A-Benign epithelial tumors

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A-Benign epithelial tumors
To through a light on the sinonasal
tumors.
Classification:
Tumors of the nose and Para nasal sinuses are
classified into:
A-Benign tumors:
 Epithelial e.g. papilloma, adenoma
 Non-epithelial e.g. osteoma, angioma,
chondroma, fibroma.
B-Malignant tumors:
 Epithelial e.g. squamous cell carcinoma,
adenocarcinoma, malignant melanoma,
adenoid cystic carcinoma.
 Non-epithelial e.g. fibrosarcoma, osteosarcoma,
angiosarcoma rhabdomyosarcoma, lymphoma
A-Benign epithelial tumors:
 Papilloma:
1-Papilloma in the nasal vestibule (squamous
papilloma): small sessile or pedunculated,
single or multiple masses in the nasal vestibule
may cause epistaxis and sometimes nasal
obstruction. Treatment is by excision and
cauterization of the base to prevent recurrence.
It may be viral infection like wart.
2- Papilloma in the nasal fossae and paranasal
sinuses (Inverted papilloma) (Transitional cell
papilloma)
 It is the most common benign tumor of the
nose and paranasal sinuses. Almost exclusively
arise from lateral nasal wall and may extends
to maxillary and ethmoidal sinuses.
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Pathologically the tumor covered by transitional
epithelium.
Clinically causes unilateral nasal obstruction and
epistaxis usually occurs in males over 50 years,
examination shows mass in the nasal cavity.
Diagnosed by:
1- Radiology (opacity of the maxillary sinus and
could extends to the ethmoid and nasal cavity and
thinning of the bone but no frank erosion)
2- Histopathology to exclude malignancy
(malignant changes occur in 3%).
Treatment is by adequate local excision (medial
maxillectomy by lateral rhinotomy approach)
B-Benign non-epithelial tumors:
1-Osteoma: it is slowly growing tumor. It often occurs in young adult
and mostly in the frontal sinuses. Usually they are asymptomatic
and found incidentally by routine radiographs. When osteoma
become large may cause headache and sometimes cause
obstruction of frontonasal duct → mucocoele which may be
secondarily infected → pyocoele. Also it may affect ethmoidal
sinus causes broad nasal bridge.

Diagnosis: by radiology.

Treatment is by surgical removal if the osteoma is symptomatic
(frontal sinus osteoma → osteoplastic flap procedure, ethmoidal
osteoma → external ethmoidectomy). If it is symptomless → no
treatment is required, just follow up.
2-Angioma (bleeding polyp): It is capillary angioma, most commonly
arise from the septum as bleeding polyp causing epistaxis.
Treatment is by excision with cauterization of the base to avoid
recurrence.
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Squamous-cell carcinoma: it is the commonest malignant
tumors of the nose and Para nasal sinuses. It is used to be
seen in nickel industries workers.
Adenocarcinoma: it arises from gland in the upper
respiratory tract mucous membrane. It is used to be seen in
hardwood dust workers.
Adenoid cystic carcinoma: it arises from minor salivary
glands in the nose & paranasal sinuses, epiglottis and
pharynx.
It appears as round mass usually on hard palate (most
commonly), alveolus and antral floor. They are generally
radio resistant.
Malignant melanoma: arises from melanocytes. They
appear as dark or pale sessile mass on the nasal septum or
lateral nasal wall.
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Sarcoma e.g. fibrosarcoma, osteosarcoma,
rhabdomyosarcoma.
Lymphoma e.g. Burkitt's lymphoma, Stewarts
lethal midline granuloma.
Sites of malignant tumors:
 80% of malignant Sino-nasal tumors are squamous
cell carcinoma.
 60% of tumors arise in the maxillary sinus.
 30% in the nose
 10% in the ethmoids.
 Tumors of frontal & sphenoid sinuses are rare.
*Lymph node metastasis is to retropharyngeal,
submandibular and upper deep cervical lymph
nodes occurs in 10−15% (the sinus has poor
lymphatic drainage).
UICC (International Union against Cancer
Committee) staging:
 Tx: primary tumor cannot be assessed.
 T0: no evidence of primary disease.
 Tis: carcinoma in situ.
Maxillary sinus:
 T1: Tumor limited to the antral mucosa with no
bone erosion.
 T2: Tumor causing bone erosion (except for the
posterior wall) including extension into the hard
palate and/or middle nasal meatus.
 T3: Tumor invades any of the following: bone of
posterior wall of maxillary sinus, skin of cheek,
floor or medial orbital wall.
 T4: Tumor invades orbital contents beyond the
floor or medial wall including apex and/or any of
the following: cribriform plate, nasopharynx,
sphenoid sinus, frontal sinus.
Ethmoid sinus:
 T1: tumor confined to ethmoid with or without
bone erosion.
 T2: tumor extends into nasal cavity.
 T3: tumor extends to anterior orbit and/or
maxillary sinus.
 T4: tumor with intracranial extension, orbital
extension including apex, involving sphenoid
and/or frontal sinus and/or nasal skin.
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Clinical features of malignant sino-nasal
tumours:
Nasal tumors → nasal features e.g. unilateral
nasal obstruction, epistaxis, anosmia.
Frontal sinus tumors → orbital features e.g.
proptosis, diplopia, and blindness
Sphenoid sinus tumors → neurological
features.
Ethmoid sinus tumors → nasal and orbital
features
Maxillary sinus tumors:
1- Early features: when the tumor is confined in the
sinus cavity-features of chronic sinusitis.
2- Late features: when the tumors spread outside
the sinus cavity leading to features according
to the site of Invasion include:
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Invasion of anterior sinus wall → cheek
swelling, ulceration of cheek skin, involvement
of infra orbital nerve causing facial pain and
paresthesia.
Invasion of superior wall (orbital floor) →
proptosis, epiphora due to damage to
nasolacrimal duct, blindness due to invasion of
optic nerve, diplopia due to limitation of
movement of the eye ball or external
ophthalmoplegia due to paralysis of extra
ocular muscles.
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Invasion of medial wall → unilateral nasal
obstruction, recurrent epistaxis and anosmia.
O/E there is mass inside the nasal cavity.
Invasion of the posterior wall → spread to
infratemporal fossa and pterygopalatine fossa
→ trismus (inability to open the mouth due to
invasion of masticatory muscles), facial pain
and parasthesia due to involvement of 5th
cranial nerve.
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Invasion of inferior wall (hard palate)
loosening of teeth, ulceration of the palate
causing oro-antral fistula and dental pain.
Intracranial spread → headache, vomiting and
other neurological features.
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Lymph node metastasis (10%−15%) → mass in
the neck.
Systemic metastasis is occasionally seen.
Investigations:
 General blood investigations (CBP, ESR, Renal function
test...etc) (as a preoperative measure and to detect distant
metastasis)
 Plain X-ray of nose & Paranasal sinuses (occipto-mental
view). Shows opacification of the sinus and bone erosion.
 CT scan & MRI: show the tumor, bone erosion& extension of
the tumor.
 Biopsy: if the tumor appears inside the nose, we can take
incisional biopsy under local anesthesia. If the tumor
confined inside the maxillary sinus cavity, we can take
biopsy through intra-nasal inferior meatal antrostomy.
Cald well is contraindicated in malignancy.
Treatment:
Usually the treatment of carcinoma is combined
surgery and radiotherapy. There are three main
surgical options for carcinoma:
 Medial maxillectomy by using lateral rhinotomy
approach: used for tumours limited to the lateral nasal
wall, nasal cavity and ethmoid.
 Total maxillectomy (removal of upper jaw as bony box
containing the tumor): used for antral carcinoma.
 Craniofacial resection: used when there is involvement
of cribriform plate.
In general an orbital exenteration is indicated only if
tumor breaches periosteum to involve orbital fat.
Follow up and after care:
 Monthly → for the 1st postoperative year.
 Bimonthly → for the 2nd postoperative year.
 Every 3 months → for the 3rd postoperative
year.
 Every 6 months → for the 4th & 5th
postoperative year.
 Annually for a further five years.
Prognosis: Poor, overall 5-year survival is 25−30%

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