Neoplasms of the Nose and Paranasal Sinuses

Sinonasal Neoplasms
3% of aerodigestive malignancies
1% of all malignancies
2 to 1 males
Sixth to seventh decades
Symptomatology difficult

Sinonasal Neoplasms
Nasal cavity (benign = malignant)
Benign - inverting papilloma
Malignant - SCCA
Sinuses (malignant)
SCCA
Maxillary most common

Epidemiology
Occupational exposure in >40%
nickel workers - SCCA
hardwood dust & leather tanning - adenoca
Viral - HPV
Cigarettes & alcohol

Presentation
Similar sx to common problems
6 to 8 month delay in diagnosis
Cranial neuropathies & proptosis
RARE

Presentation
Oral - 30%
tooth pain, trismus, palatal fullness, erosion
Nasal - 50%
obstruction, epistaxis, discharge, erosion
Ocular - 25%
diplopia, proptosis, tearing, pain, fullness
Facial
V2 numbness, asymmetry, pain
Auditory - CHL

Advanced Disease
Classic Triad
facial asymmetry
tumor bulge in oral cavity
nasal mass
All three - 40-60%
One - 90%

Diagnosis
Physical exam
Nasal endoscopy
Biopsy
Radiography

Computed Tomography
Bone erosion
orbit, cribiform plate,
fovea, post max sinus wall,
PTPF, sphenoid, post wall
of frontal sinus
85% accuracy
? Tumor vs. inflammation vs. secretions

MRI
Superior to CT
multiplanar
no ionizing radiation
Inflammatory tissue & secretions - intense T2
Tumor - intermediate T1 & T2
94% accuracy
98% accuracy with
gadolinium

Schneiderian Papillomas
Fungiform (50%) - septum
Cylindrical (3%) - lateral nasal wall
Inverting (47%) - lateral nasal wall
recurs, locally destructive, malignant potential
men, 6th-7th decades, unilateral
SCCA - 2-13%
Recurrence - 0-80%

Inverting Papilloma

Osteomas
Benign, slow-growing
15 to 40 years
frontal > ethmoid > maxillary
local excision

Fibrous Dysplasia
Normal bone replaced by collagen, fibroblasts, and osteoid material
< 20 years
ground-glass appearance
treatment?
No irradiation

Neurogenic tumors
Schwannomas
surface of nerve fibers
no malignant degeneration
along trigeminal & ANS
Neurofibromas
within nerve fibers
von Recklinghausen’s disease
malignant degeneration in 15%
Complete excision

SCCA
Most common - 80%
Max > nasal cavity > ethmoids
Males
Sixth decade
90% have eroded walls of sinuses

Adenoid Cystic Carcinoma
Palate > major salivary glands > sinuses
Resistant to tx
Multiple recurrences, distant mets
Perineural spread
Long-term followup necessary

Mucoepidermoid Carcinoma
rare, widespread local invasion
Adenocarcinoma
2nd most common, 5-20%
ethmoids
occupational exposures

Hemangiopericytoma
Uncommon
pericytes of Zimmerman
80% of sinonasal tumors in ethmoids
resembles nasal polyps
average in 55 yo
excision, XRT for (+) margins

Melanoma
1% originate in sinonasal cavity
5th-8th decades
anterior septum
maxillary antrum
polypoid mass,
pigmentation?
5 yr = 38%
10 yr = 17%

Olfactory Neuroblastoma
Neural crest origin
no urinary VMA or HVA
bimodal distribution at 20 and 50
locally aggressive
rosettes are hallmark
Kadish staging
local recurrence 50-75%
metastasis 20-30%

Osteogenic Sarcoma
most common primary bone tumor
only 5% in H & N, mandible most involved
sunray appearance
Fibrosarcoma
rarely seen in sinuses

Chondrosarcoma
3rd-5th decades
histologic dx difficult
slow erosion of skull base, (+) margins
Rhabdomyosarcoma
most common in children
35-45% in H&N, 8% in sinuses
embryonal, alveolar, pleomorphic
triple tx

Lymphoma
bimodal presentation
NHL
irradiation +/- chemo
Extramedullary plasmacytoma
40% in paranasal sinuses/nose
“benign”
must r/o myeloma
excision or irradiation

Metastatic tumors
Renal cell carcinoma
lungs
breasts
urogenital tract
gastrointestinal tract
Palliation necessary

Ohngren’s Line
Suprastructure
Infrastructure

Staging
AJCC - Maxillary sinus carcinoma

Treatment
T3 and T4
60% local recurrence
Surgery
Irradiation
Chemotherapy

Surgical resection
Unresectability (Sisson)
extension to frontal lobes
invasion of prevertebral fascia
bilateral optic nerve involvement
cavernous sinus extension

Surgical resection
Endoscopic excision
WLE
medial maxillectomy
total maxillectomy
radical maxillectomy +/- exenteration
craniofacial resection

Orbital Preservation
Harrison - proptosis, limitation of EOM, bony erosion of orbit = exenteration
Conley - save eye whenever possible
Sisson - preoperative XRT, decreased exenterations without change in survival
Stern - nonfunctional eye without inf/med support = exenteration

Orbital preservation
UVA - McCary & Levine
50 Gy preop XRT to orbit
periorbital bx
resect (+) periorbita
functional eye

Pterygopalatine Fossa
10-20% involvement
Som - PTPF invasion = unresectable lesion
Craniofacial resection (MCF)
Postop XRT

Neck Dissection
Retropharyngeal and jugulodigastric nodes
10% (+) necks
neck dissection
palpable nodes
radiographic evidence of disease
40% cervical mets at 4 yrs

Radiation therapy
Primary tx only for palliation
10-15% improved 5 year survival
XRT = 23% vs. Surgery + XRT = 44%
preoperative vs. postoperative
protection of CNS and globe
XRT 12-20% unilateral visual loss, 0-8% bilateral visual loss
Surgery 10-20% useless globes, 2X with XRT