Chapter 18 - Sinonasal Tumors

Question 1

Ohngren’s line

Answer 1

Medial canthus to angle of mandible

Max sinus tumors above here are worse, spread superoposteriorly, more perineural invasion, SB invasion

Question 2

Occupational exposures that are risks for SCC, AdenoCA

Answer 2

SCC: chromium, nickel, mustard gas, aflatoxin
AC: wood dust, leather working, org solvent
Both: smokers, heavy EtOH, salted/smoked foods

Question 3

Classic radiographic JNA findings

Answer 3

Expansion of PPF on axial vview
Widening of sphenopalatine and vidian foramina
Bony destruction of pterygoid process

Question 4

5 year survival for nasal/paranasal CA

Answer 4

40%

Question 5

Most common tumor of nasal cavity

Answer 5

inverted papilloma. Most common malignancy is SCC

Question 6

Most common tumor of sinuses

Answer 6

SCC (malignancy more common than benign in sinus)

Question 7

Sinus sx that make you think more about cancer than just sinusitis

Answer 7

worsening unilateral sx
developing orbital sx (epiphora, diplopia, exophthalmos, vision loss)
paresthesia/pain along V2, cheek swell, numbness face/palate
CN III, IV, V1, V2, VI (cavernous sinus)

Question 8

3 types of nasal papillomas

Answer 8

Exophytic (fungiform)- most common, septum, never malign
Inverted (endophytic)- Schneiderian mucosa, lateral wall maxillary sinus, high recurrence, 8-10% malignant transformation to SCC; HPV association
Oncocytic (cylindrical)- lateral, rare, rare malignant potential

Question 9

Recurrence rate for inverted papilloma with endoscopic tx

Answer 9

12% (20% with midface deglove/lateral rhinotomy)

Question 10

Fisch classification JNA

Answer 10

I- nasal cavity
II- extend to pterygomaxillary fossa or sinuses, bony destruction
III- orbit, infratemporal fossa, parasellar
IV- cavernous sinus, optic chiasm, pituitary fossa

For III+, may need craniofacial or endoscopic-assisted resection, or just radiation. I-II usually just endoscopic

Question 11

Sinus osteomas

Answer 11

Most common benign tumor
Multiple - Gardner’s (AD, FAP, skin/soft tissue tumors)
80% frontal sinus

Question 12

Benign tumors of nasal cavity

Answer 12

Osteoma
Hemangioma (septum, IT)
Pyogenic granuloma (friable, septum, irritation/trauma/hormones, 1st tri preg)
Hemangiopericytoma
Salivary gland (pleo)
Chordoma (from clivus, CN palsy)

Question 13

Malignant tumors of nasal cavity/sinus

Answer 13

SCC (80%)
Adeno (ethmoid)
Undiff (olfactory groove, rapid progressive)
Esthesioneuroblastoma (olf epithelium, teen/elderly, Kadish/Dulguerov staging)
Mucoepidermoid
Adenoid cystic (distant mets, perineural invasion)

Question 14

Most common pediatric sinonasal malignancy

Answer 14

Sarcoma (75%)

Question 15

Where malignancies occur sinonasally

Answer 15

Maxillary>Nasal cavity>Ethmoid>Sphenoid>Frontal

Question 16

When to give postop Rads for sinonasal malignancy

Answer 16

high grade, positive margins, perineural invasion, nodal disease

Question 17

4 factors making sinonasal malignancies inoperable

Answer 17

Significant brain parenchymal involvement
Invade prevertebral fascia
Invade cavernous sinus
Invade bilateral orbits or chiasm

Question 18

Method of delivering radiation to nose without injuring brain

Answer 18

proton therapy

Question 19

Nodal drainage of sinonasal

Answer 19

Anterior NC- perifacial, I
Mid-post NC, sinus: retrophary, II, periparotid (if invade orbit)
Very low rate of occult neck mets (<10%)

Question 20

When orbital exenteration is indicated

Answer 20

invasion within orbital apex

erosion of orbital bone with invasion through periosteum, into EOM (may consider palliation in these pts)

Question 21

Describe lateral rhinotomy incision

Answer 21

medial brow, down around alar, through philtrum of upper lip

Question 22

Describe Weber Ferguson

Answer 22

Lateral rhinotomy plus sublabial lip-splitting incision, plus subciliary/transconj incision

Question 23

Describe midface degloving

Answer 23

gingivobuccal, bilateral intercartilaginous incisions. Avoid external scar

Question 24

Radical approaches to sinonasal tumors (3)

Answer 24

Facial translocation
Infratemporal approach
Craniofacial Resection

Question 25

Describe different types of maxillectomies

Answer 25

Medial: lateral nasal wall, medial maxilla removed +/- sphenoethmoidectomy
Inferior: remove inferior portion, for maxillary alveolar process or limited hard palate lesions
Total: necessary if involve antrum
Radical: plus orbital exenteration

Question 26

Location and contents of PPF

Answer 26

below apex of orbit, posterior to maxillary sinus, anterior to pterygoid plates
Fat, foramen rotundum (V2), vidian nerve, PPG/nerve, less/great palatine nerves, maxillary a

Question 27

Infratemporal fossa site and contents

Answer 27

Posterior to maxilla, anterior to glenoid fossa/mandible, lateral to pterygoid plates, connects to PPF (via PMF)
Pterygoid muscles, venous plexus, foramen ovale, V3, foramen spinosum (mid mening a), maxillary a

Question 28

Sx of cavernous sinus syndrome

Answer 28

Fixed, dilated pupil (III)
numbness V1-2
Poss i/l horners