dr harjitpal singh

TUMORS OF NOSE & PNS

Dr Harjitpal SinghAssistant Professor(ENT),

Dr RKGMC, Hamirpur

TUMOURS OF NOSE & PNSEnvironmental Factors associated with sinonasal malignancy•Wood dust (Hardwood-Adeno, Softwood- SCC)•Nickel, Hydrocarbons•Chromium, Organic oils, Isopropyl oil•Mustard Gas

Many of these products are found in the furniture-making industry, the leather industry, and the textile industry.

TUMOURS OF NOSE & PNS• Cancers arising in the paranasal sinuses are rare,

constituting approximately 3 % of head and neck malignancies

• Sinonasal malignancies (SNM) are the second most common head and neck cancer behind nasopharyngeal carcinoma.

• Men are affected 1.5 times more often than women.

• 80% of these tumors occur in people aged 45-85 years.

TUMOURS OF NASAL CAVITY

• Approximately 60-70% of sinonasal malignancies (SNM) occur in the maxillary sinus and 20-30% occur in the nasal cavity itself.

• An estimated 10-15% occur in the ethmoid air cells

• Human papillomavirus (HPV) also has a frequent role in the development of sinonasal SCC

TUMOURS OF NASAL CAVITY

BENIGN TUMORS OF NOSE Benign lesions are usually smooth, localised and

covered with mucous membrane. In addition to primary tumours, nasal cavity can be

invaded by growths from paranasal sinuses, nasopharynx, cranial or buccal cavity.

BENIGN TUMORS OF NOSE

1. Squamous Papilloma : Verrucous lesions similar to skin warts arise from

the nasal vestibule or lower part of nasal septum. Single or multiple, pedunculated or sessile.Treatment :

Local excision with cauterisation of the base.CryosrugeryLaser.

ENDOSCOPIC VIEW NASAL PAPILLOMA

BENIGN TUMORS OF NOSE 2) Inverted Papilloma (Transitional Cell Papilloma or Ringertz Tumour)• Neoplastic epithelium is seen to grow

towards underlying stroma rather than on the surface.

• 40-70 years male preponderance (5:1).• Arises from the lateral wall of nose• Always unilateral, red or grey masses• Translucent and oedematous marked

tendency to recur after surgical removal.• Associated with squamous cell carcinoma

in 10- 15% of patients.

BENIGN TUMORS OF NOSE Inverted Papilloma

Modified Krause StagingA – Inverted papilloma (IP) confined to the nasal cavity, ethmoid sinus, or medial maxillary wallB – Inverted papilloma (IP) with involvement of any maxillary

wall (other than the medial wall) or frontal sinus or sphenoid sinusC – Inverted papilloma (IP) with extension beyond the paranasal sinusesTreatment : Wide surgical excision by Medial maxillectomy and enbloc ethmoidectomy or Lateral rhinotomy.

3) Schwannoma and Meningioma :• Treatment : Surgical excision by lateral

rhinotomy.

4) Pleomorphic Adenoma :• Arises from the nasal septum.• Treatment : Wide surgical excision.

Both the above mentioned are rare tumours

PLEOMORPHIC ADENOMA

5) Haemangioma :1. Capillary Haemangioma (Bleeding Polypus):• Soft, dark red, pedunculated or sessile tumour arising

from anterior part of nasal septum.•Present with recurrent epistaxis and nasal obstruction.•Treatment : Local excision with a cuff of surrounding

mucoperichondrium.2. Cavernous Haemangioma : • Arises from the turbinates on the lateral wall of nose.•Treatment : Surgical excision with preliminary cryotherapy.

BLEEDING POLYPUS

6)Intranasal Meningoencephlocele :• Herniation of brain tissues and meninges through• foramen caecum or cribriform plate.• Smooth polyp in the upper part of nose between

the septum and middle turbinate.• Seen in Infants and young children. Mass increases

in size on crying or straining.• CT scan is essential to demonstrate a defect in the

base of skull.• Treatment is frontal craniotomy, severing the stalk

form the brain, and repair of dural and bony defect. Intranasal mass is removed as secondary procedure after cranial defect has sealed.

INTRANASAL MENINGOENCEPHLOCELE

BENIGN TUMORS OF NOSE 7)Chondroma :• Arise from the ethmoid, nasal cavity or nasal septum.• Pure chondromas are smooth, firm and lobulated.• Others may be mixed type fibro-, osteo-, or angiochondromas.• Treatment is wide surgical excision• Tendency to malignant transformation after repeated

interference.8) Gliomas :•Seen in infants and children.• Of all the gliomas, 30% are intranasal and 10% both intra and

extranasal. • An intranasal glioma presents as a firm polyp.

9) Angiofibroma:• It is included in nasal tumours because its primary

site of origin is supposed to be posterior part of nasal cavity near the sphenopalatine foramen

10) Nasal Dermoid :• It presents as widening of upper part of nasal septum

with splaying of nasal bones and hypertelorism.• A pit or a sinus may be seen in the midline of nasal

dorsum with hair protruding from the opening.

NASAL DERMOID CYST

MALIGNANT TUMORS OF NOSE

• Primary carcinoma per se is rare. • It may be an extension of maxillary or ethmoid

carcinoma• Squamous cell variety, adenoid cystic carcinoma

or an adenocarcinoma.• They are usually friable, have a granular surface

and tend to bleed easily.

MALIGNANT TUMORS OF NOSE 1) Squamous cell carcinoma • It may arise from the vestibule, anterior part of nasal septum or the

lateral wall of nasal cavity.• Most of them are seen in men past 50 years of age.(i) Vestibular: It arises from the lateral wall of nasal vestibule and may extend into the columella, nasal floor and upper lip with metastases to parotid nodes.(ii) Septal: Mostly arises from mucocutaneous junction and causes burning and soreness in the nose. It has often been termed as "nose-picker's cancer. Usually, it is of low grade malignancy.(iii) Lateral wall: This is the site most commonly involved. Easily extends into ethmoid or maxillary sinuses. Grossly, it presents as a polypoid mass in the lateral wall of nose.• Treatment is combination of radiotherapy and surgery.

2) Adenocarcinoma and adenoid cystic carcinoma: • They arise from the glands of mucous membrane or minor salivary glands. • Mostly involve upper part of the lateral wall of nasal cavity.3) Lymphoma:• Rarely a non-Hodgkin lymphoma presents on the septum.4) Plasmacytoma:• Solitary plasmacytoma without generalised osseous disease may be

seen in the nasal cavity.• It predominantly affects males over 40 years.• Treatment is by radiotherapy followed three months later by

surgery if total regression does not occur.• Long-term follow up is essential to exclude development of multiple

myeloma.

5) Malignant Melanoma:• Seen in persons about 50 years of age. Both sexes equally affected. • Grossly, it presents as a slaty-grey or bluish black polypoid mass. • Amelanotic varieties are non pigmented.• Within the nasal cavity, most frequent site is anterior part of nasal

septum followed by middle and inferior turbinate. • Tumour spreads by lymphatics and blood stream.• Cervical nodal metastases may be present at the time of initial

examination.• Treatment is wide surgical excision• Radiotherapy and chemotherapy suppress the immune processes and

are avoided.• A five-year survival rate of 30% can be expected after surgical excision

6) Haemangiopericytoma:• It is a rare tumour of vascular origin.• Age group of 60-70 years.• It arises from the pericyte-a cell surrounding the capillaries.• It presents with epistaxis. • Brisk bleeding may occur on biopsy.• The tumour may be benign or malignant but it cannot be

distinguished histologically.• Treatment is wide surgical excision.• Radiotherapy is used for inoperable or recurrent lesions.

HAEMANGIOPERICYTOMA

7) Olfactory Neuroblastoma:• It is a tumour of olfactory placode seen in persons

of either sex at any age group.• It presents as a cherry red, polypoidal mass in the

upper third of the nasal cavity.• It is a vascular tumour and bleeds profusely on biopsy.• Lymph node or systemic metastases can occur.• Presently, favoured treatment is surgical excision

followed by radiation. • Craniofacial resection may be required for tumours

of the cribriform plate.

OLFACTORY NEUROBLASTOMA

8) Sarcomas:Osteogenic sarcoma, chondrosarcoma,

rhabdomyosarcoma ,angiosarcoma, malignant histiocytoma are other rare tumours affecting the nose.rare tumours affecting the nose.

NEOPLASMS OF PARANASAL SINUSES

OSTEOMAS:• Most commonly seen in the frontal sinus discovered

incidentally on X-rays• Surgical excision for rapidly growing osteomas• Complete removal of tumour with its base attachment

is done by bicoronal osteoplastic flap technique

FRONTAL SINUS OSTEOMA

Ossifying fibroma• Histologically it looks similar to fibrous

dysplasia. • Age: It is seen in young adults. • Radiology: The sclerotic bony margin can be

seen. • Treatment: It can be shelled out easily.

Ossifying fibroma

Monostotic Fibrous Dysplasia:• In this disease, bone is replaced by fibrous

tissue. �• Site: The most common site is maxilla followed

by ethmoid and frontal sinuses. �• Clinical features: Patient develops

disfigurement of the face nasal obstruction and displacement of the eye. �

• Treatment: Wide removal (surgical resculpturing) provides good cosmetic and functional results.

Fibrous dysplasia of Sphenoid bonePatient with (L) proptosis

MALIGNANT NEOPLASMS OF PARANASAL SINUSES

Clinical Features:• Early: Facial pain, nasal obstruction and epistaxis. • Eye and Orbit: Diplopia (double vision) and squint due to

involvement of oculomotor nerves and extraocular muscles. Loss of vision due to the involvement of optic. Proptosis due to tumor compression of periorbita (orbital fascia). Epiphora due to involvement of lacrimal duct.

• Facial numbness due to involvement of branches of infraorbital nerve (CNV2).

• Facial swelling due to involvement of facial soft tissue • Cranial nerves involvement: CN II, III, IV, V1 and V2, VI.

• Malocclusion, widening of upper alveolus, loose and nonvital teeth due to involvement of upper alveolus.

• Trismus due to involvement of pterygoid muscles.• Neck swelling due to involvement of jugular chain

lymph nodes. • Deafness. Serous otitis media due to involvement of

nasopharynx. • Mass: Necrotic intranasal mass and/or

alveolar/palatal mass or ulceration.

Diagnosis:1. Radiographs: CT scan has replaced plain X-rays, which show

opacity of sinus with expansion and destruction of the bony walls. 2. CT scan: Axial and coronal planes show bony and soft tissue extent

of tumor and help in the staging of disease3. Endoscopy: Endoscopy of the nose and maxillary sinus provides

not only detailed examination but also facilitates an accurate biopsy.

4. Biopsy: Biopsy is taken from the growth in the nose or mouth. In early suspected cases, sinus may be explored through Caldwell-Luc operation but preferred approach is endoscopic intranasal. Direct visualization of the tumor site helps in staging.

Nasal Mass

Cheek Swelling

Alveolar & palatal swelling

Ohngren’s classification:• Ohngren’s line is an

imaginary line (OL), which extends between medial canthus and the angle of mandible, divides the maxilla into two regions anteroinferior (AI) and posterosuperior (PS).

• AI growths are easy to manage and have better prognosis than PS tumors

Lederman’s classification: Two horizontal lines of Sebileau, one passing through the orbit floors (I) and other through antral floors (II), divide the area into three regions: 1)Suprastructure (SS), 2)Mesostructure (MS), and 3)Infrastructure (IS). 4)The vertical line (III) at the plane of medial wall of orbit separates ethmoid sinuses and nasal fossa from the maxillary sinuses

Staging of cancer of nose and paranasal sinuses

Treatment:• T1 & T2: surgery or radiotherapy

• T 3: surgery + radiotherapy

• T4 : surgery + radiotherapy+ chemotherapy

Treatment:Maxillary Sinus

Surgery: • It is the mainstay therapy. • Complete radical maxillectomy includes removal of

maxilla along with the nasal bone, the ethmoid sinus, and in some cases pterygoid plates.

• It is adequate when tumor is confined to maxilla, or extends to facial soft tissues, palate, or anterior orbit.

• But without invasion of the ethmoidal roof, posterior orbit, or pterygoid region- Weber-Ferguson incision.

WEBER-FERGUSON’S INCISIONIt starts at the upper lip philtrum on the operative side and goes up to the columella. It continues round the margin of the ala and up the lateral border of the nose. Near the medial canthus of eye it turns laterally in a rounded fashion to go 5 mm below the lower lid margin

Radiotherapy: • It is given either before or after surgery. • Curative radiotherapy or chemoradiation may make the

inoperable tumors operable. • Neutron beam irradiation is most suited to adenoid cystic

carcinomas. • Preoperative radiotherapy: A full course of preoperative

radiotherapy is followed 4–6 weeks later by total or extended maxillectomy.

Radiotherapy: • Indications of postoperative radiotherapy –

Large tumors, Positive marginsPerineural or perivascular invasionLymph node metastasis.

• Adverse affects of radiotherapy – 5,800 rad: Severe panophthalmopathy with severe corneal

ulceration in 100% cases. 2,800–5,400 rad: Cataracts and visual disturbances in 86% cases.

Prognosis Overall, 5-year survival is about 30%.

Treatment:Ethmoid Sinus

1. Early cases: Preoperative radiotherapy, followed by total ethmoidectomy through lateral rhinotomy approach.

2. Late stages: Craniofacial resection, when cribriform plate is involved, exposes anterior cranial fossa and facilitates total exenteration of the growth in one piece.Prognosis Overall, 5-year survival is about 30%.

Frontal Sinus:• It is uncommon and usually seen in males of 40–50

years age group.• Presenting features: Pain, swelling of the frontal region

and swelling above the medial canthus (erosion of floor of frontal sinus).

• Treatment: Preoperative radiation followed by surgery, which includes removal of frontal and ethmoid sinuses and orbital exenteration. This neurosurgical approach resects the dura of anterior cranial fossa.

Sphenoid Sinus:1. Very rare. 2. Clinical features similar to the inflammatory

lesions of sphenoid sinus. 3. CT and MRI scan and biopsy through

sphenoidectomy confirm the diagnosis and extent of disease.

4. Treatment: Radiotherapy is the mainstay of treatment.

dr harjitpal singh

nose

pns

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