nasal obstruction / orthodontic courses by indian dental academy

Nasal ObstructionNasal Obstruction INDIAN DENTAL ACADEMY

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HistoryHistoryCC: “I can’t breath through the left side of

my nose”• What else do you want to ask the patient?

• HPI: • 6-8 mo h/o left nasal obstruction.• Slowly progressive• Occasional epistaxis when bends over• Decreased sense of smell left nasal passage• No visual changes, no headaches


Physical ExamPhysical ExamEyes: EOMI, PERRL, no diplopia, no

proptosisEars: TM’s clearNose: Left nasal mass, edematous,

obstructing almost entire nasal passageOC/OP: No masses/lesionsNeck: no LADCN: II-XII intact


Diagnostic StudiesDiagnostic StudiesCT: evaluate bony destructionMRI: evaluate soft tissue, differentiate

mucous from mass


Differential DiagnosisDifferential Diagnosis V– hemangioma, AVM, juvenile nasoangiofibroma, hamartoma

I – sinusitis, nasal polyposis, mucocele, allergic rhinitis,

T – acquired nasal deformity

A – Wegener’s granulomatosis, relapsing polychondritis

M – none

I – Sarcoid, rhinitis medimentosum

N – mucosal melanoma, lymphoma, nasopharyngeal carcinoma, extramedullary plasmacytoma, adenoid cystic carcinoma, adenocarcinoma, squamous cell ca, papillomas, fibrous dysplasia, osteoma, hemangiopericytoma, esthesioneuroblastoma, sarcomas, SNUC

C – teratomas, dermoid,

D – none


EsthesioneuroblastomaEsthesioneuroblastoma Epidemiology:

– Male:female (1:1)– Bimodal distribution 2nd and 6th decades

Pathophyisiology:– Neuroectodermal origin– Arise from olfactory mucosa– Common symptoms:

Unilateral nasal obstruction (70%)* Epistaxis (46%)*

* Irish J, Dasgupta R, Freeman J, et al. Outcome and analysis of the surgical management of esthesioneuroblastoma J Otolaryngol 1997; 26:1-7.


Spectrum of lesionsSpectrum of lesions Broad range of lesions arise

from the olfactory mucosa Diverse cell poplulation in the

olfactory mucosa– Sensory neurons– Sustentacular cells– Basal cells

Within olfactory neuroblastoma a spectrum exists


HistologyHistology Histologic grading based on Hyams criteria

Grade I: 14% Grade III: 21%Grade II: 48% Grade IV: 17%

Prognostically grouped as high or low grade Low grade: 56%, High grade 25%

*Pilch B. Head and Neck Surgical Pathology. Lippencott. Philadelphia. 2001www.indiandentalacademy.com

ImmunohistochemistryImmunohistochemistry


HistologyHistology


Grading SystemGrading System Kadish system

Stage A: limited to nasal cavityStage B: Extends into paranasal sinusesStage C: Extends beyond nasal cavity and paranasal sinuses

Dulguerov and Calcaterra*T1: nasal cavity/paranasal sinuses (not sphenoid or superior most ethmoids)T2: includes sphenoid w/ extension to/erosion of cribiform plateT3: extends into orbit or anterior cranial fossa w/o dural invasionT4: tumor involving brain

N0: no cervical lymphadenopathyN1: any cervical metastasis

M0: no metastasesM1: distant metastases

* Dulguerov P, Allal A, Calcaterra T. Esthesioneuroblastoma: a meta-analysis and review. Lancet Oncol. 2001; 2:683-690.


Grading SystemsGrading Systems5 year survival: Kadish

– Stage A 72%– Stage B 59%– Stage C 47%

Dulguerov and Calcaterra– T1 81%– T2 93%– T3 59%– T4 48%– N0 64%– N1 29%

Distribution of Patients: Kadish

– Stage A 12%– Stage B 27%– Stage C 61%

Dulguerov and Calcaterra– T1 25%– T2 25%– T3 33%– T4 17%– N1 5%

*Dulguerov P, Allal A, Calcaterra T. Esthesioneuroblastoma: a meta-analysis and review. Lancet Oncol. 2001; 2:683-690.


TreatmentTreatment Surgery and Radiation therapy is most commonly

accepted modality of treatment Chemotherapy may be indicated for advanced lesions

but is controversial* Treatment of the neck is controversial**

*Eden BV, Debo RF, Larner JM, et al. Esthesioneruroblastoma: long-term outcome and patters of failure-the University of Virginia experience. Cancer. 1994;73:2556-2562.

** Davis RE, Weissler MC. Esthesioneuroblastom and neck metastasis. Head Neck. 1992;14:477-482.


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nasal obstruction / orthodontic courses by indian dental academy

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