><ul><ul><li>Inverted: 47%, lateral wall </li></ul></ul>
  81. 91. Inverted Papilloma <ul><li>4% of sinonasal tumors </li></ul><ul><li>Site of Origin: lateral nasal wall </li></ul><ul><li>Unilateral </li></ul><ul><li>Malignant degeneration in 2-13% (avg 10%) </li></ul>
  82. 92. Inverted Papilloma Resection <ul><li>Initially via transnasal resection: </li></ul><ul><ul><li>50-80% recurrence </li></ul></ul><ul><li>Medial Maxillectomy via lateral rhinotomy: </li></ul><ul><ul><li>Gold Standard </li></ul></ul><ul><ul><li>10-20% </li></ul></ul><ul><li>Endoscopic medial maxillectomy: </li></ul><ul><ul><li>Key concepts: </li></ul></ul><ul><ul><ul><li>Identify the origin of the papilloma </li></ul></ul></ul><ul><ul><ul><li>Bony removal of this region </li></ul></ul></ul><ul><li>Recurrent lesions: </li></ul><ul><ul><li>Via medial maxillectomy vs. Endoscopic resection </li></ul></ul><ul><ul><li>22% </li></ul></ul>
  83. 93. INVERTED PAPILLOMA
  84. 94. Osteomas <ul><li>Benign slow growing tumors of mature bone </li></ul><ul><li>Location: </li></ul><ul><ul><li>Frontal, ethmoids, maxillary sinuses </li></ul></ul><ul><li>When obstructing mucosal flow can lead to mucocele formation </li></ul><ul><li>Treatment is local excision </li></ul>
  85. 95. Fibrous dysplasia <ul><li>Dysplastic transformation of normal bone with collagen, fibroblasts, and osteoid material </li></ul><ul><li>Monostotic vs Polyostotic </li></ul><ul><li>Surgical excision for obstructing lesions </li></ul><ul><li>Malignant transformation to rhabdomyosarcoma has been seen with radiation </li></ul>
  86. 96. Neurogenic tumors <ul><li>4% are found within the paranasal sinuses </li></ul><ul><li>Schwannomas </li></ul><ul><li>Neurofibromas </li></ul><ul><li>Treatment via surgical resection </li></ul><ul><li>Neurogenic Sarcomas are very aggressive and require surgical excision with post op chemo/XRT for residual disease. </li></ul><ul><li>When associated with Von Recklinghausen’s syndrome: more aggressive (30% 5yr survival). </li></ul>
  87. 97. Malignant lesions <ul><li>Squamous cell carcinoma </li></ul><ul><li>Adenoid cystic carcinoma </li></ul><ul><li>Mucoepidermoid carcinoma </li></ul><ul><li>Adenocarcinoma </li></ul><ul><li>Hemangiopericytoma </li></ul><ul><li>Melanoma </li></ul><ul><li>Olfactory neuroblastoma </li></ul><ul><li>Osteogenic sarcoma, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma </li></ul><ul><li>Lymphoma </li></ul><ul><li>Metastatic tumors </li></ul><ul><li>Sinonasal undifferentiated carcinoma </li></ul>
  88. 98. Squamous cell carcinoma <ul><li>Most common tumor (80%) </li></ul><ul><li>Location: </li></ul><ul><ul><li>Maxillary sinus (70%) </li></ul></ul><ul><ul><li>Nasal cavity (20%) </li></ul></ul><ul><li>90% have local invasion by presentation </li></ul><ul><li>Lymphatic drainage: </li></ul><ul><ul><li>First echelon: retropharyngeal nodes </li></ul></ul><ul><ul><li>Second echelon: subdigastric nodes </li></ul></ul>
  89. 99. Treatment <ul><li>88% present in advanced stages (T3/T4) </li></ul><ul><li>Surgical resection with postoperative radiation </li></ul><ul><ul><li>Complex 3-D anatomy makes margins difficult </li></ul></ul>
  90. 100. Adenoid Cystic Carcinoma <ul><li>3 rd most common site is the nose/paranasal sinuses </li></ul><ul><li>Perineural spread </li></ul><ul><ul><li>Anterograde and retrograde </li></ul></ul><ul><li>Despite aggressive surgical resection and radiotherapy, most grow insidiously. </li></ul><ul><li>Neck metastasis is rare and usually a sign of local failure </li></ul><ul><li>Postoperative XRT is very important </li></ul>
  91. 101. Mucoepidermoid Carcinoma <ul><li>Extremely rare </li></ul><ul><li>Widespread local invasion makes resection difficult, therefore radiation is often indicated </li></ul>
  92. 102. Adenocarcinoma <ul><li>2 nd most common malignant tumor in the maxillary and ethmoid sinuses </li></ul><ul><li>Present most often in the superior portions </li></ul><ul><ul><li>Strong association with occupational exposures </li></ul></ul><ul><li>High grade: solid growth pattern with poorly defined margins. 30% present with metastasis </li></ul><ul><li>Low grade: uniform and glandular with less incidence of perineural invasion/metastasis. </li></ul>
  93. 103. Hemangiopericytoma <ul><li>Pericytes of Zimmerman </li></ul><ul><li>Present as rubbery, pale/gray, well circumscribed lesions resembling nasal polyps </li></ul><ul><li>Treatment is surgical resection with postoperative XRT for positive margins </li></ul>
  94. 104. Melanoma <ul><li>0.5- 1.5% of melanoma originates from the nasal cavity and paranasal sinus. </li></ul><ul><li>Anterior Septum: most common site </li></ul><ul><li>Treatment is wide local excision with/without postoperative radiation therapy </li></ul><ul><li>END not recommended </li></ul><ul><li>AFIP: Poor prognosis </li></ul><ul><ul><li>5yr: 11% </li></ul></ul><ul><ul><li>20yr: 0.5% </li></ul></ul>
  95. 105. Olfactory Neuroblastoma Esthesioneuroblastoma <ul><li>Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells. </li></ul><ul><li>Kadish Classification </li></ul><ul><ul><li>A: confined to nasal cavity </li></ul></ul><ul><ul><li>B: involving the paranasal cavity </li></ul></ul><ul><ul><li>C: extending beyond these limits </li></ul></ul>
  96. 106. Olfactory Neuroblastoma Esthesioneuroblastoma <ul><li>UCLA Staging system </li></ul><ul><ul><li>T1: Tumor involving nasal cavity and/or paranasal sinus, excluding the sphenoid and superior most ethmoids </li></ul></ul><ul><ul><li>T2: Tumor involving the nasal cavity and/or paranasal sinus including sphenoid/cribriform plate </li></ul></ul><ul><ul><li>T3: Tumor extending into the orbit or anterior cranial fossa </li></ul></ul><ul><ul><li>T4: Tumor involving the brain </li></ul></ul>
  97. 107. Olfactory Neuroblastoma Esthesioneuroblastoma <ul><li>Aggressive behavior </li></ul><ul><li>Local failure: 50-75% </li></ul><ul><li>Metastatic disease develops in 20-30% </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>En bloc surgical resection with postoperative XRT </li></ul></ul>
  98. 108. Sarcomas <ul><li>Osteogenic Sarcoma </li></ul><ul><ul><li>Most common primary malignancy of bone. </li></ul></ul><ul><ul><li>Mandible > Maxilla </li></ul></ul><ul><ul><li>Sunray radiographic appearance </li></ul></ul><ul><li>Fibrosarcoma </li></ul><ul><li>Chondrosarcoma </li></ul>
  99. 109. Rhabdomyosarcoma <ul><li>Most common paranasal sinus malignancy in children </li></ul><ul><li>Non-orbital, parameningeal </li></ul><ul><li>Triple therapy is often necessary </li></ul><ul><li>Aggressive chemo/XRT has improved survival from 51% to 81% in patients with cranial nerve deficits/skull/intracranial involvement. </li></ul><ul><li>Adults, Surgical resection with postoperative XRT for positive margins. </li></ul>
  100. 110. Lymphoma <ul><li>Non-Hodgkins type </li></ul><ul><li>Treatment is by radiation, with or without chemotherapy </li></ul><ul><li>Survival drops to 10% for recurrent lesions </li></ul>
  101. 111. Sinonasal Undifferentiated Carcinoma (SNUC) <ul><li>Aggressive locally destructive lesion </li></ul><ul><li>Dependent on pathological differentiation from melanoma, lymphoma, and olfactory neuroblastoma </li></ul><ul><li>Preoperative chemotherapy and radiation may offer improved survival </li></ul>
  102. 112. Metastatic Tumors <ul><li>Renal cell carcinoma is the most common </li></ul><ul><li>Palliative treatment only </li></ul>
  103. 113. Staging of Maxillary Sinus Tumors
  104. 114. Staging of Maxillary Sinus Tumors <ul><li>T1: limited to antral mucosa without bony erosion </li></ul><ul><li>T2: erosion or destruction of the infrastructure, including the hard palate and/or middle meatus </li></ul><ul><li>T3: Tumor invades: skin of cheek, posterior wall of sinus, inferior or medial wall of orbit, anterior ethmoid sinus </li></ul><ul><li>T4: tumor invades orbital contents and/or: cribriform plate, post ethmoids or sphenoid, nasopharynx, soft palate, pterygopalatine or infratemporal fossa or base of skull </li></ul>
  105. 115. Surgery <ul><li>Unresectable tumors: </li></ul><ul><ul><li>Superior extension: frontal lobes </li></ul></ul><ul><ul><li>Lateral extension: cavernous sinus </li></ul></ul><ul><ul><li>Posterior extension: prevertebral fascia </li></ul></ul><ul><ul><li>Bilateral optic nerve involvement </li></ul></ul>
  106. 116. Surgery <ul><li>Surgical approaches: </li></ul><ul><ul><li>Endoscopic </li></ul></ul><ul><ul><li>Lateral rhinotomy </li></ul></ul><ul><ul><li>Transoral/transpalatal </li></ul></ul><ul><ul><li>Midfacial degloving </li></ul></ul><ul><ul><li>Weber-Fergusson </li></ul></ul><ul><ul><li>Combined craniofacial approach </li></ul></ul><ul><li>Extent of resection </li></ul><ul><ul><li>Medial maxillectomy </li></ul></ul><ul><ul><li>Inferior maxillectomy </li></ul></ul><ul><ul><li>Total maxillectomy </li></ul></ul>
  107. 117. MIDFACIAL DEGLOVING
  108. 118. LATERAL RHINOTOMY
  109. 119. CRANIOFACIAL APPROACH
  110. 120. Treatment of the Orbit <ul><li>Before 1970’s orbital exenteration was included in the radical resection </li></ul><ul><li>Preoperative radiation reduced tumor load and allowed for orbital preservation with clear surgical margins </li></ul><ul><li>Currently, the debate is centered on what “degree” of orbital invasion is allowed. </li></ul>
  111. 121. Current indications for orbital exenteration <ul><li>Involvement of the orbital apex </li></ul><ul><li>Involvement of the extraocular muscles </li></ul><ul><li>Involvement of the bulbar conjunctiva or sclera </li></ul><ul><li>Lid involvement beyond a reasonable hope for reconstruction </li></ul><ul><li>Non-resectable full thickness invasion through the periorbita into the retrobulbar fat </li></ul>
  112. 122. Conclusions <ul><li>Neoplasms of the nose and paranasal sinus are very rare and require a high index of suspicion for diagnosis </li></ul><ul><li>Most lesions present in advanced states and require multimodality therapy </li></ul>
  113. 123. REFERENCES <ul><li>www.utmb.edu/oto </li></ul><ul><li>http://www.emedicine.com/PED/topic1550.htm </li></ul><ul><li>http://www.merck.com/mmhe/sec19/ch221/ch221g.html </li></ul>

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