NEOPLASM OF MAXILLARY SINUS

Definitions Neoplasm(willis)- abnormal mass of tissue, the

growth of which exceeds & uncoordinated with that of normal tissue & persists in same manner after cessation of stimuli which evokes the change.

Tumour- a mass of tissue formed as a result of abnormal, excessive, uncoordinated, autonomous, purposeless proliferation of cells

TNM classification TNM classification 1,2 TNM classification of carcinomas of the nasal cavity and sinuses T – Primary tumour TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ

Maxillary sinus T1- Tumour limited to the antral mucosa with no erosion or destruction of bone

T2- Tumour causing bone erosion or destruction, including extension into hard palate and/or middle nasal meatus, except extension to posterior antral

wall of maxillary sinus and pterygoid plates T3- Tumour invades any of the following: bone of posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses

T4a- Tumour invades any of the following: anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses

T4b- Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve V2, nasopharynx, clivus

N – Regional lymph nodes 3 NX: Regional lymph nodes cannot be

assessed N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph

node, 3 cm or less in greatest dimension

N2 Metastasis as specified in N2a, 2b, 2c below N2a: Metastasis in a single ipsilateral lymph node,

more than 3 cm but not more than 6 cm in greatest dimension

N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension

N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension

N3: Metastasis in a lymph node more than 6 cm in greatest dimension

M – Distant metastasis MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis

Stage grouping Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1, T2 N1 M0 T3 N0, N1 M0 Stage IVA T1, T2, T3 N2 M0 T4a N0, N1, N2 M0 Stage IVB T4b Any N M0 Any T N3 M0 Stage IVC Any T Any N M1

TUMORS Intrinsic origin Squamous papilloma Inverted papilloma Juvenile angiofibroma Vascular lesions Myxoma Giant cell tumor

Extrinsic origin Ameloblastoma OAT Odontoma Odontogenic myxoma

TUMOR-LIKE LESIONS:Giant cell granuloma

Fibrous dysplasia

MALIGNANT LESIONS

Squamous cell carcinoma

Adenoid cystic carcinoma

Adenocarcinoma

Sarcoma (Chondrosarcoma, Osteosarcoma, Fibrosarcoma)

Non-Hodgkin’s lymphoma

Ohngren lines

Polyp Nonneoplastic

epithelial & stroma tumours

Types: Inflammatory polyp Antrochoanal polyp

Papilloma Benign tumor of nasal

cavity composed of vascular connective tissue covered by well-differentiated stratified squamous epithelium that tends to grow under and elevate mucosa.

Pathogenesis

— allergy, chronic inflammation — human papilloma virus (HPV)

Clinical Features Most common in males aged 40–70 years Nasal stuffiness or obstruction. Secondary bacterial sinusitis. Postoperative recurrence 35–40%. May be associated with malignancy (about

10%).

Types (Batsakis)1) Keratotic papilloma simple cutaneous wart, exophytic with

broad base, in the nasal vestibule or nasal septum.

2) Inverted papilloma-lateral nasal wall

3)Fungiform (50%) - septum4)Cylindrical (3%) - lateral nasal wall

Inverted papilloma Arises from respiratory

mucosa of sinonasal tract

Involves lateral nasal wall & extends to adjacent maxillary sinus

Bulky, deep red, gray colour

Age>40ys ， high morbidity: 50—60ys;

M: F=3:1

Site of occurance: junction of antrum & ethmoid sinus

Unilateral nasal obstruction, congestion, epistaxis, abnormalities of smell.

HistopathologyHyperplastic epithelia

with inverting pattern of growth. Epithelial inversion into underlying stroma. Basal membrane is intact.

Fungiform papillomas an exophytic growth pattern and do not

grow down into the underlying normal stroma. They are almost always associated with human papillomavirus, and unlike inverted papillomas, do not have a tendency to recur.

Cylindrical cell papillomas They have a ragged, beefy appearance

and histologically they appear totally different. They are composed of columnar cells. They have a pink cytoplasm, their nuclei are oval or round,

Axial CT

Juvenile angiofibroma Highly vascular lesion, locally invasive, non encapsulated Age-10-17 years Site: posterior nares & nasopharyx Etiology:Popular theories include abnormal growth of

embryonal chondrocartilage, testosterone acting on a hamartomatous nidus of inferior turbinate tissue mislocated in the nasopharynx, tumor growth from normal nasopharyngeal fibrovascular stroma- may be due to androgen receptors capable of binding dihydrotestosterone & testosterone may indicate hormonal influence

trauma, inflammation, infection, allergy, and heredity.

Clinical features Site: posterolateral wall of the nasal cavity at

posterior nares & nasopharynx From its origin, tumor spreads into the nasal

cavity and nasopharynx- displacing the soft palate inferiorly, Anteriorly, it pushes forward the posterior wall of the maxillary sinus, creating the classic "antral bowing sign" visible by x-ray.

Posteriorly, it disrupts the root of the pterygoid plates. Superiorly, tumor expands into the orbit via the inferior orbital fissure, continuing eventually into the superior orbital fissure and middle cranial fossa.

With further lateral expansion, the tumor will pass through the pterygomaxillary fissure into the infratemporal fossa, often creating a bulging of the cheek. If it reaches the temporal fossa, the tumor can create a bulge above the zygoma.

lobulated, firm, non-encapsulated mass, usually pink-gray or purple-red. The tumor base may be sessile or pedunculated.

The most common presenting symptoms are nasal obstruction, epistaxis, diplopia, blindness, hearing loss, otitis media, rhinorrhea, nasal speech, noisy sleep, mouth breathing, eye pain, and headache.

histopathology CT- cleft like vascular

vascular channels Cellular atypia

Ameloblastoma Secondary to direct extension from

maxillary alveolar ridge Misplaced dental analage from epithelial

lining of dentigerous cyst c/f:asymptomatic swelling of cheek and

mucobuccal fold On penetration it enlarges & fills the antral

space Proptosis, nasal obstruction due to

involvment of superior & lateral nasal wall.

R/F

odontoma End products of anomalous anomalous

completion or lack of completion of tooth formation by odontogenic epithelium & ectomesenchyme

Complex Compound c/f- nasal obstruction, discharge, sinusitis

R/F

Odontogenic myxoma Site- maxillary bone, antral mucosa slow-growing, persistent and destructive,

may cross midline Gross feature: slimy, pale yellow mucoid

substance. Consistency is soft to moderate firm. Poorly circumscribed & infiltrates to surrounding tissues

R/F

unilocular/multilocular radioluscency with honeycomb or soap bubble appearance

H/F Loosely arranged

fibroblast and myofibroblast.

Cells are stellate with long protoplasmic process

Fibrous dysplasia Site: posterior maxilla C/F: rapid growth and enlargement of jaw

with facial deformity, Painless swelling

R/F

3D CT

Ossifying fibroma C/F: nasal obstruction, proptosis, malar

enlargement, vestibular swelling R/F: expansion, margination, demarcation,

cortication, displacement of teeth

Malignant tumorsMetaplastic type of epithelium- squamous

cell groupGlandular cell type epithelium-

adenocarcinoma group.

Squamous cell carcinoma A malignant epithelial neoplasm

originating from the mucosal epithelium of the nasal cavities or paranasal sinuses that includes a keratinizing and a non-keratinizing type.

Etiology Reported risk factors have include

exposure to nickel, chlorophenols, and textile dust, smoking, and a history or concurrence of sinonasal papilloma.

Clinical features More than 60% originate in maxillary sinuses,

followed by nasal cavity, and ethmoid sinuses nasal fullness, stuffiness, or obstruction;

epistaxis; rhinorrhea; pain; paraesthesia; fullness or swelling of the

nose or cheek or a palatal bulge; a persistent or non-healing nasal sore or ulcer; nasal mass;

In advanced cases, proptosis, diplopia, or lacrimation

Macroscopy exophytic, fungating,

or papillary; friable, haemorrhagic, partially necrotic, or indurated; demarcated or infiltrative.

R/F

R/F

Destruction of LT maxilla Intrasinus mass with irregular

destruction

Coronal CT

Intrasinus mass with irregular destruction of alveolus MRI- intrasinus & intraoral mass

H/F extracellulr or intracellular

keratin (pink cytoplasm, dyskeratotic cells) and/or intercellular bridges. Tumour cells are generally apposed to one another in a “mosaic tile” arrangement.

The tumour may be arranged in nests, masses, or as small groups of cells or individual cells.

Invasion occurs as blunt projections or ragged, irregular strands. carcinomas may be well, moderately, or

poorly differentiated

Adenoid cystic carcinoma Adenoid cystic carcinoma is the most

frequent malignant salivary gland-type tumour of the sinonasal tract.

Age-11-92 years. C/F: nasal obstruction, epistaxis, pain,

paraesthesia, displacement of orbital content, swelling of the palate or face, loosening of the teeth.

Evidence of perineural & intraneural spread

R/F CT scan shows a nasal

sinus mass focally extending into the bone.

H/F An intact surface

mucosa overlying the cribriform and cystic patterns

Common route of distant metastasis Lung, bone, liver, brain

adenocarcinoma glandular malignancies of the sinonasal tract. Etiology: wood dust and leather dust C/F: unilateral nasal obstruction, rhinorrhea and

epistaxis. Advanced tumours may cause pain, neurologic disturbances exophthalmos and visual disturbances.

R/F

H/F papillary growth

pattern and occasional tubular glands

Non Hodgkin’s lymphoma Involve lymph nodes, lymphoid organs,

extranodal organs and tissues B lymphomas are found mostly in

maxillary sinus C/F: swelling which may ulcerate later,

pain.

Staging of Maxillary Sinus Tumors T1: limited to antral mucosa without bony erosion T2: erosion or destruction of the infrastructure,

including the hard palate and/or middle meatus T3: Tumor invades: skin of cheek, posterior wall

of sinus, inferior or medial wall of orbit, anterior ethmoid sinus

T4: tumor invades orbital contents and/or: cribriform plate, post ethmoids or sphenoid, nasopharynx, soft palate, pterygopalatine or infratemporal fossa or base of skull

TREATMENT OF NEOPLASM OF

MAXILLARY SINUS

Surgery Unresectable tumors:

Superior extension: frontal lobes Lateral extension: cavernous sinus Posterior extension: prevertebral fascia Bilateral optic nerve involvement

Surgery Surgical approaches:

Lateral rhinotomy Transoral/transpalatal Midfacial degloving Weber-Fergusson Combined craniofacial approach

Extent of resection Medial maxillectomy Inferior maxillectomy Total maxillectomy

Culd wel luc procedure Indications: Mucoceles Antrochoanal polyp OKC

Transpalatal approach Indications: Small tumors of inferior and posterior

aspect

Lateral Rhinotomy & medial maxillectomy Indications: Well differentiated or low grade tumour Ameloblastoma Inverted papilloma

Medial maxillectomy A. access ostectom B. Removal of septum

to gain contralateral access

C.More lateral extension to gain access to ethmoids

D.Bone cuts to gain access to antrum

Webwr fergusson approach OKC, myxoma, Ameloblastoma, CEOT

Midfacial degloving

Chemotherapy Palliation, unresectable disease (+) margins, perineural spread, surgical

refusal, ECS Robbins - 86% response of T4 lesions Lee - 91% satisfactory response Agents: 5FU(1000mg/m2),

Cisplatinum(150mg/m2/wk/4wk)

Radiation therapy

Primary tx only for palliation 10-15% improved 5 year survival XRT = 23% vs. Surgery + XRT = 44% 68-72 Gy

Reconstruction Split thickness skin graft with obturator Soft tissue flaps and bone graft

MAXILLECTOMYSurgical removal of maxilla

Classification of maxillectomy

Type 1 defects (limited maxillectomy) Type 2 defects (subtotal maxillectomy). Type 3 (total maxillectomy) which is

subdivided into type 3a (orbital content preservation) and type 3b (orbital content exenteration).

Type 4 defects (orbitomaxillectomy)

According to Cordeiro and Sanatamaria

Maxillectomy classification scheme according to Okay et al. Class 1a includes defects of any

portion of the hard palate excluding tooth bearing maxillary alveolus.

Class 1b includes defects of premaxilla or any portion of alveolus or dentition posterior to canines.

Class 2 defects include any portion of hard palate, alveolus and only one canine tooth. Also includes transverse palatectomy involving less than 50% of the hard palate.

Class 3 defects include resection of any portion of hard palate, alveolus and both canine teeth. Also includes transverse palatectomy involving greater than 50% of the hard palate.

Subtotal maxillectomy Indications: Lesions of palate,

antrum, beyond the confines of antrum

Medial maxillectomy Indications:well

differentiated/low grade malignant tumour, inverted papilloma, or other tumors of limited extent to lateral wall of nasal cavity or medial wall of antrum

Total maxillectomy Indications: Primary tumour

arising from surface lining of maxillary antrum fills the entire antrum.

Treatment of the Orbit Before 1970’s orbital exenteration was

included in the radical resection Preoperative radiation reduced tumor load

and allowed for orbital preservation with clear surgical margins

Currently, the debate is centered on what “degree” of orbital invasion is allowed.

Current indications for orbital exenteration Involvement of the orbital apex Involvement of the extraocular muscles Involvement of the bulbar conjunctiva or

sclera Lid involvement beyond a reasonable hope

for reconstruction Non-resectable full thickness invasion

through the periorbita into the retrobulbar fat

Classification and Concepts in Reconstruction

Flaps used in maxillary reconstruction Palatal mucoperiosteal island flap Buccal fat pad Submental island flap Temporalis flap system Radial forearm flap Fibula flap Scapular flap system Iliac crest flap Abdominal rectus flap

A Class 1 defect can be simply treated with obturation or a soft tissue flap often preferred at the junction of the hard and soft palate.

Pedicled flaps:iliac crest maintained in a titanium mesh structure, the buccal fat pad, submental island flap

Free tissue transfer: composite fibula flap, Radial forearm flap

Class 2b-c fibula flap iliac crest Class 3a-c iliac crest with internal oblique titanium mesh or free bone from the hip Class 4a iliac crest with internal oblique, Rectus,

Lattisimus dorsi

Radial Forearm Flap 1978 (China) by Yang etal, 1985 (pharyngeal

recon) Oral cavity, base of tongue, pharynx, soft palate,

cutaneous defects, base of skull, small volume bone and soft tissue defects of face

Thin, pliable skin Reconstitution of contours, sulci, vestibules

Fasciocutaneous flaps are highly tolerant of radiation therapy

Composite flap with bone, tendon, brachioradialis muscle and vascularized nerve.

Neurovascular pedicle Up to 20 cm long Vessel caliber 2 – 2.5 mm Radial artery cephalic vein Lateral antebrachial

cutaneous nerve (sensory)

Technical considerations Tourniquet

Flap designed with skin paddle centered over the radial artery

Dissection in subfascial level as the pedicle is approached.

Pedicle identified b/w medial head of the brachioradialis, and the flexor carpi radialis

Radial artery is dissected to its origin

External skin monitor can be incorporated into the flap (proximal segment)

Radial Forearm Flap

Radial Forearm Flap Morbidity

Hand ischemia Fistula rates - 42% to 67% in early series Radial nerve injury Variable anesthesia over dorsum of hand.

Advantage:Thin pliable skin, often hairless,long pedicle(12-

15cm),Disadvantage:Donor site defect visible

Fibular free flap 1975 Hidalgo – mandibular recon

1989 Longest possible segment of

revasularized bone (25 cm) Ideal for osseointegrated

implant placement Mandible reconstruction (near

total), maxillary reconstruction

Neurovascular pedicle Peroneal artery and vein Sensate restoration with lateral sural

cutaneous nerve Peroneal communicating branch

vascularized nerve graft for lower lip sensation

Skin perforators Posterior intermuscular septum

(septocutaneous or musculocutaneous through flexor hallucis longus and soleus)

Should always include cuff of flexor hallucis longus and soleus in flap harvest

5-10% of cases blood supply to skin paddle is inadequate

Technical considerations Choose leg based on ease

of insetting Intraoral skin paddle

Harvest flap from contralateral side of recipient vessels

8 cm segment preserved proximally and distally to protect common peroneal nerve and ensure ankle stability

Center flap over posterior intermuscular septum Anterior to soleus and

posterior to peroneus

Fibular free flap Morbidity

Donor site complications Edema Weakness in dorsiflexion of great toe

Skin loss in 5 – 10% of flaps

Submental artery island flap

Thin, supple skin Submental branch of

facial artery Primary closure of

donor site Poor reliability if:

Facial artery sacrificed Irradiated neck Adv: Large flap size (7-15

cm) Superior skin color

match

disadvantage Not suitable if patient has previous level 1

nodal disease

Temperoparietal Fascia Flap Described by Golovine More commonly transferred as a pedicled flap but can be

used as a free flap when arc of rotation is inadequate Ultra thin – 2 to 4 mm thick Highly vascular, pliable and durable Fascial, fasciocutaneous

Neurovascular pedicle Superficial temporal artery and vein – travel in TPF

layer 3 cm superior to root of helix Vessels branch into frontal and temporal divisions Most commonly based on parietal branch Ligation of frontal artery 3 – 4 cm distal to branching

point to avoid frontal nerve injury Venous pedicle may course with arteries or 2 to 3 cm

posteriorly Middle temporal artery – proximal superficial

temporal artery at zygomatic arch (supplies temporalis muscular fascia)

Including middle temporal artery enables a two-layered fascial flap on a single pedicle.

Temperoparietal Fascia Flap

Technical considerations Vertical incision over

root of helix to superior temporal line

V-shaped extension at superior limit of incision

Scalp elevation ant and post

Dissect deep to flap Loose areolar tissue

deep to flap

Temperoparietal Fascia Flap Morbidity

Frontal branch weakness (travels in TPF) Secondary alopecia – damage to hair follicles

due to superficial dissection

Buccal fat pad A – branches of buccinator artery Rapid reepithelialization & only suitable for

medium sized defects up to 4cm Adv: Rapid reepithelialization Rich vascular supply No donor site skin scars

Disadvantage: Only suitable for medium sized defects up

to 4cm Prone to dehiscence

Iliac crest flaps Osteocutaneous, osteomusculocutaneous Up to 16 cm bone Oromandibular reconstruction Only vascularized bone used extensively with simultaneous or delayed

endosteal dental implant placement Skin paddle was not ideal for relining the oral cavity

Too thick for accurate restoration of the 3D anatomy

Neurovascular pedicle

Deep circumflex iliac artery from lateral aspect of external iliac artery

1 – 2 cm cephalic to inguinal ligament

Ascending branch of deep circumflex iliac artery supplies internal oblique muscle

Deep circumflex iliac vein – Can pass either superficial to deep

to artery Artery caliber – 2 to 3 mm Vein caliber – 3 to 5 mm Pedicle to internal oblique can

arise separately from deep circumflex iliac artery

Iliac crest flaps Morbidity

Hernia Need to approximate cut edge of iliacus muscle to

transversus abdominis Can be reinforced by drilling holes into cut edge of iliac

bone Approximate external obliques and aponeurosis to tensor

fascia lata and gluteus muscles Keep inferior oblique inferior and anterior to ASIS

Skin loss from perforator sheer injury poor color match

Rectus abdominis Easy to harvest Long pedicle(10cm) Skin from abdomen and lower chest Myocutaneous flap or muscle only flap Not used for functional motor reconstruction Can include entire muscle or only small portion in

paraumbilical region Plentiful people – thinner flap created by skin grafting the

muscle Skinny people

Flap used for moderately volume defects Poor color match Tends to become ptotic Able to fill large tissue deficits

Neurovascular pedicle Two dominant pedicles

Deep superior epigastric artery/vein Deep inferior epigastric artery and

vein Based on inferior epigastrics when

used for h/n recon because of larger pedicle size

Inferior epigastric diameter – 3 to 4 mm

Reinnervated with any of the lower six intercostal nerves.

Pedicle may travel along lateral aspect of muscle before taking intramuscular route

Scapular flaps Fasciocutaneous, osteofasciocutaneous,

cutaneous flap, parascapular cutaneous flap, latissimus dorsi myocutaneous flap, and serratus anterior flap

Thin, hairless skin Two cutaneous flaps may be harvested

Horizontally oriented flap – transverse cutaneous branch

Vertically oriented flap parascapular flap – descending cutaneous branch

Long pedicle length Large surface area Complex composite midfacial or

oromandibular defects Up to 10 cm bone Osseointegrated implants possible Single team approach

Neurovascular pedicle Subscapular artery and vein

Circumflex scapular artery and vein emerge from triangular space (teres major, teres minor and long head of triceps)

Paired venae comitantes Artery caliber – 4 mm at takeoff from subscapular

Subscapular caliber – 6 mm at takeoff from axillary artery

Pedicle length – 7 to 10 cm, 11 to 14 cm (from axillary artery)

Largest amount of tissue available for transfer

Technical considerations Decubitis positioning

15 degree angle Separate axillary incision

helpful in dissecting pedicle to axillary artery and vein

Bone harvest Teres major, subscapularis

and latissimus dorsi need to be reattached to scapula

Flap harvest opposite side of modified or radical neck dissection

Scapular flaps Morbidity

Brachial plexus injury 2/2 lateral decubitis positioning

Use axillary roll Stay 1 cm inferior to glenoid fossa Detach teres major and minor to harvest bone

Can cause shoulder weakness and limit range of motion.

Scapular flaps Preoperative

Considerations Prior axillary node

dissection – contraindication

Postoperative management Immobilize for 3 to 4

days Early ambulation 5 days for bone harvest PT

This long implant is anchored in the upper jawbone and in the very dense zygoma bone. A temporary prosthesis can be fixed immediately after placing the implant and until the final restoration, once the aesthetic criteria have been met and your expectations have been fulfilled

Zygomatic implants

obturator