Neoplasms of the Nose & Para Nasal Sinuses

Department of ENTKSHEMA

NEOPLASMS

• BENIGN– Osteomas– Fibrous Dysplasia– Ossifying Fibroma– Ameloblastoma– Inverted Papilloma

• MALIGNANT– Maxillary Sinus– Ethmoids– Frontal Sinus

Osteomas• Benign neoplasms of bone

• TYPES– Localized Ivory Osteoma(Compact Bone) – FRONTAL Sinus

– Cancellous Osteoma – Maxillary & Ethmoidal sinuses

• C/F:– Asymptomatic– Sinusitis– Mucocele

• Mx– Inv: Radiology- Xray/ CT– Rx: Surgical Excision

FIBROUS DYSPLASIABenign hamartomatous lesion affecting bones

(replaced by Fibrous tissue)

• Maxilla > Ethmoids & Frontal• Age: 1st – 2nd decade

• TYPES:– MONO-OSTOTIC– POLY-OSTOTIC ( usually Unilateral)– DISSEMMINATED

• C/FDisfigurement of FaceNasal ObstructionDisplacement of eyes

• Radiology: Lesion – Diffuse margins with Ground glass appearance

(Fine Orange Peel Texture)

• Rx – Cosmetic restructuring surgery

Fibrous dysplasia – Maxilla (Alveolus)

Fibrous dysplasia – Maxilla (Alveolus)

Fibrous dysplasia – Maxilla (Alveolus)

Fibrous dysplasia – Maxilla (Alveolus)

Fibrous dysplasia – Maxilla

Fibrous dysplasia – Ethmoids

Fibrous dysplasia – Ethmoids

Fibrous dysplasia – Ethmoids

Fibrous dysplasia – Ethmoids

Fibrous dysplasia – Ethmoids

HISTORY

• Named in honor of C.Victor Schneider-1600s,

• Ringertz was the first to identify the tendency of SPs to invert into the underlying connective tissue stroma, which differs from other types of papillomas.

Synonyms• Schneiderian papilloma,

• Schneider papilloma,

• Inverting papilloma, inverted papilloma,

• Ringertz tumour

• Fungiform papilloma,cylindrical papilloma,

• Oncocytic papilloma, epithelial papilloma,

• Transitional cell papilloma.

Schneiderian papillomas• Derived from schneiderian mucosa which is of ectodermal

origin(squamous)

– Fungiform: 50%, nasal septum

– Cylindrical: 3%, lateral wall/sinuses

– Inverted: 47%, lateral wall

Inverted Papilloma • Benign/intermediate

• 0.5% to 4% of sinonasal tumors

• Site of Origin: lateral nasal wall esp from the middle turbinate & middle meatus.

• Men ,6 to 7th decades

Inverted Papilloma• locally destructive.

• Recurrence – 0 to 80 %

• Malignant degeneration -2-13%(Av10%)

CLINICAL FEATURESUnilateral nasal obstruction-common

Epistaxis,

Rhinorrhea,

Anosmia

Facial pressure,

Headaches,

Polyps

CLINICAL FEATURES

Unilateral

Grossly appears as a

bulky

firm

granular polyp

HISTOLOGY

Investigations – CT

Investigations - MRI

Investigations - BIOPSY

Inverted Papilloma resection

• Initially via transnasal resection:– 50-80% recurrence

• Medial Maxillectomy via lateral rhinotomy:– Gold Standard– 10-20%

• Midfacial degloving

• Trans antral \ Caldwell-Luc

Inverted Papilloma resection• Endoscopic resection

• Endoscopic medial maxillectomy:– Key concepts:

• Identify the origin of the papilloma• Bony removal of this region

• Recurrent lesions:– Via medial maxillectomy vs. Endoscopic resection– 22%

Inverted papilloma

• Syn: Ringertz Tumor / Transitional cell papilloma• Neoplastic epithelium grows towards basement

membrane• Middle aged males• May be associated with malignancy ( SCC) in

10%• Lateral nasal wall – Unilateral.• Rx: WIDE excision by Lateral rhinotomy

approach/ medial maxillectomy

Paranasal Malignancies

MALIGNANT NEOPLASMS

• PNS Ca:– 1% of all malignancies– 3% of H& N Tumors– 15% of all neoplasms of URT– Max > Ethm > Frontal > Sphenoid

AETIOLOGY

• Mahogany wood industries ( Adeno Ca)

• Nickel refining (Sq. Cell Ca & Anaplastic)

• Leather Tanning industries

• Bantu tribes of South africa

Clinical Features

• Middle Aged Males

• Nasal Stuffiness

• Blood stained Nasal discharge

• Parasthesia over cheek

• Epiphora

Ca. Rt Maxilla

Investigations

• Xray PNS• CT Scan with contrast – PNS ( Coronal & Axial)• Biopsy – Nasal Mass / Endoscopic

Spread

Classification

• OHNGREN’s Classification• AJCC Classification• Lederman’s Classification

OHNGREN’S LINE

STAGING

• T1- Infrastructure without bone destruction

• T2- Suprastructure without bone destructionor Infrastructure with bone destruction (medial & Infr. walls)

• T3- cheek,orbit,anterior ethmoids or pterygoid M

• T4- cribriform plate, posterior ethmoids, sphenoid, NaPhx,Pterygoid plates or skull base.

•SuprastructureEthmoidal,Sphenoidal, Frontal&Olfactory area

•MesostructureMaxillary sinus

Nasal cavity

•InfrastructureAlveolar Process

Lines of SEBILEAU

N2a pN2a

>3cm

Weber Fergusson Incision

Lynch extensionSupra ciliary extension

Sub ciliary extension

Lateral Rhinotomy

Surgeries

• Total Maxillectomy• Partial Maxilectomy

Radiotherapy

• 200 RADS - 5days a week X 6 weeks

~ 6000RADS

5 Year survival rate = 25-30%.