Chapter 18 - Sinonasal Tumors Flashcards
Ohngren’s line
Medial canthus to angle of mandible
Max sinus tumors above here are worse, spread superoposteriorly, more perineural invasion, SB invasion
Occupational exposures that are risks for SCC, AdenoCA
SCC: chromium, nickel, mustard gas, aflatoxin
AC: wood dust, leather working, org solvent
Both: smokers, heavy EtOH, salted/smoked foods
Classic radiographic JNA findings
Expansion of PPF on axial vview
Widening of sphenopalatine and vidian foramina
Bony destruction of pterygoid process
5 year survival for nasal/paranasal CA
40%
Most common tumor of nasal cavity
inverted papilloma. Most common malignancy is SCC
Most common tumor of sinuses
SCC (malignancy more common than benign in sinus)
Sinus sx that make you think more about cancer than just sinusitis
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)
3 types of nasal papillomas
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
Recurrence rate for inverted papilloma with endoscopic tx
12% (20% with midface deglove/lateral rhinotomy)
Fisch classification JNA
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
Sinus osteomas
Most common benign tumor
Multiple - Gardner’s (AD, FAP, skin/soft tissue tumors)
80% frontal sinus
Benign tumors of nasal cavity
Osteoma Hemangioma (septum, IT) Pyogenic granuloma (friable, septum, irritation/trauma/hormones, 1st tri preg) Hemangiopericytoma Salivary gland (pleo) Chordoma (from clivus, CN palsy)
Malignant tumors of nasal cavity/sinus
SCC (80%)
Adeno (ethmoid)
Undiff (olfactory groove, rapid progressive)
Esthesioneuroblastoma (olf epithelium, teen/elderly, Kadish/Dulguerov staging)
Mucoepidermoid
Adenoid cystic (distant mets, perineural invasion)
Most common pediatric sinonasal malignancy
Sarcoma (75%)
Where malignancies occur sinonasally
Maxillary>Nasal cavity>Ethmoid>Sphenoid>Frontal
When to give postop Rads for sinonasal malignancy
high grade, positive margins, perineural invasion, nodal disease
4 factors making sinonasal malignancies inoperable
Significant brain parenchymal involvement
Invade prevertebral fascia
Invade cavernous sinus
Invade bilateral orbits or chiasm
Method of delivering radiation to nose without injuring brain
proton therapy
Nodal drainage of sinonasal
Anterior NC- perifacial, I
Mid-post NC, sinus: retrophary, II, periparotid (if invade orbit)
Very low rate of occult neck mets (<10%)
When orbital exenteration is indicated
invasion within orbital apex
erosion of orbital bone with invasion through periosteum, into EOM (may consider palliation in these pts)
Describe lateral rhinotomy incision
medial brow, down around alar, through philtrum of upper lip
Describe Weber Ferguson
Lateral rhinotomy plus sublabial lip-splitting incision, plus subciliary/transconj incision
Describe midface degloving
gingivobuccal, bilateral intercartilaginous incisions. Avoid external scar
Radical approaches to sinonasal tumors (3)
Facial translocation
Infratemporal approach
Craniofacial Resection
Describe different types of maxillectomies
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
Location and contents of PPF
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
Infratemporal fossa site and contents
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
Sx of cavernous sinus syndrome
Fixed, dilated pupil (III)
numbness V1-2
Poss i/l horners
