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TUMOURS OF NASAL CAVITY & PARANASAL
SINUSES
Col Shoaib Ahmed
Consultant ENT Head & Neck Surgeon
MBBS (Honours) FCPS(Pakistan) FRCS(Glasgow)
Review of Anatomy
• Paranasal sinuses are air filled cavities that communicate with the nasal cavity
• There are close anatomical relations with orbit & skull base• Cranial nerves 1st, 2nd, 3rd ,4th , 5th and 6th are in close vicinity
Unique Features of Sinonasal Tumours
• Relatively rare of head & neck tumours• Present late
Large air filled sinuses with no vital structure in immediate vicinity → remain clinically silent
Highly non specific early symptoms – (rhinorrhea & nasal obstruction) → receive scant attention
• Wide variety of pathological lesions• Extension to anatomically critical areas
Generally advanced disease with poor clinical outcome
Classification
• BENIGN• Epithelial
Inverted papilloma
Non epithelial
Fibroma
Chondroma
Hemangioma
Nerve sheath tumour
Classification contd. • MALIGNANT• Epithelial
Squamous cell carcinoma
Adenocarcinoma
Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Olfactory neuroblastoma / Esthesioneuroblastoma
Non epithelial
Sarcomas
Lymphoma
Giant cell tumour
Environmental Factors associated with sinonasal malignancy
• Wood dust• Nickel• Hydrocarbons• Chromium• Organic oils• Isopropyl oil
Clinical Features
• EARLY • Nasal obstruction• Rhinorrhea
• LATE• Epistaxis• Proptosis• Facial pain / swelling• Cranial nerve dysfunction• Trismus
How to identify early on ?
• Can be readily mimicked by common respiratory conditions (e.g. Sinusitis )
↓•Unilaterality of symptoms & signs
• Persistent & progressive symptoms
• No improvement with antibiotics / anti histamines
• Unilateral facial pain / numbness / fullness• Short span of symptoms suggests a malignant tumour
Clinical Examination
• Thorough ENT head & neck examination
↓TrismusOrbitNeurological exam (cranial nerves 1st to 6th)Cervical lymph nodes
Diagnosis
• Clinical • Imaging (X rays, CT , MRI , PET )• Biopsy
Always done after imaging
(highly vascular lesion, or intra cranial)
Generally under LA
Radiological ImagingPlain X rays have lesser value !
45 degrees Occipitomental projection – “X ray PNS”
Plain X- rays - Findings
• Unilateral findings• Opaque sinus• Gross bone destruction
CT scans
• Initial investigation of choice• Shows bony details• Areas of bone destruction• Extension into adjacent areas
Normal CT scan
Ethmoid sinuses
Frontal sinus
CT scan
•Unilateral sinonasal mass
• Bony erosion of lateral nasal wall and skull base
Inverted papilloma
Olfactory neuroblastoma in a 14 year old
MRI
• Better soft tissue detail• Useful to detect intracranial extension• Able to distinguish nasal secretions from
tumour• Indicates extension into dural venous sinuses
Positron Emission Tomography (PET scan)
• Routine evaluation for recurrent disease after primary tumour
• Mainly used for squamous cell carcinoma• Very expensive modality
TREATMENT OPTIONS
• Surgery • Radiotherapy• Combined surgery & radiotherapy• Chemotherapy
Palliation
Lymphomas
Olfactory Neuroblastoma in a young lady
CONCLUSION
• These are rare tumours with poor survival & are generally advanced at presentation
• Comprise of several histologic types with varying biological behaviour
• Early diagnosis requires being alert for any persistent unilateral symptoms
• Diagnosis is based on CT, MRI and biopsy• For cure, extensive mutilating surgery followed
by reconstruction is often required
DEPARTMENT OF ENT HEAD & NECK SURGERY
COMBINED MILITARY HOSPITAL
RAWALPINDI
Any Questions ?