nose & sinuses

DISEASES OF THE NOSE DISEASES OF THE NOSE AND PARANASAL AND PARANASAL

SINUSESSINUSESRYAN DUNCAN, MDRYAN DUNCAN, MD

PGY-4 RESIDENTPGY-4 RESIDENTOTOLARYNGOLOGY-HEAD AND NECK SURGERYOTOLARYNGOLOGY-HEAD AND NECK SURGERY

February 6, 2006February 6, 2006

NASAL ANATOMYNASAL ANATOMY

EthmoidMaxillaPalatineLacrimalPterygoid plate of

SphenoidNasal Inferior Turbinate

Bony Structure

7 bones4 paired sinuses4 turbinates3 meatiDrainage systemNervous supplyVascular supplyRelated structures

Sinus Anatomy Overview

Arterial Supply

External Carotid Maxillary A. SphenopalatineInternal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear

Innervation

VIRAL RHINITISVIRAL RHINITIS

Inflammation and swelling of the Inflammation and swelling of the mucous membranes of the nose usually mucous membranes of the nose usually caused by rhinovirus (common cold)caused by rhinovirus (common cold)

Symptoms consist of runny nose, Symptoms consist of runny nose, congestion, post-nasal drip, cough, and congestion, post-nasal drip, cough, and a low-grade fever a low-grade fever

Diagnosis made by history; adjunct Diagnosis made by history; adjunct tests usually not necessarytests usually not necessary

VIRAL RHINITISVIRAL RHINITIS

Complications may prolong illnessComplications may prolong illness often triggers asthma attacks often triggers asthma attacks Secondary infections: congestion in Secondary infections: congestion in

nose/ear blocks normal drainage nose/ear blocks normal drainage allowing bacteria to grow allowing bacteria to grow sinusitis, sinusitis, otitis mediaotitis media

VIRAL RHINITIS-TREATMENTVIRAL RHINITIS-TREATMENT

No vaccines availableNo vaccines available Echinacea, Vit C, Zinc effectiveness Echinacea, Vit C, Zinc effectiveness

not confirmed not confirmed Currently available antiviral drugs not Currently available antiviral drugs not

effectiveeffective Symptomatic treatment with Symptomatic treatment with

antihistamines, decongestants, cough antihistamines, decongestants, cough preparationspreparations

Function of Paranasal SinusesFunction of Paranasal Sinuses

Humidifying and warming inspired airHumidifying and warming inspired air Regulation of intranasal pressureRegulation of intranasal pressure Increasing surface area for olfactionIncreasing surface area for olfaction Lightening the skullLightening the skull ResonanceResonance Absorbing shockAbsorbing shock Contribute to facial growthContribute to facial growth generate 1 L mucus/daygenerate 1 L mucus/day

RhinosinusitisRhinosinusitis

IntroductionIntroduction 37 million Americans suffer from 37 million Americans suffer from

“sinusitis”“sinusitis” 25 million office visits in 1994-incidence 25 million office visits in 1994-incidence

increasingincreasing Over $200 million spent on prescriptions Over $200 million spent on prescriptions

for cold products; over half is for products for cold products; over half is for products containing antihistaminescontaining antihistamines

97 % of patients who see a physician with 97 % of patients who see a physician with “cold symptoms” receive a prescription“cold symptoms” receive a prescription


Defining “Sinusitis”Defining “Sinusitis” Acute rhinosinusitis (ARS)Acute rhinosinusitis (ARS) Subacute rhinosinusitis (SARS)Subacute rhinosinusitis (SARS) Chronic rhinosinusitis (CRS)Chronic rhinosinusitis (CRS) Recurrent acute rhinosinusitis (RARS)Recurrent acute rhinosinusitis (RARS) Acute superimposed upon chronic Acute superimposed upon chronic

rhinosinusitis (ARS/CRS)rhinosinusitis (ARS/CRS)


Major SymptomsMajor Symptoms Facial pain/pressureFacial pain/pressure Facial congestionFacial congestion Nasal obstructionNasal obstruction Purulent PNDPurulent PND Altered sense of Altered sense of

smellsmell Fever (ARS)Fever (ARS)

Minor SymptomsMinor Symptoms HeadacheHeadache Fever (all non-acute)Fever (all non-acute) HalitosisHalitosis FatigueFatigue Dental painDental pain CoughCough Ear pain/pressureEar pain/pressure


Acute RhinosinusitisAcute Rhinosinusitis Duration Duration << 4 weeks 4 weeks >> 2 major or 1 major and 2 minor 2 major or 1 major and 2 minor

factors or purulence seen on factors or purulence seen on examinationexamination

Subacute RhinosinusitisSubacute Rhinosinusitis Duration-4-12 weeksDuration-4-12 weeks

Middle turbinate

MSO

Septum


Chronic RhinosinusitisChronic Rhinosinusitis Duration-Duration->> 12 weeks 12 weeks

Recurrent Acute RhinosinusitisRecurrent Acute Rhinosinusitis >> 4 episodes/yr. of ARS with symptoms 4 episodes/yr. of ARS with symptoms

lasting lasting >> 7 days with no intervening 7 days with no intervening signs and symptoms of CRSsigns and symptoms of CRS

Acute Exacerbation of Chronic Acute Exacerbation of Chronic RhinosinusitisRhinosinusitis

Sudden worsening of CRSSudden worsening of CRS

Septum

MT remnant

MSO

CRS-”Empty nose”-Pseudomonas, Staph. aureus


DiagnosisDiagnosis Physical examination-anterior Physical examination-anterior

rhinoscopy vs. nasal endoscopyrhinoscopy vs. nasal endoscopy EdemaEdema HyperemiaHyperemia PurulencePurulence PolypsPolyps


DiagnosisDiagnosis Plain radiography of the paranasal Plain radiography of the paranasal

sinusessinuses Magnetic resonance imagingMagnetic resonance imaging Computerized tomography (non-contrast)Computerized tomography (non-contrast)

Screening CTScreening CT Standard CTStandard CT Timing of CTTiming of CT

Other testsOther tests


ManagementManagement GoalsGoals

Elimination of infectionElimination of infection Restoration of ventilation and drainageRestoration of ventilation and drainage


Surgical ManagementSurgical Management Prior to 1985, most surgery via Prior to 1985, most surgery via

external approach with emphasis on external approach with emphasis on maximum tissue removalmaximum tissue removal

With introduction of functional With introduction of functional endoscopic sinus surgery (FESS) in endoscopic sinus surgery (FESS) in 1985, emphasis is on maximum 1985, emphasis is on maximum tissue preservationtissue preservation


Surgical ManagementSurgical Management ARS-no role for surgery except for ARS-no role for surgery except for

management of complicationsmanagement of complications CRS-indicated for medically refractory CRS-indicated for medically refractory

disease; 80-98 % improvement, disease; 80-98 % improvement, revision rate < 10 %, major revision rate < 10 %, major complications <0.3 %complications <0.3 %

RARS-focused surgery often helpfulRARS-focused surgery often helpful

Techniques of Functional Techniques of Functional Endoscopic Sinus SurgeryEndoscopic Sinus Surgery

Uncinectomy

LNW

MT

MT

LNW

Techniques of Functional Techniques of Functional Endoscopic Sinus SurgeryEndoscopic Sinus Surgery

0 degree telescope 45 degree telescope

Maxillary Antrostomy

MSO

Accessoryostium


Surgical ManagementSurgical Management Computer assisted surgery (CAS) of Computer assisted surgery (CAS) of

the anterior skull base and paranasal the anterior skull base and paranasal sinuses has been commercially sinuses has been commercially available since 1996available since 1996

CAS has allowed us to safely expand CAS has allowed us to safely expand minimally invasive endoscopic minimally invasive endoscopic transnasal techniquestransnasal techniques


ConclusionConclusion ““Sinusitis” is a complicated diseaseSinusitis” is a complicated disease Defining categories is beneficialDefining categories is beneficial Management options are varied Management options are varied Surgical therapy plays a role for a Surgical therapy plays a role for a

well-defined, small population of well-defined, small population of patientspatients

EPISTAXISEPISTAXIS(nosebleeds)(nosebleeds)

Why bleeding from the nose Why bleeding from the nose ??

Vascular organ secondary to Vascular organ secondary to incredible heating/humidification incredible heating/humidification requirementsrequirements

Vasculature runs just under mucosa Vasculature runs just under mucosa (not squamous)(not squamous)

Arterial to venous anastamosesArterial to venous anastamoses ICA and ECA blood flowICA and ECA blood flow

EPISTAXISEPISTAXIS

External Carotid ArteryExternal Carotid Artery -Sphenopalatine artery-Sphenopalatine artery -Greater palatine artery-Greater palatine artery -Ascending pharyngeal artery-Ascending pharyngeal artery -Posterior nasal artery-Posterior nasal artery -Superior Labial artery-Superior Labial artery Internal Carotid ArteryInternal Carotid Artery -Anterior Ethmoid artery-Anterior Ethmoid artery -Posterior Ethmoid artery-Posterior Ethmoid artery

Kesselbach’s Plexus/Little’s Area:

-Anterior Ethmoid (Opth)

-Superior Labial A (Facial)

-Sphenopalatine A (IMAX)

-Greater Palatine (IMAX)

Woodruff’s Plexus:

-Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)

Anterior vs. PosteriorAnterior vs. Posterior

Maxillary sinus ostiumMaxillary sinus ostium Anterior: younger, usually septal vs. Anterior: younger, usually septal vs.

anterior ethmoid, most common anterior ethmoid, most common (>90%), typically less severe(>90%), typically less severe

Posterior: older population, usually Posterior: older population, usually from Woodruff’s plexus, more from Woodruff’s plexus, more serious.serious.

EtiologyEtiology

Local factorsLocal factors VascularVascular Infectious/InflammatoryInfectious/Inflammatory Trauma (most common)Trauma (most common) IatrogenicIatrogenic NeoplasmNeoplasm DessicationDessication Foreign Bodies/otherForeign Bodies/other

EtiologyEtiology

Systemic factorsSystemic factors VascularVascular Infection/InflammationInfection/Inflammation Coagulopathy Coagulopathy

Local Factors -- VascularLocal Factors -- Vascular

ICA Aneurysms ICA Aneurysms extradural extradural cavernous sinus cavernous sinus

Local Factors - Local Factors - Infection/InflammationInfection/Inflammation

Rhinitis/SinusitisRhinitis/Sinusitis AllergicAllergic BacterialBacterial FungalFungal ViralViral

Local Factors - TraumaLocal Factors - Trauma

Nose pickingNose picking Nose blowing/sneezingNose blowing/sneezing Nasal fractureNasal fracture Nasogastric/nasotracheal intubationNasogastric/nasotracheal intubation Trauma to sinuses, orbits, middle Trauma to sinuses, orbits, middle

ear, base of skullear, base of skull BarotraumaBarotrauma

Nasal Fracture with Septal Hematoma

Local Factors - Iatrogenic nasal Local Factors - Iatrogenic nasal injuryinjury

Functional endoscopic sinus surgeryFunctional endoscopic sinus surgery RhinoplastyRhinoplasty Nasal reconstructionNasal reconstruction

Local Factors - NeoplasmLocal Factors - Neoplasm

Juvenile nasopharyngeal angiofibromaJuvenile nasopharyngeal angiofibroma Inverted papillomaInverted papilloma SCCASCCA AdenocarcinomaAdenocarcinoma MelanomaMelanoma EsthesioneuroblastomaEsthesioneuroblastoma LymphomaLymphoma

Local Factors – Local Factors – Dessication Dessication

Cold, dry air—more common in Cold, dry air—more common in wintertimewintertime

Dry heat—Phoenix and Death valleyDry heat—Phoenix and Death valley Nasal oxygenNasal oxygen Anatomic abnormalitiesAnatomic abnormalities Atrophic rhinitisAtrophic rhinitis

Local Factors - OtherLocal Factors - Other

Self-inflicted (pedi) vs. traumatic foreign Self-inflicted (pedi) vs. traumatic foreign bodiesbodies

Intranasal parasitesIntranasal parasites Septal perforationSeptal perforation Chemical (cocaine, nasal sprays, ammonia, Chemical (cocaine, nasal sprays, ammonia,

etc.)etc.)

Systemic Factors -- VascularSystemic Factors -- Vascular

Hypertension/ArteriosclerosisHypertension/Arteriosclerosis Hereditary Hemorrhagic Hereditary Hemorrhagic

Telangectasias (OWR)Telangectasias (OWR)

EpistaxisEpistaxis

Osler-Weber- Rendu (HHT)

R L

Systemic Factors – Systemic Factors – Infection/InflammationInfection/Inflammation

TuberculosisTuberculosis SyphillisSyphillis Wegener’s GranulomatosisWegener’s Granulomatosis Periarteritis nodosaPeriarteritis nodosa SLESLE

Systemic Factors – Systemic Factors – CoagulopathiesCoagulopathies

ThrombocytopeniaThrombocytopenia Platelet dysfunctionPlatelet dysfunction

Systemic disease (Uremia)Systemic disease (Uremia) drug-induced (Coumadin/NSAIDs/Herbal drug-induced (Coumadin/NSAIDs/Herbal

supplements)supplements) Clotting Factor DeficienciesClotting Factor Deficiencies

HemophiliaHemophilia VonWillebrand’s diseaseVonWillebrand’s disease Hepatic failureHepatic failure

Hematologic malignanciesHematologic malignancies

Etiology and AgeEtiology and Age

Children—foreign body, nose picking, Children—foreign body, nose picking, nasal diptheria (1/3 with chronic nasal diptheria (1/3 with chronic bleeds have coagulation d/o)bleeds have coagulation d/o)

Adults—trauma, idiopathicAdults—trauma, idiopathic Middle age—tumorsMiddle age—tumors Old age--hypertensionOld age--hypertension

Initial ManagementInitial Management

ABC’sABC’s Medical history/MedicationsMedical history/Medications Vital signs—need IV?Vital signs—need IV? Physical examPhysical exam

Anterior rhinoscopyAnterior rhinoscopy Endoscopic rhinoscopyEndoscopic rhinoscopy

Laboratory examLaboratory exam Radiologic studiesRadiologic studies

suction

good lightanesthetic

silver nitrate

merocels

gelfoam

bacitracin

endoscopes

suction bovie/bipolar

Afrin

T.C.A.

surgicel

epistat

bayonet forceptsvaseline gauze

Non-surgical treatments Non-surgical treatments Control of hypertension Control of hypertension Correction of Correction of

coagulopathies/thrombocytopenia coagulopathies/thrombocytopenia FFP or whole blood/reversal of FFP or whole blood/reversal of

anticoagulant/plateletsanticoagulant/platelets Pressure/Expulsion of clotsPressure/Expulsion of clots Topical decongestants/vasocontrictorsTopical decongestants/vasocontrictors Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie)Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie) Nasal packing (effective 80-90% of time)Nasal packing (effective 80-90% of time) Greater palatine foramen blockGreater palatine foramen block

Non-surgical treatments – Non-surgical treatments – on d/con d/c

Humidity/emolientsHumidity/emolients Discontinue offending medsDiscontinue offending meds Nasal saline spraysNasal saline sprays Avoidance of nose picking/blowingAvoidance of nose picking/blowing Sneeze with mouth openSneeze with mouth open Avoid straining/bedrestAvoid straining/bedrest

Nasal packsNasal packs

Anterior nasal packsAnterior nasal packs TraditionalTraditional Recent modificationsRecent modifications

Posterior nasal packsPosterior nasal packs Traditional Traditional Recent modificationsRecent modifications

Ant/Post nasal packingAnt/Post nasal packing

TSS—Nugauze vs. Merocel

Electron microscopy

Posterior Packs – Admission Posterior Packs – Admission

Elderly and those with other chronic Elderly and those with other chronic diseases may need to be admitted to the diseases may need to be admitted to the ICUICU

Continuous cardiopulmonary monitoringContinuous cardiopulmonary monitoring AntibioticsAntibiotics Oxygen supplementation may be neededOxygen supplementation may be needed Mild sedation/analgesiaMild sedation/analgesia IVFIVF

Indications for Indications for surgery/embolizationsurgery/embolization

Continued bleeding despite nasal Continued bleeding despite nasal packingpacking

Pt requires transfusion/admit hct of Pt requires transfusion/admit hct of <38% (barlow)<38% (barlow)

Nasal anomaly precluding packingNasal anomaly precluding packing Patient refusal/intolerance of packingPatient refusal/intolerance of packing Posterior bleed vs. failed medical mgmt Posterior bleed vs. failed medical mgmt

after >72hrs (wang vs. schaitkin)after >72hrs (wang vs. schaitkin)

Selective Selective Angiography/embolizationAngiography/embolization

Helps identify location of bleedingHelps identify location of bleeding Embolization most effective in patients whoEmbolization most effective in patients who

Still bleeding after surgical arterial ligationStill bleeding after surgical arterial ligation Bleeding site difficult to reach surgicallyBleeding site difficult to reach surgically Comorbidities prohibit general anestheticComorbidities prohibit general anesthetic

Effective only when bleeding is >.5 ml/minEffective only when bleeding is >.5 ml/min 90+% success rate, complication rate of 0.1%90+% success rate, complication rate of 0.1% Only able to embolize external carotid & branchesOnly able to embolize external carotid & branches Complications: minor (18-45%)/major (0-2%)Complications: minor (18-45%)/major (0-2%) Contraindicated in bad atherosclerosis, Ethmoid Contraindicated in bad atherosclerosis, Ethmoid

bleedbleed

Surgical treatmentSurgical treatment

Transmaxillary IMA ligationTransmaxillary IMA ligation Intraoral IMA ligationIntraoral IMA ligation Anterior/Posterior Ethmoidal ligationAnterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligationTransnasal Sphenopalatine ligation External carotid artery ligationExternal carotid artery ligation

Septodermoplasty/Laser ablationSeptodermoplasty/Laser ablation

Transmaxillary IMA ligationTransmaxillary IMA ligation

Waters view Waters view Caldwell-LucCaldwell-Luc Electrocautery of posterior wall before Electrocautery of posterior wall before

removalremoval Microscopic dissection and ligation of IMA --Microscopic dissection and ligation of IMA --

descending palatine & sphenopalantine descending palatine & sphenopalantine most importantmost important

Recurrence rate (failure rate) of 10-15%Recurrence rate (failure rate) of 10-15% Complication rate of 25-30% (oa Complication rate of 25-30% (oa

fistula,dental, n)fistula,dental, n)

Intraoral IMA ligationIntraoral IMA ligation

Posterior gingivobuccal incision beginning Posterior gingivobuccal incision beginning at second molarat second molar

Temporalis mm split and partially dissectedTemporalis mm split and partially dissected IMAX visualized, clipped and dividedIMAX visualized, clipped and divided Advantages: children/facial fracturesAdvantages: children/facial fractures Disadvantages: more proximal ligationDisadvantages: more proximal ligation Complications: trismus, damage to Complications: trismus, damage to

infraorbital ninfraorbital n

Ant./Post. Ethmoidal ligationAnt./Post. Ethmoidal ligation

Patients s/p IMAX ligation still bleeding, Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in superior nasal cavity epistaxis, or in conjunction when source unclearconjunction when source unclear

Lynch incisionLynch incision Fronto-ethmoidFronto-ethmoid suture linesuture line 12-24-6 12-24-6 (14-18, 8-10, 4-6)(14-18, 8-10, 4-6)

Transnasal Endoscopic Transnasal Endoscopic Sphenopalatine Artery Sphenopalatine Artery

ligationligation Follow Middle Turbinate to posteriormost Follow Middle Turbinate to posteriormost

aspectaspect Vertical mucoperiosteal incision 7-8mm Vertical mucoperiosteal incision 7-8mm

anterior to post middle turb (between mid. anterior to post middle turb (between mid. and inf. turbs)and inf. turbs)

Elevation of flap—ID neurovascular bundle Elevation of flap—ID neurovascular bundle at foramenat foramen

Ligation with titanium clipLigation with titanium clip Reapproximate flapReapproximate flap Complications –few, Failures—0-13%Complications –few, Failures—0-13%

Transnasal Spheno-palatine Artery ligation

ECA ligationECA ligation

EffectivenessEffectiveness Anterior border of SCMAnterior border of SCM ID ECA/ICAID ECA/ICA Ligation after clear that surrounding Ligation after clear that surrounding

structures are safe.structures are safe.

Septodermoplasty/LaserSeptodermoplasty/Laser

Remove mucosa from anterior ½ Remove mucosa from anterior ½ septum, floor of nose, lateral wallseptum, floor of nose, lateral wall

STSG vs. cutaneous, myocutaneous, STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autograftsmicrovascular free flaps vs. Autografts

Neodymium-yttrium-garnet (Nd-YAG) Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid laser or Argon laser + topical steroid best nonsurg rx for mild/mod diseasebest nonsurg rx for mild/mod disease

Still bleed, but not as badStill bleed, but not as bad Definitive treatment (severe disease)—Definitive treatment (severe disease)—

closure of noseclosure of nose

Statistically speaking,….Statistically speaking,…. Some authors (Wang and Vogel) showed surgical Some authors (Wang and Vogel) showed surgical

intervention to have lower failure rates (14.3 vs. intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those shorter hospital stays (2.2 less) than those w/posterior packs.w/posterior packs.

Others compared all medical treatment to surgery Others compared all medical treatment to surgery and showed cost cut using medical management.and showed cost cut using medical management.

Complication rates: posterior packs-25-40%, Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28%embolization 27%, IMAX ligation 28%

Cost analysis: IMAX vs. Embolization vs. Surgical Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equalCautery—about equal

Failure rates: PP-30%, Sx-17%, Emb-4%Failure rates: PP-30%, Sx-17%, Emb-4%

Neoplasms of Nose and Neoplasms of Nose and Paranasal SinusesParanasal Sinuses

Very rare 3%Very rare 3% Delay in diagnosis due to similarity to Delay in diagnosis due to similarity to

benign conditionsbenign conditions Nasal cavityNasal cavity

½ benign½ benign ½ malignant½ malignant

Paranasal SinusesParanasal Sinuses MalignantMalignant

NeoplasmNeoplasm

BenignBenign Schneiderian papillomaSchneiderian papilloma

SquamousSquamous Inverted-13 % incidence of malignant Inverted-13 % incidence of malignant

degenerationdegeneration CylindricalCylindrical

MalignantMalignant Squamous cell carcinomaSquamous cell carcinoma Salivary gland tumorsSalivary gland tumors Neuroepithelial tumorsNeuroepithelial tumors

MRI demonstrating right nasal masswith no intracranial involvement

Nasalmass

Septum

Nasal mass

Angiofibroma

Neoplasms of Nose and Neoplasms of Nose and Paranasal SinusesParanasal Sinuses

Multimodality treatmentMultimodality treatment Orbital PreservationOrbital Preservation Minimally invasive surgical Minimally invasive surgical

techniquestechniques

EpidemiologyEpidemiology

Predominately of older malesPredominately of older males Exposure:Exposure:

Wood, nickel-refining processesWood, nickel-refining processes Industrial fumes, leather tanning Industrial fumes, leather tanning

Cigarette and Alcohol consumptionCigarette and Alcohol consumption No significant association has been No significant association has been

shownshown

LocationLocation

Maxillary sinusMaxillary sinus 70%70%

Ethmoid sinusEthmoid sinus 20%20%

SphenoidSphenoid 3%3%

FrontalFrontal 1%1%

PresentationPresentation

Oral symptoms: 25-35%Oral symptoms: 25-35% Pain, trismus, alveolar ridge fullness, erosionPain, trismus, alveolar ridge fullness, erosion

Nasal findings: 50%Nasal findings: 50% Obstruction, epistaxis, rhinorrheaObstruction, epistaxis, rhinorrhea

Ocular findings: 25%Ocular findings: 25% Epiphora, diplopia, proptosisEpiphora, diplopia, proptosis

Facial signsFacial signs Paresthesias, asymmetryParesthesias, asymmetry

RadiographyRadiography

CTCT Bony erosionBony erosion Limitations with periorbita involvementLimitations with periorbita involvement

MRIMRI 94 -98% correlation with surgical findings94 -98% correlation with surgical findings Inflammation/retained secretions: low T1, high T2Inflammation/retained secretions: low T1, high T2 Hypercellular malignancy: low/intermediate on Hypercellular malignancy: low/intermediate on

bothboth Enhancement with GadoliniumEnhancement with Gadolinium

Benign LesionsBenign Lesions

PolypsPolyps PapillomasPapillomas OsteomasOsteomas Fibrous DysplasiaFibrous Dysplasia Neurogenic tumorsNeurogenic tumors

NASAL POLYPSNASAL POLYPS Benign, Benign,

semitransparent lesionssemitransparent lesions Arise from nasal Arise from nasal

mucosamucosa Caused by chronic Caused by chronic

inflammationinflammation a/w asthma, CF, aspirin a/w asthma, CF, aspirin

intolerance, CRS, intolerance, CRS, Allergic RhinitisAllergic Rhinitis

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NASAL POLYPSNASAL POLYPS

Nasal EndoscopyNasal Endoscopy CT/MRICT/MRI Medical Tx: Medical Tx:

topical/systemic topical/systemic steroidssteroids

Surgical Tx: FESS Surgical Tx: FESS with polypectomywith polypectomy

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PapillomaPapilloma

Vestibular papillomasVestibular papillomas Schneiderian papillomas derived Schneiderian papillomas derived

from schneiderian mucosa from schneiderian mucosa (squamous)(squamous) Fungiform: 50%, nasal septumFungiform: 50%, nasal septum Cylindrical: 3%, lateral wall/sinusesCylindrical: 3%, lateral wall/sinuses Inverted: 47%, lateral wallInverted: 47%, lateral wall

Inverted PapillomaInverted Papilloma

4% of sinonasal tumors4% of sinonasal tumors Site of Origin: lateral nasal wallSite of Origin: lateral nasal wall UnilateralUnilateral Malignant degeneration in 2-13% Malignant degeneration in 2-13%

(avg 10%)(avg 10%)

Inverted PapillomaInverted PapillomaResectionResection

Initially via transnasal resection:Initially via transnasal resection: 50-80% recurrence50-80% recurrence

Medial Maxillectomy via lateral rhinotomy:Medial Maxillectomy via lateral rhinotomy: Gold StandardGold Standard 10-20%10-20%

Endoscopic medial maxillectomy:Endoscopic medial maxillectomy: Key concepts:Key concepts:

Identify the origin of the papillomaIdentify the origin of the papilloma Bony removal of this regionBony removal of this region

Recurrent lesions:Recurrent lesions: Via medial maxillectomy vs. Endoscopic resectionVia medial maxillectomy vs. Endoscopic resection 22%22%

INVERTED PAPILLOMAINVERTED PAPILLOMA

http://ctscans.hawkelibrary.com/album21/Inverting_Papilloma_Sphenoid?full=1

OsteomasOsteomas

Benign slow growing tumors of Benign slow growing tumors of mature bonemature bone

Location:Location: Frontal, ethmoids, maxillary sinusesFrontal, ethmoids, maxillary sinuses

When obstructing mucosal flow can When obstructing mucosal flow can lead to mucocele formationlead to mucocele formation

Treatment is local excisionTreatment is local excision

Fibrous dysplasiaFibrous dysplasia

Dysplastic transformation of normal Dysplastic transformation of normal bone with collagen, fibroblasts, and bone with collagen, fibroblasts, and osteoid materialosteoid material

Monostotic vs PolyostoticMonostotic vs Polyostotic Surgical excision for obstructing lesionsSurgical excision for obstructing lesions Malignant transformation to Malignant transformation to

rhabdomyosarcoma has been seen rhabdomyosarcoma has been seen with radiationwith radiation

Neurogenic tumorsNeurogenic tumors

4% are found within the paranasal sinuses4% are found within the paranasal sinuses SchwannomasSchwannomas NeurofibromasNeurofibromas Treatment via surgical resectionTreatment via surgical resection Neurogenic Sarcomas are very aggressive Neurogenic Sarcomas are very aggressive

and require surgical excision with post op and require surgical excision with post op chemo/XRT for residual disease.chemo/XRT for residual disease.

When associated with Von Recklinghausen’s When associated with Von Recklinghausen’s syndrome: more aggressive (30% 5yr syndrome: more aggressive (30% 5yr survival).survival).

Malignant lesionsMalignant lesions

Squamous cell carcinomaSquamous cell carcinoma Adenoid cystic carcinomaAdenoid cystic carcinoma Mucoepidermoid carcinomaMucoepidermoid carcinoma AdenocarcinomaAdenocarcinoma HemangiopericytomaHemangiopericytoma MelanomaMelanoma Olfactory neuroblastomaOlfactory neuroblastoma Osteogenic sarcoma, fibrosarcoma, Osteogenic sarcoma, fibrosarcoma,

chondrosarcoma, rhabdomyosarcomachondrosarcoma, rhabdomyosarcoma LymphomaLymphoma Metastatic tumorsMetastatic tumors Sinonasal undifferentiated carcinomaSinonasal undifferentiated carcinoma

Squamous cell carcinomaSquamous cell carcinoma

Most common tumor (80%)Most common tumor (80%) Location:Location:

Maxillary sinus (70%)Maxillary sinus (70%) Nasal cavity (20%)Nasal cavity (20%)

90% have local invasion by presentation90% have local invasion by presentation Lymphatic drainage:Lymphatic drainage:

First echelon: retropharyngeal nodesFirst echelon: retropharyngeal nodes Second echelon: subdigastric nodesSecond echelon: subdigastric nodes

TreatmentTreatment

88% present in advanced stages 88% present in advanced stages (T3/T4)(T3/T4)

Surgical resection with postoperative Surgical resection with postoperative radiationradiation Complex 3-D anatomy makes margins Complex 3-D anatomy makes margins

difficultdifficult

Adenoid Cystic CarcinomaAdenoid Cystic Carcinoma

33rdrd most common site is the most common site is the nose/paranasal sinusesnose/paranasal sinuses

Perineural spreadPerineural spread Anterograde and retrogradeAnterograde and retrograde

Despite aggressive surgical resection Despite aggressive surgical resection and radiotherapy, most grow insidiously.and radiotherapy, most grow insidiously.

Neck metastasis is rare and usually a Neck metastasis is rare and usually a sign of local failuresign of local failure

Postoperative XRT is very importantPostoperative XRT is very important

Mucoepidermoid CarcinomaMucoepidermoid Carcinoma

Extremely rareExtremely rare Widespread local invasion makes Widespread local invasion makes

resection difficult, therefore radiation resection difficult, therefore radiation is often indicatedis often indicated

AdenocarcinomaAdenocarcinoma 22ndnd most common malignant tumor in the most common malignant tumor in the

maxillary and ethmoid sinusesmaxillary and ethmoid sinuses Present most often in the superior portionsPresent most often in the superior portions

Strong association with occupational exposuresStrong association with occupational exposures High grade: solid growth pattern with poorly High grade: solid growth pattern with poorly

defined margins. 30% present with metastasisdefined margins. 30% present with metastasis Low grade: uniform and glandular with less Low grade: uniform and glandular with less

incidence of perineural invasion/metastasis.incidence of perineural invasion/metastasis.

HemangiopericytomaHemangiopericytoma

Pericytes of ZimmermanPericytes of Zimmerman Present as rubbery, pale/gray, well Present as rubbery, pale/gray, well

circumscribed lesions resembling nasal polypscircumscribed lesions resembling nasal polyps Treatment is surgical resection with Treatment is surgical resection with

postoperative XRT for positive marginspostoperative XRT for positive margins

MelanomaMelanoma

0.5- 1.5% of melanoma originates from the 0.5- 1.5% of melanoma originates from the nasal cavity and paranasal sinus.nasal cavity and paranasal sinus.

Anterior Septum: most common siteAnterior Septum: most common site Treatment is wide local excision Treatment is wide local excision

with/without postoperative radiation with/without postoperative radiation therapytherapy

END not recommendedEND not recommended AFIP: Poor prognosisAFIP: Poor prognosis

5yr: 11%5yr: 11% 20yr: 0.5%20yr: 0.5%

Olfactory NeuroblastomaOlfactory NeuroblastomaEsthesioneuroblastomaEsthesioneuroblastoma

Originate from stem cells of neural Originate from stem cells of neural crest origin that differentiate into crest origin that differentiate into olfactory sensory cells.olfactory sensory cells.

Kadish ClassificationKadish Classification A: confined to nasal cavityA: confined to nasal cavity B: involving the paranasal cavityB: involving the paranasal cavity C: extending beyond these limitsC: extending beyond these limits


UCLA Staging systemUCLA Staging system T1: Tumor involving nasal cavity and/or T1: Tumor involving nasal cavity and/or

paranasal sinus, excluding the sphenoid and paranasal sinus, excluding the sphenoid and superior most ethmoidssuperior most ethmoids

T2: Tumor involving the nasal cavity and/or T2: Tumor involving the nasal cavity and/or paranasal sinus including sphenoid/cribriform paranasal sinus including sphenoid/cribriform plateplate

T3: Tumor extending into the orbit or anterior T3: Tumor extending into the orbit or anterior cranial fossacranial fossa

T4: Tumor involving the brainT4: Tumor involving the brain


Aggressive behaviorAggressive behavior Local failure: 50-75%Local failure: 50-75% Metastatic disease develops in 20-Metastatic disease develops in 20-

30%30% Treatment:Treatment:

En bloc surgical resection with En bloc surgical resection with postoperative XRTpostoperative XRT

SarcomasSarcomas

Osteogenic SarcomaOsteogenic Sarcoma Most common primary malignancy of Most common primary malignancy of

bone.bone. Mandible > MaxillaMandible > Maxilla Sunray radiographic appearanceSunray radiographic appearance

FibrosarcomaFibrosarcoma ChondrosarcomaChondrosarcoma

RhabdomyosarcomaRhabdomyosarcoma

Most common paranasal sinus malignancy in Most common paranasal sinus malignancy in childrenchildren

Non-orbital, parameningealNon-orbital, parameningeal Triple therapy is often necessaryTriple therapy is often necessary Aggressive chemo/XRT has improved Aggressive chemo/XRT has improved

survival from 51% to 81% in patients with survival from 51% to 81% in patients with cranial nerve deficits/skull/intracranial cranial nerve deficits/skull/intracranial involvement.involvement.

Adults, Surgical resection with postoperative Adults, Surgical resection with postoperative XRT for positive margins.XRT for positive margins.

LymphomaLymphoma

Non-Hodgkins typeNon-Hodgkins type Treatment is by radiation, with or Treatment is by radiation, with or

without chemotherapywithout chemotherapy Survival drops to 10% for recurrent Survival drops to 10% for recurrent

lesionslesions

Sinonasal Undifferentiated Sinonasal Undifferentiated Carcinoma (SNUC)Carcinoma (SNUC)

Aggressive locally destructive lesionAggressive locally destructive lesion Dependent on pathological Dependent on pathological

differentiation from melanoma, differentiation from melanoma, lymphoma, and olfactory lymphoma, and olfactory neuroblastomaneuroblastoma

Preoperative chemotherapy and Preoperative chemotherapy and radiation may offer improved survivalradiation may offer improved survival

Metastatic TumorsMetastatic Tumors

Renal cell carcinoma is the most Renal cell carcinoma is the most commoncommon

Palliative treatment onlyPalliative treatment only

Staging of Maxillary Sinus Staging of Maxillary Sinus TumorsTumors

Staging of Maxillary Sinus Staging of Maxillary Sinus TumorsTumors

T1: limited to antral mucosa without bony T1: limited to antral mucosa without bony erosionerosion

T2: erosion or destruction of the infrastructure, T2: erosion or destruction of the infrastructure, including the hard palate and/or middle meatusincluding the hard palate and/or middle meatus

T3: Tumor invades: skin of cheek, posterior T3: Tumor invades: skin of cheek, posterior wall of sinus, inferior or medial wall of orbit, wall of sinus, inferior or medial wall of orbit, anterior ethmoid sinusanterior ethmoid sinus

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

SurgerySurgery

Unresectable tumors:Unresectable tumors: Superior extension: frontal lobesSuperior extension: frontal lobes Lateral extension: cavernous sinusLateral extension: cavernous sinus Posterior extension: prevertebral fasciaPosterior extension: prevertebral fascia Bilateral optic nerve involvementBilateral optic nerve involvement

SurgerySurgery

Surgical approaches:Surgical approaches: EndoscopicEndoscopic Lateral rhinotomyLateral rhinotomy Transoral/transpalatalTransoral/transpalatal Midfacial deglovingMidfacial degloving Weber-FergussonWeber-Fergusson Combined craniofacial approachCombined craniofacial approach

Extent of resectionExtent of resection Medial maxillectomyMedial maxillectomy Inferior maxillectomyInferior maxillectomy Total maxillectomyTotal maxillectomy

MIDFACIAL DEGLOVINGMIDFACIAL DEGLOVING

LATERAL RHINOTOMYLATERAL RHINOTOMY

CRANIOFACIAL APPROACHCRANIOFACIAL APPROACH

Treatment of the OrbitTreatment of the Orbit

Before 1970’s orbital exenteration was Before 1970’s orbital exenteration was included in the radical resectionincluded in the radical resection

Preoperative radiation reduced tumor Preoperative radiation reduced tumor load and allowed for orbital load and allowed for orbital preservation with clear surgical marginspreservation with clear surgical margins

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

Current indications for orbital Current indications for orbital exenterationexenteration

Involvement of the orbital apexInvolvement of the orbital apex Involvement of the extraocular musclesInvolvement of the extraocular muscles Involvement of the bulbar conjunctiva or Involvement of the bulbar conjunctiva or

sclerasclera Lid involvement beyond a reasonable hope Lid involvement beyond a reasonable hope

for reconstructionfor reconstruction Non-resectable full thickness invasion Non-resectable full thickness invasion

through the periorbita into the retrobulbar through the periorbita into the retrobulbar fatfat

ConclusionsConclusions

Neoplasms of the nose and paranasal Neoplasms of the nose and paranasal sinus are very rare and require a sinus are very rare and require a high index of suspicion for diagnosishigh index of suspicion for diagnosis

Most lesions present in advanced Most lesions present in advanced states and require multimodality states and require multimodality therapytherapy

REFERENCESREFERENCES

www.utmb.edu/otowww.utmb.edu/oto http://www.emedicine.com/PED/topichttp://www.emedicine.com/PED/topic

1550.htm1550.htm http://www.merck.com/mmhe/http://www.merck.com/mmhe/

sec19/ch221/ch221g.htmlsec19/ch221/ch221g.html

http://www.utmb.edu/oto

http://www.emedicine.com/PED/topic1550.htm

http://www.emedicine.com/PED/topic1550.htm

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