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 ?