Masses of nose and paranasal sinusesparanasal sinuses

• Nasal polypsNasal polyps.its apedunculated portion of .its apedunculated portion of

oedematous mucosa of nose oedematous mucosa of nose and paranasal sinuses.and paranasal sinuses.

AetiolgyAetiolgyThere are five theories of causes:There are five theories of causes:1.1. Bernouli phenomena.Bernouli phenomena.2.2. Polysaccharide changes.Polysaccharide changes.3.3. Vasomotor imbalance.Vasomotor imbalance.4.4. Infection.Infection.5.5. Allergy.Allergy.

1.Conditions associated with nasal polyps:

a.asthma.b.Aspirin hyperactivity.c.Cystic fibrosis.d.Kartageners syndrome.e.Youngs syndrome.

• Types of nasal polyps:Types of nasal polyps:1.1.Simple polypSimple polyp..

.it arise from a mucosal lining of .it arise from a mucosal lining of ethmoid sinus through medial ethmoid sinus through medial meatusmeatus

.pale insensitive to touch by probing..pale insensitive to touch by probing.

.its multiple and bilateral..its multiple and bilateral.

.Redness is due to repeated trauma .Redness is due to repeated trauma and infection which cause squamous and infection which cause squamous metaplasia of the epitheliem.metaplasia of the epitheliem.

.its a disease of adulthood ..its a disease of adulthood .

.mostly in males..mostly in males.

.there is genetic preisposition..there is genetic preisposition.

.the epithelial lining is ciliated .the epithelial lining is ciliated columnar .columnar .

.fluid analysis shows IGE,IGA and .fluid analysis shows IGE,IGA and eosinophilia in 90%.eosinophilia in 90%.

.culture may shows sreptococcus and .culture may shows sreptococcus and G_ve bacteria.G_ve bacteria.

. Below 10 years of age is associated . Below 10 years of age is associated with cystic fibrosis.with cystic fibrosis.

• C/FC/F1. Nasal obstruction.1. Nasal obstruction.2. Nasal congestion (watery running and sneezing.2. Nasal congestion (watery running and sneezing.3.Partial or perminant loss of smell and taste.3.Partial or perminant loss of smell and taste.4.Pain due to sinusitis.4.Pain due to sinusitis.5. Postnasal drip.5. Postnasal drip.6. Epistaxis is infrequent.6. Epistaxis is infrequent.

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• TreatmentTreatment1.1.Preoperative therapyPreoperative therapy::

.Intranasal corticosteroid , for 1 .Intranasal corticosteroid , for 1 month since half of patient month since half of patient respond .betamethasone nasal respond .betamethasone nasal drop 2 drop /twice/daily.drop 2 drop /twice/daily.

or or beclomethasone,budesonide,flutbeclomethasone,budesonide,fluticasone spray 2 icasone spray 2 puffs/twice/daily.puffs/twice/daily.

2. Postoperative therapy2. Postoperative therapy : :

.Intranasal corticosteroid, in .Intranasal corticosteroid, in patient with recurence or patient with recurence or symptoms.symptoms.

.Oral prednislone is indicated if .Oral prednislone is indicated if there is no response ,5there is no response ,5——30 30 mg/daily for 10 days with mg/daily for 10 days with topical steroid.topical steroid.

•SurgerySurgery1.1.Simple intranasal Simple intranasal

polypectomy.polypectomy.

2.2.Intranasal ethmoidectomy.Intranasal ethmoidectomy.

3.3.External External ethmoidectomy.ethmoidectomy.

Postoperative antihistamine Postoperative antihistamine have no role for recurence.have no role for recurence.

22. Antrocoanal polyp. Antrocoanal polyp::.Arise from floor and lateral wall of .Arise from floor and lateral wall of

maxillary antrum.maxillary antrum..Common in male..Common in male..It has three parts ,antral,nasal and .It has three parts ,antral,nasal and

choanal.choanal..Its single and unilateral..Its single and unilateral..It cause unilateral nasal obstruction, if .It cause unilateral nasal obstruction, if

large may cause bilateral obstruction large may cause bilateral obstruction mostly on expiration. mostly on expiration.

.It may be seen by posterior .It may be seen by posterior rhinoscopy.rhinoscopy.

.There is mucoid nasal discharge..There is mucoid nasal discharge.

•Radiological Radiological examinationexamination::

Occipitomental view will show Occipitomental view will show complete opacity of maxillary complete opacity of maxillary antrum.antrum.

Lateral XLateral X——Ray of postnasal Ray of postnasal view will shows shadow in view will shows shadow in nasal cavity and postnasal nasal cavity and postnasal space .space .

•TREATMENT:TREATMENT:.NO role of medical treatment , .NO role of medical treatment ,

almost always almost always

Its surgery.Its surgery.

.Simple intranasal polypectomy can .Simple intranasal polypectomy can be done with risk of recurence.be done with risk of recurence.

.Caldwell.Caldwell–– Luc operation is Luc operation is treatment of choice with no treatment of choice with no recurrence.recurrence.

TumorsTumors..Benign tumorsBenign tumors

Epithelial tissueEpithelial tissue Connective tissueConnective tissue

Neural tissueNeural tissue

• Epithelial tissue tumorsEpithelial tissue tumors::

1- Papiloma1- Papiloma– In the nasal vestibule it may arise In the nasal vestibule it may arise

as a small sessile or pedunculated as a small sessile or pedunculated wart ,single or multiple.wart ,single or multiple.

– Treated by excision with cautary to Treated by excision with cautary to the base to prevent recurrence.the base to prevent recurrence.

– Histopathological examination is Histopathological examination is essential to exclude carcinoma.essential to exclude carcinoma.

– In the nasal fossa and paranasal In the nasal fossa and paranasal sinuses ,transitional or inverted papiloma, sinuses ,transitional or inverted papiloma, appear as gross thickening of the appear as gross thickening of the epithelial surface leads to infolding but epithelial surface leads to infolding but the basement membrane remains intactthe basement membrane remains intact

– Malignant change occur in about 3% of Malignant change occur in about 3% of casescases

– Rare tumors occur in men over 50 years Rare tumors occur in men over 50 years old old

– The commonest site is on the lateral wall The commonest site is on the lateral wall of the nasal cavity and or in the antrum of the nasal cavity and or in the antrum and ethmoids ,it may be multicentric and ethmoids ,it may be multicentric

–Nasal obstruction is the Nasal obstruction is the presenting symptom presenting symptom

–It should be removed It should be removed surgically surgically

–Recurrence indicate Recurrence indicate malignancymalignancy

2- Adenoma2- Adenoma– Rare ,it remains Rare ,it remains

encapsulated and is encapsulated and is frequently symptomless but frequently symptomless but it may cause nasal it may cause nasal obstruction , it may become obstruction , it may become malignantmalignant

– Rx surgical excision Rx surgical excision

•Connective tissueConnective tissue tumorstumors1 1 –– fibroma fibroma – Its rare tumor, the septum and turbinate are the commonest Its rare tumor, the septum and turbinate are the commonest

sitessites– Usually remain small and cause no symptom other than slight Usually remain small and cause no symptom other than slight

nasal obstruction and occasionally epistaxisnasal obstruction and occasionally epistaxis

2- osteoma2- osteoma– There are two main typeThere are two main type * localized compact osteoma* localized compact osteoma - mostly occur in the frontal sinus- mostly occur in the frontal sinus - it may be sessile or pedunculated- it may be sessile or pedunculated - it has ivory - it has ivory ––hard consistancyhard consistancy

– Symptom usually evident in young adult Symptom usually evident in young adult – It may remain small and symptomless and discovered It may remain small and symptomless and discovered

on radiographic examination on radiographic examination – Displacement of the eye is sometime caused by Displacement of the eye is sometime caused by

expansion of the affected sinus .expansion of the affected sinus .– Empyema or mucocele of the sinus results from Empyema or mucocele of the sinus results from

obstruction of frontonasal duct obstruction of frontonasal duct – Pressure atrophy of the wall of the anterior cranial Pressure atrophy of the wall of the anterior cranial

fossa may cause CSF rhinorrhea and intracranial fossa may cause CSF rhinorrhea and intracranial infectionsinfections

– A dense bony mass with well defined edge is seen on A dense bony mass with well defined edge is seen on x ray,a large one may completely fill the sinusx ray,a large one may completely fill the sinus

– Rx:surgery if symptom develop.Rx:surgery if symptom develop.

3- Angioma3- Angioma – capillary haemangioma : capillary haemangioma :

• itit’’s the commonest type ,mostly affect the s the commonest type ,mostly affect the nasal septum so its also known as a nasal septum so its also known as a bleeding polypusbleeding polypus

•Epistaxis is the usual symptom Epistaxis is the usual symptom

•Rx by excision ,cautery of the site of origin Rx by excision ,cautery of the site of origin

– Cavernous Cavernous •May involve the whole tip of the noseMay involve the whole tip of the nose

Capillary haemangiomaCapillary haemangioma

4- Rhinophyma4- Rhinophyma – Its not strictly a neoplasm its caused by Its not strictly a neoplasm its caused by

fibrosis and hyperplasia of the fibrosis and hyperplasia of the sebaceous tissue of the skin of the nosesebaceous tissue of the skin of the nose

– Swelling of the nasal tip and nostril Swelling of the nasal tip and nostril results results

– Rx by shaving of the excessive tissue,a Rx by shaving of the excessive tissue,a covering skin graft rarely necessary .covering skin graft rarely necessary .

RhinophymaRhinophyma

• Malignant tumorsMalignant tumorsA.A.Epithelial TumorsEpithelial Tumors..

1. 1. Squamous cell carcinomaSquamous cell carcinoma... It. It’’s the commonest malignant tumour of s the commonest malignant tumour of

nose and paranasal sinuses.nose and paranasal sinuses.

.lymph node metastasis is to upper .lymph node metastasis is to upper cervical and retropharyngeal cervical and retropharyngeal groups but its uncommon.groups but its uncommon.

.distant metastasis is also .distant metastasis is also uncommon.uncommon.

.Its seen in nickel industry..Its seen in nickel industry.

2.adenocarcinoma.2.adenocarcinoma..it arise from glands of URT mucous .it arise from glands of URT mucous

membrane,especially in maxillary membrane,especially in maxillary antrum.antrum.

.its a slow growing tumour..its a slow growing tumour.

.exposure to wood dust for along .exposure to wood dust for along time may be the cause.time may be the cause.

3.Adenoid cystic ca3.Adenoid cystic ca....

.they appear as a .they appear as a firm,round,localized,encapsulatefirm,round,localized,encapsulated tumour,especialy in the d tumour,especialy in the alveolus,hard palate,and antral alveolus,hard palate,and antral floor.floor.

.they tend to recur locally and spread .they tend to recur locally and spread intracranially along the cranial nerves.intracranially along the cranial nerves.

.they are regarded as malignant..they are regarded as malignant.

.L.N metastasis is rare..L.N metastasis is rare.

.its radioresistant..its radioresistant.

4.Olfactory neuroblastoma.4.Olfactory neuroblastoma..Rare tumour ,may present as .Rare tumour ,may present as

intranasal,ethmoidal,or intracranial intranasal,ethmoidal,or intracranial tumour.tumour.

Treatment is by craniofascial resection Treatment is by craniofascial resection and radiotherapy.and radiotherapy.

B.Connective tissueB.Connective tissue tumorstumors 1.Sarcoma .1.Sarcoma ..very rare ,it may be .very rare ,it may be

osteosarcoma,fibrosarcoma and osteosarcoma,fibrosarcoma and lymphosarcoma.lymphosarcoma.

.treated by radiotherapy or chemotherapy..treated by radiotherapy or chemotherapy.2.Nasal lymphoma2.Nasal lymphoma...suggested to be a T cell lymphoma..suggested to be a T cell lymphoma..it is a slow progressive destructive tumor of .it is a slow progressive destructive tumor of

the midline.the midline..treated by radiotherapy..treated by radiotherapy.

c.Secondary metastasisc.Secondary metastasis..

.from breast ,prostate and .from breast ,prostate and thyroid may affect the thyroid may affect the sinuses even many years sinuses even many years after cure of primary one.after cure of primary one.

Sites of malignant Sites of malignant tumorstumors..

.80% of malignant tumors of the nose .80% of malignant tumors of the nose and paranasal sinuses are S.C.C.and paranasal sinuses are S.C.C.

.60% arise in the antrum ..60% arise in the antrum .

.30% in the nasal cavity..30% in the nasal cavity.

.10% in the ethmoidal sinuses..10% in the ethmoidal sinuses.

.frontal and sphenoid sinuses are .frontal and sphenoid sinuses are rarely affected.rarely affected.

C/FC/F

1.1.Unilateral nasal obstruction.Unilateral nasal obstruction.2.2.Bleeding and discharge from the Bleeding and discharge from the

nose .nose .3.3.Swelling of the cheek,alveolar Swelling of the cheek,alveolar

margin,nasal bridge and palate.margin,nasal bridge and palate.4.4.Loosening of teeth.Loosening of teeth.5.5.Unilateral proptosis.Unilateral proptosis.6.6.Involvement of facial skin is later.Involvement of facial skin is later.

7.7.Ulceration of the palate .Ulceration of the palate .8.8.Pain is relatively late facial,ear or Pain is relatively late facial,ear or

dental.dental.9.9.Epiphoria.Epiphoria.10.10.Others like Others like

diplopia,trismus,limitation of jaw diplopia,trismus,limitation of jaw movement ,anosmia,optic movement ,anosmia,optic atrophy,maxilary and frontal atrophy,maxilary and frontal sinusitis.sinusitis.

11.11.L.N metastasis ,deep upper L.N metastasis ,deep upper cervical and retropharyngeal nodes cervical and retropharyngeal nodes are involved in 10are involved in 10——15% of cases.15% of cases.

Diagnosis.Diagnosis.1.Radiography.1.Radiography..cyst and benign tumors appear as .cyst and benign tumors appear as

awell defined shadow.awell defined shadow.

.Malignant tumors appear as a .Malignant tumors appear as a dense,ill defined shadow,with or dense,ill defined shadow,with or without bony erosion.without bony erosion.

.CT and MRI..CT and MRI.

2.Biopsy.2.Biopsy.

Treatment.Treatment..Surgical excision ,radiotherapy .Surgical excision ,radiotherapy

and chemotherapy.and chemotherapy.

.prognosis ,5 year survival with .prognosis ,5 year survival with treatment is 25---35%.treatment is 25---35%.

Cysts.Cysts.1.1.Cyst associated with fusion of Cyst associated with fusion of

embryological elements forming embryological elements forming the maxilla.the maxilla.

A.A.Medial groups.Medial groups.B.B.Lateral groupsLateral groups

2.2.Cyst of dental origin.Cyst of dental origin.

a.Primordial cysts.a.Primordial cysts.

b.Cyst of eruption.b.Cyst of eruption.

c.Dentigerus cyst.c.Dentigerus cyst.

d.Dental cyst.d.Dental cyst.

3.3.Dermoid cyst, in the midline of the Dermoid cyst, in the midline of the face may extend into the septum.face may extend into the septum.

4.4.Mucoceles of the paranasal Mucoceles of the paranasal sinuses.sinuses.

May be due to:May be due to:

.blockage of mucous gland duct..blockage of mucous gland duct.

.cystic formation of the mucosa .cystic formation of the mucosa underlying polyposis.underlying polyposis.

Mucoceles mostly occur in frontal Mucoceles mostly occur in frontal sinuses.sinuses.

1.Specific like 1.Specific like T.B ,syphilis,leprosy,yaws,AidsT.B ,syphilis,leprosy,yaws,Aids

,scleroma,actinomycosis, ,scleroma,actinomycosis, mucormycosis,leishmaniasis,rhinmucormycosis,leishmaniasis,rhinosporidosis,and Aspergillosis.osporidosis,and Aspergillosis.

Nasal granulomaNasal granuloma

2. Non specific like sarcoidosis,sinonasal 2. Non specific like sarcoidosis,sinonasal lymphoma,and lymphoma,and

wegeners granuloma: characterized by wegeners granuloma: characterized by focal necrosis, vasculitis, and granuloma focal necrosis, vasculitis, and granuloma in upper and lower air passage and in upper and lower air passage and kidneys presented as epistaxis, kidneys presented as epistaxis, hemoptysis, hematuria, Dx by high ESR, hemoptysis, hematuria, Dx by high ESR, presence of anti-neutrophilic presence of anti-neutrophilic cytoplasmic antibody, Rx by cytoplasmic antibody, Rx by radiotherapy or Chemotherapy.radiotherapy or Chemotherapy.

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