Sino-nasal Tumours Dr. Vishal Sharma. Classification Benign Simple papilloma Ossifying Fibroma Osteoma Haemangioma Neurofibroma Intermediate Inverted

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Text of Sino-nasal Tumours Dr. Vishal Sharma. Classification Benign Simple papilloma Ossifying Fibroma...

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  • Sino-nasal Tumours Dr. Vishal Sharma
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  • Classification Benign Simple papilloma Ossifying Fibroma Osteoma Haemangioma Neurofibroma Intermediate Inverted papilloma Malignant Squamous cell carcinoma Adenocarcinoma Anaplastic carcinoma Transitional cell carcinoma Malignant melanoma Salivary gland tumours Rhabdomyosarcoma
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  • Oeteoma Osteomas are common incidental finding in frontal sinus x-ray Majority are asymptomatic & do not grow Surgery is done for symptomatic osteomas or those that rapidly increase in size Complete removal of tumor with its base attachment is done by bicoronal osteoplastic flap technique
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  • Frontal sinus osteoma
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  • Bicoronal osteoplastic flap
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  • Osteoma exposed
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  • Tumor removal + closing of bone flap
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  • Ossifying fibroma Synonym: Fibrous dysplasia Normal medullary bone is replaced by abnormal proliferation of fibrous tissue, resulting in distortion & expansion of bone C.T. scan: ground - glass appearance with regions of osteolysis & calcification Treatment: complete surgical excision
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  • Ossifying fibroma
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  • Inverted papilloma Locally aggressive sino-nasal tumour Synonyms: Ringertz or Schneiderian papilloma Common in males between 50-70 years It arises from the lateral wall of nose Presents as unilateral, friable, pale, pink mass arising from middle meatus Diagnosis made by punch biopsy
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  • Inverted papilloma Treatment: medial maxillectomy and en bloc ethmoidectomy by lateral rhinotomy or midfacial degloving. Inverted papilloma has a marked tendency to recur after surgical removal. Squamous cell ca is present in 1015% cases. Radiotherapy is avoided.
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  • Anterior rhinoscopy
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  • Contrast C.T. scan P.N.S. Left intra-nasal mass with opacification of maxillary and ethmoid sinuses (African continent sign). Bone destruction of lateral nasal wall.
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  • Punch Biopsy & H.P.E. Inward invasion of hyperplastic epithelium into underlying stroma. No evidence of malignancy.
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  • Moures lateral rhinotomy
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  • Osteotomy cuts
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  • Bone removed & tumor exposed
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  • Tumour removed & inicision closed
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  • Midfacial degloving approach
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  • Sino-nasal Malignancy
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  • Epidemiology O.5% of all body cancers 15% of all upper respiratory neoplasm Maxillary sinus is most common 80-85% are squamous cell carcinoma Male : female = 2:1 Commonly seen in 45-60 years
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  • Risk factors Hardwood dust (adenocarcinoma) Softwood dust (squamous carcinoma) Nickel refining; chromium workers Boot, shoe and textile workers Mustard gas exposure Human papilloma virus
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  • Maxillary sinus malignancy
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  • Early Clinical features Mimic maxillary sinusitis Nasal stuffiness Blood-stained nasal discharge Facial paraesthesias or pain Epiphora
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  • Spread
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  • Medial spread: Unilateral nasal obstruction Unilateral purulent nasal discharge Epistaxis Unilateral, friable, nasal mass Anterior spread: Cheek swelling Invasion of facial skin Late Clinical features
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  • . 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
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  • Late Clinical features Posterior spread: Pterygoid muscle involvement trismus Intracranial spread via: Ethmoids, cribriform plate or foramen lacerum Lymphatic spread: Neck node metastases in late stages Systemic spread: Lungs, bone
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  • Cheek swelling
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  • Cheek skin involvement
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  • Alveolar & Palatal swelling
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  • Nasal mass
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  • Diagnostic nasal endoscopy X-ray paranasal sinus: expansion & destruction of bony wall C.T. Scan: axial & coronal cuts with contrast Biopsy Diagnosis
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  • X-ray paranasal sinus
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  • C.T. Scan
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  • Ohngrens Classification
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  • Ohngren's Classification Ohngren's line: An imaginary plane extending between medial canthus of eye & angle of mandible Supra structural growths situated above this plane have a poorer prognosis Intra structural growths situated below this plane have better prognosis
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  • Ledermans Classification
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  • 2 horizontal lines of Sebileau pass through floors of orbits & maxillary sinus, producing: Suprastructure: ethmoid, sphenoid & frontal sinuses; olfactory area of nose Mesostructure: maxillary sinus & respiratory part of nose Infrastructure: alveolar process
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  • T.N.M. Staging T1 = tumor confined to antral mucosa T2 = bone destruction of hard palate / middle meatus T3 = involvement of skin of cheek, floor or medial wall of orbit, ethmoid sinus, posterior antral wall, pterygoid plates, infratemporal fossa T4 = involvement of orbital contents, cribriform plate, frontal or sphenoid sinus, skull base, nasopharynx
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  • Treatment T1 & T2 = Surgery or Radiotherapy T3 = Surgery + Radiotherapy T4 = Surgery + Radiotherapy + Chemotherapy Europeans: pre-operative Radiotherapy (5000- 6500 cGy) surgery after 4-6 weeks Americans: Surgery post-operative Radiotherapy after 4-6 weeks
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  • Surgical Options 1. Total maxillectomy (Weber Fergusson incision) = malignancy limited to maxilla 2. Radical maxillectomy with orbital exenteration (Weber Fergusson Diffenbach incision) = involvement of orbital fat 3. Anterior Cranio Facial Resection (extended lateral rhinotomy incision) = involvement of cribriform plate, frontal sinus
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  • Total Maxillectomy
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  • Tarsorrhaphy
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  • Weber Fergusson incision
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  • Osteotomy cuts
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  • Total maxillectomy done & incision closed
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  • Palatal defect & prosthesis
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  • Orbital exenteration indications Involvement of orbital apex Involvement of extra-ocular muscles Involvement of bulbar conjunctiva or sclera Lid involvement beyond a reasonable hope for reconstruction Non-resectable full thickness invasion through periorbita into retrobulbar fat
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  • Orbital exenteration
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  • Cranio-facial resection
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  • Thank You

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