1. Sino-nasal Tumours
Dr.Mohammad aloulah

2. Classification Benign Simple papilloma Ossifying Fibroma Osteoma
Haemangioma
Neurofibroma
Intermediate
Inverted papilloma
Malignant
Squamous cell carcinoma
Adenocarcinoma
Anaplastic carcinoma
Transitional cell carcinoma
Malignant melanoma
Salivary gland tumours
Rhabdomyosarcoma

3. Oeteoma
Osteomas are common incidental finding in frontal sinus CT scan
Majority are asymptomatic & do not grow
Surgery is done for symptomatic osteomas or those that rapidly increase in size
Complete removal of tumor with its base attachment is done by FESS, bicoronal osteoplastic flap technique

4. Frontal sinus osteoma

5. Bicoronal osteoplastic flap

6. Osteoma exposed

7. Tumor removal + closing of bone flap

8. Ossifying fibroma Synonym: Fibrous dysplasia
Normal medullary bone is replaced by abnormal proliferation of fibrous tissue, resulting in distortion & expansion of bone
C.T. scan: ground - glass appearance with regions of osteolysis & calcification
Treatment: surgical excision for symptomatic Pt

9. Ossifying fibroma

10. Ossifying fibroma

11. Inverted papilloma Locally aggressive sino-nasal tumour
Synonyms: Ringertz or Schneiderian papilloma
Common in males between years
It arises commonly from the lateral wall of nose
Presents as unilateral, Bilatral, friable, pale, pink mass arising from middle meatus
Diagnosis made by punch biopsy

12. Inverted papilloma
Treatment: Endscopic medial maxillectomy and en bloc ethmoidectomy by lateral rhinotomy or midfacial degloving.
Inverted papilloma has a marked tendency to recur after surgical removal.
Squamous cell ca is present in 5 – 10 % cases.

13. Anterior rhinoscopy

14. Contrast C.T. scan P.N.S.
Left intra-nasal mass with opacification of maxillary and ethmoid sinus

15. Punch Biopsy & H.P.E. Inward invasion of hyperplastic epithelium into
underlying stroma. No evidence of malignancy.

16. lateral rhinotomy

17. Bone removed & tumor exposed

18. Tumour removed & inicision closed

19. Midfacial degloving approach

20. Sino-nasal Malignancy

21. Epidemiology Uncommon tumors - >1% of all neoplasms
Produces very little symptoms
Commonly mistaken for rhinosinusitis
Average delay from first symptom to diagnosis is about 6 months
Accurate staging is still not possible – Current staging system is only for maxillary & ethmoid sinuses

22. Epidemiology Incidence – 1% per 100,000 / year
Commonly develop during 5th – 6th decades of life
Twice as common in men than women
Common sino-nasal malignancy – Primary epithelial tumors followed by non-epithelial malignant tumors
Tumors arising from nose 25% and tumors arising from sinuses 75%
60% of squamous carcinomas arise from maxillary sinus, 20% from nasal cavity rest from ethmoids. 1% arise from sphenoid

23. Common sinonasal malignancy
Squamous cell carcinoma – commonest
Adenocarcinomas
Adenocystic carcinomas
Undifferentiated carcinomas
Non Hodgkin's lymphoma
Melanomas

24. Adenocarcinoma

26. Risk factors Hardwood dust (adenocarcinoma)
Softwood dust (squamous carcinoma)
Nickel refining; chromium workers
Boot, shoe and textile workers
Mustard gas exposure
Human papilloma virus

27. Maxillary sinus malignancy

28. Early Clinical features
Mimic maxillary sinusitis
Nasal stuffiness
Blood-stained nasal discharge
Facial paraesthesias or pain
Epiphora

29. Spread

30. Late Clinical features
Medial spread:
Unilateral nasal obstruction
Unilateral purulent nasal discharge
Epistaxis
Unilateral, friable, nasal mass
Anterior spread:
Cheek swelling
Invasion of facial skin

31. Late Clinical features
Inferior spread:
Expansion of alveolus with dental pain
Loosening of teeth, poor fitting of dentures
Swelling in hard palate or alveolus
Superior spread:
Proptosis
Diplopia
Ocular pain .

32. Late Clinical features
Posterior spread:
Pterygoid muscle involvement  trismus
Intracranial spread via:
Ethmoids, cribriform plate
Lymphatic spread:
Neck node metastases in late stages
Systemic spread: Lungs, bone

33. Cheek swelling

34. Cheek skin involvement

35. Alveolar & Palatal swelling

36. Nasal mass

37. Diagnosis Diagnostic nasal endoscopy
X-ray paranasal sinus: expansion & destruction of bony wall
C.T. Scan: axial & coronal cuts with contrast
Biopsy

38. C.T. Scan

39. Ohngren’s Classification

40. Ohngren's Classification
Ohngren's line: An imaginary plane extending between medial canthus of eye & angle of mandible
Supra structural growths situated above this plane have a poorer prognosis
Intra structural growths situated below this plane have better prognosis

41. Lederman’s Classification

42. Lederman’s Classification
2 horizontal lines of Sebileau pass through floors of orbits & maxillary sinus, producing:
Suprastructure: ethmoid, sphenoid & frontal
sinuses; olfactory area of nose
Mesostructure: maxillary sinus & respiratory
part of nose
Infrastructure: alveolar process

43. T.N.M. Staging T1 = tumor confined to antral mucosa
T2 = bone destruction of hard palate / middle meatus
T3 = involvement of skin of cheek, floor or medial
wall of orbit, ethmoid sinus, posterior antral wall,
pterygoid plates, infratemporal fossa
T4 = involvement of orbital contents, cribriform plate,
frontal or sphenoid sinus, skull base, nasopharynx

44. Treatment T1 & T2 = Surgery or Radiotherapy
T3 = Surgery + Radiotherapy
T4 = Surgery + Radiotherapy + Chemotherapy
Europeans: pre-operative Radiotherapy ( cGy)  surgery after 4-6 weeks
Americans: Surgery  post-operative Radiotherapy after 4-6 weeks

45. Surgical Options Total maxillectomy malignancy limited to maxilla
2. Radical maxillectomy with orbital exenteration
involvement of orbital fat
3. Anterior Cranio Facial Resection (extended
lateral rhinotomy incision) = involvement of cribriform plate, frontal sinus

46. Palatal defect & prosthesis

47. Orbital exenteration indications
Involvement of orbital apex
Involvement of extra-ocular muscles
Involvement of bulbar conjunctiva or sclera
Non-resectable full thickness invasion through periorbita into retrobulbar fat

48. Thank You