max sinus tumours
TRANSCRIPT
NEOPLASM OF MAXILLARY SINUS
Definitions Neoplasm(willis)- abnormal mass of tissue, the
growth of which exceeds & uncoordinated with that of normal tissue & persists in same manner after cessation of stimuli which evokes the change.
Tumour- a mass of tissue formed as a result of abnormal, excessive, uncoordinated, autonomous, purposeless proliferation of cells
TNM classification TNM classification 1,2 TNM classification of carcinomas of the nasal cavity and sinuses T – Primary tumour TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ
Maxillary sinus T1- Tumour limited to the antral mucosa with no erosion or destruction of bone
T2- Tumour causing bone erosion or destruction, including extension into hard palate and/or middle nasal meatus, except extension to posterior antral
wall of maxillary sinus and pterygoid plates T3- Tumour invades any of the following: bone of posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses
T4a- Tumour invades any of the following: anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
T4b- Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve V2, nasopharynx, clivus
N – Regional lymph nodes 3 NX: Regional lymph nodes cannot be
assessed N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph
node, 3 cm or less in greatest dimension
N2 Metastasis as specified in N2a, 2b, 2c below N2a: Metastasis in a single ipsilateral lymph node,
more than 3 cm but not more than 6 cm in greatest dimension
N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N3: Metastasis in a lymph node more than 6 cm in greatest dimension
M – Distant metastasis MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis
Stage grouping Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1, T2 N1 M0 T3 N0, N1 M0 Stage IVA T1, T2, T3 N2 M0 T4a N0, N1, N2 M0 Stage IVB T4b Any N M0 Any T N3 M0 Stage IVC Any T Any N M1
TUMORS Intrinsic origin Squamous papilloma Inverted papilloma Juvenile angiofibroma Vascular lesions Myxoma Giant cell tumor
Extrinsic origin Ameloblastoma OAT Odontoma Odontogenic myxoma
TUMOR-LIKE LESIONS:Giant cell granuloma
Fibrous dysplasia
MALIGNANT LESIONS
Squamous cell carcinoma
Adenoid cystic carcinoma
Adenocarcinoma
Sarcoma (Chondrosarcoma, Osteosarcoma, Fibrosarcoma)
Non-Hodgkin’s lymphoma
Ohngren lines
Polyp Nonneoplastic
epithelial & stroma tumours
Types: Inflammatory polyp Antrochoanal polyp
Papilloma Benign tumor of nasal
cavity composed of vascular connective tissue covered by well-differentiated stratified squamous epithelium that tends to grow under and elevate mucosa.
Pathogenesis
— allergy, chronic inflammation — human papilloma virus (HPV)
Clinical Features Most common in males aged 40–70 years Nasal stuffiness or obstruction. Secondary bacterial sinusitis. Postoperative recurrence 35–40%. May be associated with malignancy (about
10%).
Types (Batsakis)1) Keratotic papilloma simple cutaneous wart, exophytic with
broad base, in the nasal vestibule or nasal septum.
2) Inverted papilloma-lateral nasal wall
3)Fungiform (50%) - septum4)Cylindrical (3%) - lateral nasal wall
Inverted papilloma Arises from respiratory
mucosa of sinonasal tract
Involves lateral nasal wall & extends to adjacent maxillary sinus
Bulky, deep red, gray colour
Age>40ys , high morbidity: 50—60ys;
M: F=3:1
Site of occurance: junction of antrum & ethmoid sinus
Unilateral nasal obstruction, congestion, epistaxis, abnormalities of smell.
HistopathologyHyperplastic epithelia
with inverting pattern of growth. Epithelial inversion into underlying stroma. Basal membrane is intact.
Fungiform papillomas an exophytic growth pattern and do not
grow down into the underlying normal stroma. They are almost always associated with human papillomavirus, and unlike inverted papillomas, do not have a tendency to recur.
Cylindrical cell papillomas They have a ragged, beefy appearance
and histologically they appear totally different. They are composed of columnar cells. They have a pink cytoplasm, their nuclei are oval or round,
Axial CT
Juvenile angiofibroma Highly vascular lesion, locally invasive, non encapsulated Age-10-17 years Site: posterior nares & nasopharyx Etiology:Popular theories include abnormal growth of
embryonal chondrocartilage, testosterone acting on a hamartomatous nidus of inferior turbinate tissue mislocated in the nasopharynx, tumor growth from normal nasopharyngeal fibrovascular stroma- may be due to androgen receptors capable of binding dihydrotestosterone & testosterone may indicate hormonal influence
trauma, inflammation, infection, allergy, and heredity.
Clinical features Site: posterolateral wall of the nasal cavity at
posterior nares & nasopharynx From its origin, tumor spreads into the nasal
cavity and nasopharynx- displacing the soft palate inferiorly, Anteriorly, it pushes forward the posterior wall of the maxillary sinus, creating the classic "antral bowing sign" visible by x-ray.
Posteriorly, it disrupts the root of the pterygoid plates. Superiorly, tumor expands into the orbit via the inferior orbital fissure, continuing eventually into the superior orbital fissure and middle cranial fossa.
With further lateral expansion, the tumor will pass through the pterygomaxillary fissure into the infratemporal fossa, often creating a bulging of the cheek. If it reaches the temporal fossa, the tumor can create a bulge above the zygoma.
lobulated, firm, non-encapsulated mass, usually pink-gray or purple-red. The tumor base may be sessile or pedunculated.
The most common presenting symptoms are nasal obstruction, epistaxis, diplopia, blindness, hearing loss, otitis media, rhinorrhea, nasal speech, noisy sleep, mouth breathing, eye pain, and headache.
histopathology CT- cleft like vascular
vascular channels Cellular atypia
Ameloblastoma Secondary to direct extension from
maxillary alveolar ridge Misplaced dental analage from epithelial
lining of dentigerous cyst c/f:asymptomatic swelling of cheek and
mucobuccal fold On penetration it enlarges & fills the antral
space Proptosis, nasal obstruction due to
involvment of superior & lateral nasal wall.
R/F
odontoma End products of anomalous anomalous
completion or lack of completion of tooth formation by odontogenic epithelium & ectomesenchyme
Complex Compound c/f- nasal obstruction, discharge, sinusitis
R/F
Odontogenic myxoma Site- maxillary bone, antral mucosa slow-growing, persistent and destructive,
may cross midline Gross feature: slimy, pale yellow mucoid
substance. Consistency is soft to moderate firm. Poorly circumscribed & infiltrates to surrounding tissues
R/F
unilocular/multilocular radioluscency with honeycomb or soap bubble appearance
H/F Loosely arranged
fibroblast and myofibroblast.
Cells are stellate with long protoplasmic process
Fibrous dysplasia Site: posterior maxilla C/F: rapid growth and enlargement of jaw
with facial deformity, Painless swelling
R/F
3D CT
Ossifying fibroma C/F: nasal obstruction, proptosis, malar
enlargement, vestibular swelling R/F: expansion, margination, demarcation,
cortication, displacement of teeth
Malignant tumorsMetaplastic type of epithelium- squamous
cell groupGlandular cell type epithelium-
adenocarcinoma group.
Squamous cell carcinoma A malignant epithelial neoplasm
originating from the mucosal epithelium of the nasal cavities or paranasal sinuses that includes a keratinizing and a non-keratinizing type.
Etiology Reported risk factors have include
exposure to nickel, chlorophenols, and textile dust, smoking, and a history or concurrence of sinonasal papilloma.
Clinical features More than 60% originate in maxillary sinuses,
followed by nasal cavity, and ethmoid sinuses nasal fullness, stuffiness, or obstruction;
epistaxis; rhinorrhea; pain; paraesthesia; fullness or swelling of the
nose or cheek or a palatal bulge; a persistent or non-healing nasal sore or ulcer; nasal mass;
In advanced cases, proptosis, diplopia, or lacrimation
Macroscopy exophytic, fungating,
or papillary; friable, haemorrhagic, partially necrotic, or indurated; demarcated or infiltrative.
R/F
R/F
Destruction of LT maxilla Intrasinus mass with irregular
destruction
Coronal CT
Intrasinus mass with irregular destruction of alveolus MRI- intrasinus & intraoral mass
H/F extracellulr or intracellular
keratin (pink cytoplasm, dyskeratotic cells) and/or intercellular bridges. Tumour cells are generally apposed to one another in a “mosaic tile” arrangement.
The tumour may be arranged in nests, masses, or as small groups of cells or individual cells.
Invasion occurs as blunt projections or ragged, irregular strands. carcinomas may be well, moderately, or
poorly differentiated
Adenoid cystic carcinoma Adenoid cystic carcinoma is the most
frequent malignant salivary gland-type tumour of the sinonasal tract.
Age-11-92 years. C/F: nasal obstruction, epistaxis, pain,
paraesthesia, displacement of orbital content, swelling of the palate or face, loosening of the teeth.
Evidence of perineural & intraneural spread
R/F CT scan shows a nasal
sinus mass focally extending into the bone.
H/F An intact surface
mucosa overlying the cribriform and cystic patterns
Common route of distant metastasis Lung, bone, liver, brain
adenocarcinoma glandular malignancies of the sinonasal tract. Etiology: wood dust and leather dust C/F: unilateral nasal obstruction, rhinorrhea and
epistaxis. Advanced tumours may cause pain, neurologic disturbances exophthalmos and visual disturbances.
R/F
H/F papillary growth
pattern and occasional tubular glands
Non Hodgkin’s lymphoma Involve lymph nodes, lymphoid organs,
extranodal organs and tissues B lymphomas are found mostly in
maxillary sinus C/F: swelling which may ulcerate later,
pain.
Staging of Maxillary Sinus Tumors T1: limited to antral mucosa without bony erosion T2: erosion or destruction of the infrastructure,
including the hard palate and/or middle meatus T3: Tumor invades: skin of cheek, posterior wall
of sinus, inferior or medial wall of orbit, anterior ethmoid sinus
T4: tumor invades orbital contents and/or: cribriform plate, post ethmoids or sphenoid, nasopharynx, soft palate, pterygopalatine or infratemporal fossa or base of skull
TREATMENT OF NEOPLASM OF
MAXILLARY SINUS
Surgery Unresectable tumors:
Superior extension: frontal lobes Lateral extension: cavernous sinus Posterior extension: prevertebral fascia Bilateral optic nerve involvement
Surgery Surgical approaches:
Lateral rhinotomy Transoral/transpalatal Midfacial degloving Weber-Fergusson Combined craniofacial approach
Extent of resection Medial maxillectomy Inferior maxillectomy Total maxillectomy
Culd wel luc procedure Indications: Mucoceles Antrochoanal polyp OKC
Transpalatal approach Indications: Small tumors of inferior and posterior
aspect
Lateral Rhinotomy & medial maxillectomy Indications: Well differentiated or low grade tumour Ameloblastoma Inverted papilloma
Medial maxillectomy A. access ostectom B. Removal of septum
to gain contralateral access
C.More lateral extension to gain access to ethmoids
D.Bone cuts to gain access to antrum
Webwr fergusson approach OKC, myxoma, Ameloblastoma, CEOT
Midfacial degloving
Chemotherapy Palliation, unresectable disease (+) margins, perineural spread, surgical
refusal, ECS Robbins - 86% response of T4 lesions Lee - 91% satisfactory response Agents: 5FU(1000mg/m2),
Cisplatinum(150mg/m2/wk/4wk)
Radiation therapy
Primary tx only for palliation 10-15% improved 5 year survival XRT = 23% vs. Surgery + XRT = 44% 68-72 Gy
Reconstruction Split thickness skin graft with obturator Soft tissue flaps and bone graft
MAXILLECTOMYSurgical removal of maxilla
Classification of maxillectomy
Type 1 defects (limited maxillectomy) Type 2 defects (subtotal maxillectomy). Type 3 (total maxillectomy) which is
subdivided into type 3a (orbital content preservation) and type 3b (orbital content exenteration).
Type 4 defects (orbitomaxillectomy)
According to Cordeiro and Sanatamaria
Maxillectomy classification scheme according to Okay et al. Class 1a includes defects of any
portion of the hard palate excluding tooth bearing maxillary alveolus.
Class 1b includes defects of premaxilla or any portion of alveolus or dentition posterior to canines.
Class 2 defects include any portion of hard palate, alveolus and only one canine tooth. Also includes transverse palatectomy involving less than 50% of the hard palate.
Class 3 defects include resection of any portion of hard palate, alveolus and both canine teeth. Also includes transverse palatectomy involving greater than 50% of the hard palate.
Subtotal maxillectomy Indications: Lesions of palate,
antrum, beyond the confines of antrum
Medial maxillectomy Indications:well
differentiated/low grade malignant tumour, inverted papilloma, or other tumors of limited extent to lateral wall of nasal cavity or medial wall of antrum
Total maxillectomy Indications: Primary tumour
arising from surface lining of maxillary antrum fills the entire antrum.
Treatment of the Orbit Before 1970’s orbital exenteration was
included in the radical resection Preoperative radiation reduced tumor load
and allowed for orbital preservation with clear surgical margins
Currently, the debate is centered on what “degree” of orbital invasion is allowed.
Current indications for orbital exenteration Involvement of the orbital apex Involvement of the extraocular muscles Involvement of the bulbar conjunctiva or
sclera Lid involvement beyond a reasonable hope
for reconstruction Non-resectable full thickness invasion
through the periorbita into the retrobulbar fat
Classification and Concepts in Reconstruction
Flaps used in maxillary reconstruction Palatal mucoperiosteal island flap Buccal fat pad Submental island flap Temporalis flap system Radial forearm flap Fibula flap Scapular flap system Iliac crest flap Abdominal rectus flap
A Class 1 defect can be simply treated with obturation or a soft tissue flap often preferred at the junction of the hard and soft palate.
Pedicled flaps:iliac crest maintained in a titanium mesh structure, the buccal fat pad, submental island flap
Free tissue transfer: composite fibula flap, Radial forearm flap
Class 2b-c fibula flap iliac crest Class 3a-c iliac crest with internal oblique titanium mesh or free bone from the hip Class 4a iliac crest with internal oblique, Rectus,
Lattisimus dorsi
Radial Forearm Flap 1978 (China) by Yang etal, 1985 (pharyngeal
recon) Oral cavity, base of tongue, pharynx, soft palate,
cutaneous defects, base of skull, small volume bone and soft tissue defects of face
Thin, pliable skin Reconstitution of contours, sulci, vestibules
Fasciocutaneous flaps are highly tolerant of radiation therapy
Composite flap with bone, tendon, brachioradialis muscle and vascularized nerve.
Neurovascular pedicle Up to 20 cm long Vessel caliber 2 – 2.5 mm Radial artery cephalic vein Lateral antebrachial
cutaneous nerve (sensory)
Technical considerations Tourniquet
Flap designed with skin paddle centered over the radial artery
Dissection in subfascial level as the pedicle is approached.
Pedicle identified b/w medial head of the brachioradialis, and the flexor carpi radialis
Radial artery is dissected to its origin
External skin monitor can be incorporated into the flap (proximal segment)
Radial Forearm Flap
Radial Forearm Flap Morbidity
Hand ischemia Fistula rates - 42% to 67% in early series Radial nerve injury Variable anesthesia over dorsum of hand.
Advantage:Thin pliable skin, often hairless,long pedicle(12-
15cm),Disadvantage:Donor site defect visible
Fibular free flap 1975 Hidalgo – mandibular recon
1989 Longest possible segment of
revasularized bone (25 cm) Ideal for osseointegrated
implant placement Mandible reconstruction (near
total), maxillary reconstruction
Neurovascular pedicle Peroneal artery and vein Sensate restoration with lateral sural
cutaneous nerve Peroneal communicating branch
vascularized nerve graft for lower lip sensation
Skin perforators Posterior intermuscular septum
(septocutaneous or musculocutaneous through flexor hallucis longus and soleus)
Should always include cuff of flexor hallucis longus and soleus in flap harvest
5-10% of cases blood supply to skin paddle is inadequate
Technical considerations Choose leg based on ease
of insetting Intraoral skin paddle
Harvest flap from contralateral side of recipient vessels
8 cm segment preserved proximally and distally to protect common peroneal nerve and ensure ankle stability
Center flap over posterior intermuscular septum Anterior to soleus and
posterior to peroneus
Fibular free flap Morbidity
Donor site complications Edema Weakness in dorsiflexion of great toe
Skin loss in 5 – 10% of flaps
Submental artery island flap
Thin, supple skin Submental branch of
facial artery Primary closure of
donor site Poor reliability if:
Facial artery sacrificed Irradiated neck Adv: Large flap size (7-15
cm) Superior skin color
match
disadvantage Not suitable if patient has previous level 1
nodal disease
Temperoparietal Fascia Flap Described by Golovine More commonly transferred as a pedicled flap but can be
used as a free flap when arc of rotation is inadequate Ultra thin – 2 to 4 mm thick Highly vascular, pliable and durable Fascial, fasciocutaneous
Neurovascular pedicle Superficial temporal artery and vein – travel in TPF
layer 3 cm superior to root of helix Vessels branch into frontal and temporal divisions Most commonly based on parietal branch Ligation of frontal artery 3 – 4 cm distal to branching
point to avoid frontal nerve injury Venous pedicle may course with arteries or 2 to 3 cm
posteriorly Middle temporal artery – proximal superficial
temporal artery at zygomatic arch (supplies temporalis muscular fascia)
Including middle temporal artery enables a two-layered fascial flap on a single pedicle.
Temperoparietal Fascia Flap
Technical considerations Vertical incision over
root of helix to superior temporal line
V-shaped extension at superior limit of incision
Scalp elevation ant and post
Dissect deep to flap Loose areolar tissue
deep to flap
Temperoparietal Fascia Flap Morbidity
Frontal branch weakness (travels in TPF) Secondary alopecia – damage to hair follicles
due to superficial dissection
Buccal fat pad A – branches of buccinator artery Rapid reepithelialization & only suitable for
medium sized defects up to 4cm Adv: Rapid reepithelialization Rich vascular supply No donor site skin scars
Disadvantage: Only suitable for medium sized defects up
to 4cm Prone to dehiscence
Iliac crest flaps Osteocutaneous, osteomusculocutaneous Up to 16 cm bone Oromandibular reconstruction Only vascularized bone used extensively with simultaneous or delayed
endosteal dental implant placement Skin paddle was not ideal for relining the oral cavity
Too thick for accurate restoration of the 3D anatomy
Neurovascular pedicle
Deep circumflex iliac artery from lateral aspect of external iliac artery
1 – 2 cm cephalic to inguinal ligament
Ascending branch of deep circumflex iliac artery supplies internal oblique muscle
Deep circumflex iliac vein – Can pass either superficial to deep
to artery Artery caliber – 2 to 3 mm Vein caliber – 3 to 5 mm Pedicle to internal oblique can
arise separately from deep circumflex iliac artery
Iliac crest flaps Morbidity
Hernia Need to approximate cut edge of iliacus muscle to
transversus abdominis Can be reinforced by drilling holes into cut edge of iliac
bone Approximate external obliques and aponeurosis to tensor
fascia lata and gluteus muscles Keep inferior oblique inferior and anterior to ASIS
Skin loss from perforator sheer injury poor color match
Rectus abdominis Easy to harvest Long pedicle(10cm) Skin from abdomen and lower chest Myocutaneous flap or muscle only flap Not used for functional motor reconstruction Can include entire muscle or only small portion in
paraumbilical region Plentiful people – thinner flap created by skin grafting the
muscle Skinny people
Flap used for moderately volume defects Poor color match Tends to become ptotic Able to fill large tissue deficits
Neurovascular pedicle Two dominant pedicles
Deep superior epigastric artery/vein Deep inferior epigastric artery and
vein Based on inferior epigastrics when
used for h/n recon because of larger pedicle size
Inferior epigastric diameter – 3 to 4 mm
Reinnervated with any of the lower six intercostal nerves.
Pedicle may travel along lateral aspect of muscle before taking intramuscular route
Scapular flaps Fasciocutaneous, osteofasciocutaneous,
cutaneous flap, parascapular cutaneous flap, latissimus dorsi myocutaneous flap, and serratus anterior flap
Thin, hairless skin Two cutaneous flaps may be harvested
Horizontally oriented flap – transverse cutaneous branch
Vertically oriented flap parascapular flap – descending cutaneous branch
Long pedicle length Large surface area Complex composite midfacial or
oromandibular defects Up to 10 cm bone Osseointegrated implants possible Single team approach
Neurovascular pedicle Subscapular artery and vein
Circumflex scapular artery and vein emerge from triangular space (teres major, teres minor and long head of triceps)
Paired venae comitantes Artery caliber – 4 mm at takeoff from subscapular
Subscapular caliber – 6 mm at takeoff from axillary artery
Pedicle length – 7 to 10 cm, 11 to 14 cm (from axillary artery)
Largest amount of tissue available for transfer
Technical considerations Decubitis positioning
15 degree angle Separate axillary incision
helpful in dissecting pedicle to axillary artery and vein
Bone harvest Teres major, subscapularis
and latissimus dorsi need to be reattached to scapula
Flap harvest opposite side of modified or radical neck dissection
Scapular flaps Morbidity
Brachial plexus injury 2/2 lateral decubitis positioning
Use axillary roll Stay 1 cm inferior to glenoid fossa Detach teres major and minor to harvest bone
Can cause shoulder weakness and limit range of motion.
Scapular flaps Preoperative
Considerations Prior axillary node
dissection – contraindication
Postoperative management Immobilize for 3 to 4
days Early ambulation 5 days for bone harvest PT
This long implant is anchored in the upper jawbone and in the very dense zygoma bone. A temporary prosthesis can be fixed immediately after placing the implant and until the final restoration, once the aesthetic criteria have been met and your expectations have been fulfilled
Zygomatic implants
obturator