NEOPLASMS OF NOSE AND PNS

DR MD ROOHIA

CLASSIFICATIONNasal cavity

PNSBENIGN NEOPLASMS

MALIGNANT NEOPLASMS

Osteomas Carcinoma of Maxillary Sinus

Fibrous Dysplasias Ethmoidal sinus malignancy

Ossifying Fibroma Frontal sinus malignancy

Ameloblastoma(adamantinoma)

Sphenoid sinus malignancy

Inverted papilloma

Meningioma&haemangioma

EPIDEMIOLOGY

RISK FACTORS

Benign neoplasms of nasal cavity1. Squamous papillomaVerrucous lesions similar to skin

warts. Involves nasal vestibule or lower

part of nasal septum. Single or multiple,

pedunculated or sessile Treatment is

cauterisation ,cryosurgery or laser.

2. Pleomorphic adenomaRare ,arises from the nasal

septum. 3. Schwannoma and

meningiomaUncommon , found intranasally.

Endoscopic view nasal papilloma

4.Haemangiomaa) Capillary

haemangioma (Bleeding polypus of the septum) . It is a soft, dark red, pedunculated orsessile

Epiastaxis,nasal obstruction

Treatment is local excision(b) Cavernous

haemangioma . It arises from the turbinates

surgical excision

5. Chondroma from the ethmoid, nasal cavity or nasal

septum. Pure chondromas are smooth, firm and lobulated.

Treatment is surgical excision6. AngiofibromaIt is included in nasal tumours because its

primary site of origin is supposed to be posterior part of nasal

cavity near the sphenopalatine foramen

7. Intranasal meningoencephalocele

It is herniation of brain tissues and meninges through foramen caecum or cribriform plate.

It presents as a smooth polyp in the upper part of nose between the septum and middle turbinate,

usually in infants and young children. The 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 from the brain, and repair of dural and bony

defect. Intranasal mass is removed

Meningoencehalocele b/n middle.t & sup.t

8. GliomasOf all the gliomas, 30% are

intranasal and 10% both intra and extranasal. They are seen in infants and children.

An intranasal glioma presents as a firm polyp.

9. 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.

Intra nasal glioma

Nasal dermoid cyst

Malignant neolasms of nasal cavityPrimary carcinoma per se is rare. It may be an extension of

maxillary or ethmoid carcinoma(a) Squamous cell carcinoma . It may arise from the

vestibule, anterior part of nasal septum or the lateral wall of nasal cavity. (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 thenose. It has often been termed as "nose-picker's cancer.(iii) Lateral wall: Easily extends into ethmoid or maxillary

sinuses. Grossly, it presents as a polypoid mass in the lateral wall of nose.

(b) Adenocarcinoma and adenoid cystic carcinoma . They arise from the glands of mucous membrane or minor salivary glands and mostly involve upper part of the lateral wall of nasal cavity

SCC of vestibule

2. Malignant melanoma 50 years of age. Both sexes are equally

affected. presents as a slaty-grey or

bluish-black polypoid mass. 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.

Treatment is wide surgical excision.

3. Olfactory neuroblastoma (esthesio neuroblastoma) tumour of olfactory placode . either sex at any age group. It presents as a cherry red,

polypoidal mass in the upper third of the nasal cavity

surgical excision followed by radiation

4. Haemangiopericytoma tumour of vascular origin. age group of 60-70 and presents

with epistaxis It arises from the pericyte-a cell

surrounding the capillaries Treatment is wide surgical

excision.

5. LymphomaRarely a non-Hodgkin lymphoma presents on the

septum.6. Plasmacytomapredominantly affects males over 40 years. Treatment is by radiotherapy followed three months

later bysurgery if total regression does not occur.7. SarcomasOsteogenic sarcoma, chondrosarcoma,

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

Neoplasms of Paranasal SinusesOSTEOMAS:most commonly seen in

the frontal sinusdiscovered incidentally

on X-raysSurgical excision for

raidly growing osteomasComplete removal of

tumour with its base attachment is done by bicoronal osteoplastic flap technique

Frontal sinus osteoma

Osteoplastic flap technique

Osteoma exposed

Tumour removal+closing of bone flap

Ossifying fibromaSynonym: Fibrous dysplasiaNormally medullary bone is

replaced by abnormal proliferation of fibrous tissue, resulting in distortion & expantion of bone.

CT SCAN: ground glass appearance with regioins of osteolysis & calcification

TREATMENT: complete surgical excision

INVERTED PAPILLOMALocally aggressive sino-

nasal tumour.Synonym:Rigertz 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

INVERTED PAPILLOMATreatment: medial

maxillectomy & enbloc ethmoidectomy by lateral rhinotomy or midfacial degloving.

Inverted papilloma has a marked tendency to recur after surgical removal

Sqamous cell ca.present in 10-15% cases

Radiotherapy avoided.Anterior rhinoscopy

Contrast CT PNS Left intra nasal mass

with opacification of maxillary & ethmoid sinuses (African continent sign)

Bone destruction of lateral nasal wall

Punch biopsy & HPEInward invasion of hyperplastic epithelium

into underlying stroma No evidence of malignancy.

Moure’s lateral rhinotomy

Osteotomy cuts Bone removed & tumour exosed

Tumour removed & incision closed

Midfacial degloving approach

Malignant neoplasms of PNSMAXILLARY SINUS CARCINOMAEarly clinical featuresNasal stuffinessBlood stained nasal dischargeFacial paraesthesias or painepiphora

Late clinical featuresMedial spread:Unilateral nasal

obstructionUnilateral purulent

nasal dischargeEpistaxis Unilateral ,friable,

nasal mass Anterior spread:cheek swelling Invasion of Facial skin

Cheek skin involved Nasal mass

Inferior spread: expansion of alveolus

with dental pain Loosening of teeth ,poor

fitting of dentaturesSwelling in hard palate

or alveolus Superior spread:Proptosis DiplopiaOccular pain Alveola &palatal swelling

Posterior spread:Pterygoid muscle

involvement- trismusIntracranial spread via:Ethmoids, cribriform

or foramen lacerumLymphatic spread:

neck node metastasis in late stages

Systemic spread: lungs ,bone

Diagnosis Diagnostic nasal

endoscopy Xray PNS :

expansion & destruction of bony wall

C.t, scan PNS: with contrast

Biopsy

Ohngren’s classificationOhngren’s line: An imaginary plane

extending b/n medial canthas of eye & angle of mandible

Supra structural growth situated above this plane have poor prognosis

Infra structural growth below this plane have better prognosis

LEDERMAN’S CLASSIFICATION2 horizantal lines of

sebileau pass through floors of orbits & maxillary sinus, producing:

Supra structure: ethmoid,sphenoid& frontal sinuses:olfactory area of nose.

Mesostructure : maxillary sinus & respiratory part of nose

Infrastructure: Alveolar processes

TNM STAGING

TREATMENTT1 & T2: surgery or radiotherapyT 3: surgery + radiotherapyT4 : surgery + radiotherapy+ chemotherapyEuropeans : Preop radiotherapy (5000cGy-

6000cGy) then surgery after 4-6wksAmericans : surgery then postop RT 4-6wks

later.

Surgical options1.Total maxillectomy Weber fergusson incision In Malignancy limited to maxilla2. radical maxillectomy with orbital

exenterationIn involvement of orbital fat 3.anterior cranio facial ressection Extended lateral rhinotomy incision In involvement of cribriform late, frontal

sinus

TOTAL MAXILLECTOMYTARSORRHAPHY

WEBER FERGUSSON INCISION

OSTEOTOMY CUTS

TOTAL ,MAXILLETOMY DONE &INCISION CLOSED

PALATAL DEFECTS & PROSTHESIS

CRANIO FACIAL RESSECTION

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