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406
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A. Malik and P. Clarke
The patients are advised to take regular care of the TEP.It
needs to be brushed, and often, a topical anti-fungal may also
applied. Normally, the TEP needs to be changed 3–6 monthly.
There are several adjuncts, which are used along with TEP:
heat and moisture exchanger (HME) lters are placed over
the tracheostoma using a base plate. This helps in allowing
conditioned air to go into the lungs and reduces unnecessary
irritation and cough production. These can also be tted with
a hand-free attachment, which has a one way valve and can
help the patient speak without the need for occluding the
stoma.
40.6 Secondary TEP Insertion
Secondary puncture is when the creation of the tracheooesophageal puncture is undertaken as a separate procedure
after the laryngectomy. This might be planned in the case of
salvage surgery when stula rates are higher or with circumferential pharyngeal resection when the posterior tracheal
wall is separated from the neopharynx.
The valve may also be lost by patients and the track
unable to be re-opened at the time and the stula closes.
If some time has passed between laryngectomy and secondary puncture or after the loss of a valve, it may be prudent
to consider videouroscopy. This allows assessment of the
PE segment and neopharynx, so neopharyngeal dilatation
and/or botox injection can be undertaken at the same time.
Whilst this can be performed as an ofce procedure, it is
often easier to do these under a short general anaesthetic.
Procedure: A pharyngoscope/esophagoscope is passed
trans-orally to the level of the stoma. The bevelled end is
then rotated so is open anteriorly towards the trachea. This
will usually allow the light to be seen through the tracheal
mucosa to ensure it is in the correct position. A puncture is
made in the party wall 1–1.5cm below the junction of the
skin and the mucosa. The trocar enters the bevelled end of
the scope preventing damage to the posterior oesophageal
wall. A sizer may be part of the insertion kit and helps decide
the size of the prosthesis to be inserted. The rest of the procedure is similar to the primary insertion, with the exception
being that the tip of the guidewire is pulled out from the oral
cavity rather than the open pharynx.
In the salvage setting, it is occasionally impossible to
insert an oesophagoscope into the neopharnyx due to poor
mouth opening, poor neck extension or stenosis. In this situation, a number of alternatives may be attempted. A videolaryngoscope may be used in such cases to dilate the neopharynx
and also to target the botox for injections [5]. For secondary
puncture in such cases, an endotracheal tube may be inserted
transorally. A nasendoscope may be inserted through it, and
guided by it, the puncture can be made over the bevelled end
of the tube. This prevents any inadvertent trauma to the posterior wall.
40.7 Problem-Solving/Complications
Speech valves are associated with several problems, which are
unique to them. In this section, we have summarised some of
the issues related to them, as well as their remedies. Managing
speech valves are a perfect example of a multidisciplinary
team approach, consisting of a team of SLT, ENT surgeon,
gastroenterologist and radiologist for problem-solving.
Leak: This is one of the commonly encountered issues
with prostheses. There can be central or peripheral leak.
Central leak is seen when the valvular mechanism becomes
faulty and saliva/drink from the neopharynx comes through
the valve into the trachea externally. This can be caused by
food debris in the valve, which prevents normal valvular
function. Fungal colonisation and biolm may also affect
valve function, and this may be exacerbated by acid reux.
Usually, this is a marker for the end of the useful life of the
valve, and it will need to be changed. If valves are not lasting
the expected time, patients are asked to clean the prosthesis
with a topical anti-fungal like nystatin. Anti-reux medications may also be tried [6].
Candida infection: This can lead to valve dysfunction and
leak through the TEP.The patients are advised to regularly
clean the TEP with nystatin drops. Few studies have also
found the benet of yogurt in preventing the biolm formation over the TEP and subsequent valve dysfunction.
Peripheral leakage is seen around/alongside the prosthesis. This is often seen when the prosthesis is longer than the
thickness of the party wall, and there is a pistoning effect.
The party wall may be thin because of prior radiotherapy and
nutritional reasons. A silastic ring may be placed along the
prosthesis as a temporary measure. Filler or fat injection in
the surrounding tissue may be considered to bulk the tissue
surrounding the valve. Alternatively, an additional wider
silastic ange may be added to the valve. As a general rule, if
the tracheo-oesophageal party wall is thinner than 8mm, a
16 or 17 FG valve should be considered to reduce the risk of
peripheral leak. Great care not to traumatise the party wall
during valve change may also help maintain the elasticity of
the tissues.
Granulations: Granulations can develop around the puncture site due to constant irritation. These may be responsible
for improper tting of the prosthesis and many need
excision.
Aphonia: This can happen due to multiple reasons, one
being hypertonicity or spasm of the PE segment [7]. All
40 Voice Restoration Following Laryngectomy
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407
these cases merit undergoing a videouoroscopy, which can
give further information about the status of the PE segment.
Those with hypertonic or spasmodic segment will have
strained or no voice. These patients may need botulinum
toxin injection into the affected segment. This can be injected
under videouoroscopy guidance or under general anaesthesia while performing a pharyngoscopy. Pharyngoscopy may
be required in cases where a stricture is noted and dilatation
of the segment is required.
Rarely, this can happen due to hypotonic segment too.
Those with hypotonic segment will have a weak voice and
may require digital pressure over the neck to increase voice
intensity.
Stomal size: The tracheostoma should be wide enough to
allow digital occlusion in order to produce voice. It should
also be of adequate size to allow insertion, cleaning and handling of the prosthesis.
Valve extrusion: This may happen rarely at the time of
manipulation of the valve for cleaning or due to coughing. A
catheter may be inserted from the TEP tract to prevent it
from closing, and the valve should be replaced as soon as
possible.
References
1. Lefebvre JL.Laryngeal preservation in head and neck cancer: multidisciplinary approach. Lancet Oncol. 2006;7(9):747–55.
2. Max L, Steurs W, De Bruyn W.Vocal capacities in esophageal and
tracheoesophageal speakers. Laryngoscope. 1996;106:93–6.
3. Culton GL, Gerwin JM.Current trends in laryngectomy rehabilitation: a survey of speech-language pathologists. Otolaryngol Head
Neck Surg. 1998;118(4):458–63.
4. Blom ED. Evolution of tracheoesophageal voice prostheses. In:
Blom ED, Singer MI, Hamaker RC, editors. Tracheoesophageal
voice restoration following total laryngectomy. San Diego: Singular
Publishing Group; 1998. p.1–8.
5. Devabalan Y, Malik A, Coffey M, Clarke P. Video laryngoscopeguided (GlideScope®) injection of botulinum toxin in laryngectomy patients with limited neck extension. Clin Otolaryngol.
2020;46:116. https://doi.org/10.1111/coa.13644.
6. Pattani KM, Morgan M, Nathan CA.Reux as a cause of tracheoesophageal puncture failure. Laryngoscope. 2009;119(1):121–5.
7. Rhys-Evans P, Bloom E.Functional restoration of speech. In: RhysEvans PH, Montgomery PQ, Gullane PJ, editors. Principles and
practice of head and neck surgery and oncology. 1st ed. London:
Martin Dunitz; 2003. p.571–602.
Part XVII
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Maxilla, Nose, and Paranasal Sinuses Surgery
Endoscopic Resection ofNasal
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andParanasal Sinus Neoplasms
PavolSurda, DavidRanford, SteveConnor, PhilipTouska,
LuigiVolpini, andAbigailWalker
41
41.1 Introduction
There are two broad presentations of tumour of the sinonasal
tract—asymptomatic tumours that are discovered incidentally and symptomatic tumours. Both benign and malignant
tumours can present in either of these two ways, although
there is a general predilection for malignant tumours to progress at pace and thus cause symptoms whereas benign
tumours may exist silently for many years before being
discovered.
Benign tumours are far more common than malignant
tumours, and over 90% of tumours that present to an ENT
service are benign. Osteomas are the most common sinonasal tumour overall, followed by inverted papillomas.
However, osteomas rarely require treatment and as such
make up a smaller proportion of the surgical caseload [1].
P. Surda (*) · D. Ranford
ENT Department, Guy’s and St Thomas’ University Hospital,
London, UK
e-mail: Pavol.surda@gstt.nhs.uk; David.ranford@nhs.net
S. Connor
Department of Neuroradiology, King’s College Hospital, London,
UK
e-mail: steve.connor@nhs.net
P. Touska
Department of Radiology, Guy’s and St. Thomas’ NHS Foundation
Trust, London, UK
e-mail: philip.touska@gstt.nhs.uk
L. Volpini
Department of Otolaryngology, Head and Neck Surgery, Hywel
Dda University Health Board, Glangwili General Hospital,
Carmarthen, UK
A. Walker
ENT Department, Guy’s and St Thomas’ University Hospital,
London, UK
Royal Brisbane and Women’s Hospital, New Farm, QLD, Australia
e-mail: abiwalker@doctors.org.uk
Sinonasal malignancies account for up about 3% of head
and neck cancers, with an overall incidence of 1 case per
100,000 population. The incidence increases from 0.1 to 0.3
cases per 100,000 population in the rst decade of life to 7
per 100,000in the eighth decade of life. They are twice as
frequent in males as females and are most diagnosed in
patients in their fth or sixth decade of life. The prevalence
is eightfold higher in the Caucasian population when compared to other ethnic groups. Predisposing factors include
exposure to human papillomavirus, wood dust, industrial
carcinogens, leather, textiles, organic bres and heavy metals such as nickel and chromium. The role of alcohol and
tobacco in sinonasal cancer is lesser than other head and
neck malignancies [1, 2].
Patients often present with vague symptoms such as nasal
obstruction, rhinorrhoea, anosmia, epistaxis, headache and
facial pain or swelling. The non-specic presentation often
results in delays to diagnosis and progression to locally
advanced disease. This results in a poor overall prognosis,
with a 5- and 10-year overall survival rate of 50% and 30%,
respectively [1].
Sinonasal neoplasms can potentially pose signicant
management dilemmas due to either proximity or frank invasion of the orbit and intracranial contents. Both endoscopic
and external surgeries are the mainstay of treatment with or
without adjuvant chemotherapy or radiotherapy.
41.2 Anatomy
The sinonasal tract comprises the nasal cavity, maxillary
sinuses, ethmoid sinuses, frontal sinuses and sphenoid
sinuses. The sinuses are air lled cavities lined by ciliated
respiratory epithelium. The nasal cavity is divided by the
nasal septum in the midline. Bilateral nasal cavities include
the superior, middle and inferior turbinates. Neoplasms can
be found in any part of the sinonasal tract. Locally advanced
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_41
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disease can spread to clinically important structures including the pterygopalatine fossa, infratemporal fossa, superior
border of the sphenoid, orbit, parapharyngeal space, retropharyngeal space and anterior skull base. Later, we will
focus on anatomy of these areas.
41.2.1 Anterior Skull Base
The olfactory fossae or grooves of the cribriform are shallow
depressions located within the ethmoid bone in the anterior
cranial fossa and contain the olfactory bulb of the rst cranial
nerve. It is bordered medially by the perpendicular plate and
laterally by the lateral lamella, which is a thin plate of bone
and is at risk of injury during endoscopic sinus surgery. The
Keros classication is a method of classifying the depth of
the olfactory fossa and is determined by the height of the
lateral lamella of the cribriform plate, which can be divided
into three categories: type 1 (1–3mm), type 2 (4–7mm) and
type 3 (8–16mm). Type 3 exposes more of the cribriform
plate to potential damage from trauma and is the most common site of a cerebrospinal uid leak during endoscopic
sinus surgery. Of equal importance is not only the absolute
depth of the olfactory fossae but also asymmetry, as the operator may need to reorient to different heights of the skull
base when moving from right to left.
The anterior ethmoidal artery is a branch of the ophthalmic artery. It exits the orbit through the anterior ethmoidal
foramen. It supplies the anterior and middle ethmoidal
sinuses, frontal sinus, lateral nasal wall and nasal septum.
Radiologically, the AEA can be identied by visualisation of
the anterior ethmoidal notch (‘Kennedy’s nipple’), which is
present in 95% of patients [3]. This is important in frontal
and ethmoid sinus surgery as is it a potential bleeding risk.
The posterior ethmoidal artery runs within the orbit between
the superior rectus and superior oblique muscles and exits
via the posterior ethmoidal canal, which, crossing horizontally the ethmoidal roof, forms the posterior margin of the
olfactory groove, only few millimetres from the anterior
margin of the planum sphenoidale (Fig.41.1) [4].
41.2.3 Infratemporal Fossa
The infratemporal fossa lies posterolateral to the maxillary
sinus and deep to the masseter muscle. It is closely associated with the temporal and pterygopalatine fossa and many
nerves and vessels transverse its space. Its contents include
maxillary artery branches, the pterygoid venous plexus,
mandibular nerve and the chorda tympani nerve.
41.2.4 Orbit
The lateral surface of the ethmoid air cells, which is also the
principal component of the medial wall of the orbit is known
as the lamina papyracea.
Within the orbit, we recognise two compartments:
• Intraconal space has got conical shape where globe is the
anterior margin, sides are formed by the extraocular muscles and their surrounding fascia, which pass posteriorly
and converge on the tendinous ring at the orbital apex
porteriorly
• External to this space is the extraconal space
41.2.5 Structures Beyond theSphenoid Bone
The sphenoid bone is often described as buttery shaped.
The body lies at the centre and houses the sphenoidal sinuses,
which are separated by an intersinus septum. The superior
surface of the sphenoid body contains some important anatomical structures. In the deepest part of a saddle-shaped
depression named the sella turcica sits the hypophyseal
fossa, and this is where the pituitary gland is located. Anterior
to this is the chiasmatic groove, a sulcus formed by the optic
chiasm. The internal carotid artery course is lateral to the
sinuses bilaterally, and care must be taken during sinus surgery with many signicant structures nearby.
41.2.6 Parapharyngeal Space
41.2.2 Pterygopalatine Fossa
Another important structure anatomically is the pterygopalatine fossa (PPF). The PPF is a small inverted pyramidal space
situated below the apex of the orbit, between the maxillary
bone anteriorly and the pterygoid process posteriorly. It is
the neurovascular crossroad for the nasal cavity, orbit, oral
cavity, masticator muscle and the middle cranial fossa, and
care of this area must be taken during endoscopic resection.
It is also a common pathway in the spread of neoplastic or
infectious processes.
The parapharyngeal space is a deep compartment containing
Eustachian tube around which most suprahyoid fascial
spaces are arranged. It occupies the space between the prevertebral fascia and the buccopharyngeal fascia. It is an
inverted pyramid extending from skull base superiorly to
hyoid inferiorly, from prevertebral fascia posteriorly to buccopharyngeal fascia anteriorly and from superior constrictors medially to the masticator space and parotid laterally. It
is usefully divided by the styloid process into anterior and
posterior compartments. The anterior pre-styloid space contains the maxillary artery, lymph nodes, parotid and branches
41 Endoscopic Resection ofNasal andParanasal Sinus Neoplasms
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a
413
***
AEA
LC
PEA
OP
ocr
CPs CPs
PS
**
*
SF
***
AEA
PEA
OP
ocr
OO
b
PS
OP
ocr
**
OP
ocr
Fig. 41.1 Anterior skull base depicting anatomical landmarks (a) and
closer look at the posterior wall of sphenoid sinus (b). Note that septum,
middle turbinate and ethmoids were completely removed. AEA anterior
ethmoidal artery; PEA posterior ethmoidal artery; O orbita; OP optic
of the trigeminal nerve, whilst the post-styloid space contains internal carotid artery, internal jugular vein and cranial
nerves IX, X, XI and XII.
41.2.7 Retropharyngeal Space
The retropharyngeal space is a potential space bound by the
buccopharyngeal fascia anteriorly and the alar fascia posteriorly. It spans from the base of skull to the mediastinum and
contains largely fatty areolar tissue and lymph nodes that
drain the pharynx, nose and middle ear.
ICAs
CPc
nerve; OCR opticocarotid recess; PS planum sphenoidale; * intersinus
septum; SF sphenoid sinus; *** frontal sinus; ICA internal carotid
artery
*
C
ICAs
CPc
41.3 Dierential Diagnosis ofSinonasal
Neoplasms
When faced with a suspicious nasal mass, a clinician should
consider not only the imperative to make a diagnosis but also
some principles that are seen to improve the nal outcome
for the patient. If a malignant tumour is suspected, it is vital
that essential imaging is obtained before biopsy, so that a
clear denition of the tumour extent can be made without
any artefact that might be created by post-biopsy inammatory changes. Both contrast-enhanced MRI and CT scan of
the head and neck should be taken, to differentiate the tumour
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P. Surda et al.
from retained secretions, assess the invasion of nearby structures (e.g. orbit, dura, brain, etc.), identify the presence of
perineural spread and evaluate the bony boundaries of the
nasal cavity and sinuses. In some cases, the initial imaging
can also provide with hints regarding the nature of the neoplasm (e.g. origin from the olfactory fossa, vascular tumours,
etc.) that may guide throughout the following diagnostic
steps [1].
A summary of common benign tumours found in the
nasal cavity and paranasal sinuses and their characteristics is
found in Table41.1.
Virtually, any malignant histology has been described in
the sinonasal area, and this includes both primary tumours
and metastases from other anatomical sites. Table41.2 sum-
Table 41.1 Characteristics of most common benign sinonasal tumours
% of
surgical
cases
Osteoma 14 Three types:
Inverted papilloma 52 Ribbons of epithelium
Juvenile nasal
angiobroma
Lobular capillary
haemangioma
Fibrous dysplasia 5 Replacement of
Schwannoma 1 Cellular Antoni A
12 Endothelium lined
5 Proliferation of
Histological
characteristic Imaging characteristic Area of origin Notes
CT: lesion contains at
eburnated; mature;
mixed
that invert into
underlying stroma
spaces embedded in a
brous stroma
capillaries arranged in
lobules with varying
degrees of
inammation
normal bony tissue by
brous tissue of
variable cellularity
and immature woven
bone
areas with Verocay
bodies alternating
with hypocellular
myxoid Antoni B
areas
least some dense cortical
bone with varying
regions of ossication;
regular edges
CT: hyperostotic cone at
point of origin
MRI: cerebriform
appearance
CT: Holman- Miller sign
of bowing of posterior
maxillary sinus wall.
MRI: avid enhancement
with gadolinium; ow
voids
MRI: T2 hyperintensity,
vivid enhancement with
gadolinium
CT: ground glass
appearance
MRI: well circumscribed
mass; Antoni A regions
have intermediate T1
and T2 signal while
Antoni B are
hyperintense on T2
marises the malignant tumours that can be found in the
region according to the fourth Edition of the WHO
Classication of Head and Neck Tumours.
However, this list is not exhaustive; in fact, malignant
tumours may also arise from the numerous salivary glands
scattered all over the mucosa of the upper aerodigestive tract,
as they can arise primarily from the odontogenic tissue
embedded in the maxillary alveolus. Moreover, numerous
other haematological malignancies may primarily or secondarily present in the sinonasal area, and as previously mentioned, this can be the site of distant metastatic spread from
cancers arising from other organs. Table41.3 presents a summary of the main characteristics.
Ethmoid; frontal. Rarely
sphenoid
Lateral nasal wall and
maxillary sinus
Pterygopalatine fossa Found almost exclusively
Anterior nose—Little’s
area, head of IT
Throughout sinonasal tract
and ventral skull base
V1 and V2 divisions;
sympathetic bres of
carotid plexus or
parasympathetic bres of
pterygopalatine ganglion
Multiple osteomas
associated with Gardner’s
syndrome
Malignant transformation
in 5–15%. Successful
resection achieved by
subperiosteal resection,
focused at hyperostotic
cone of origin. Role of
HPV ambiguous
in adolescent males. May
extend to orbit, skull base,
parapharyngeal space
Formerly referred to as
pyogenic granuloma. May
be related to digital trauma.
Can be differentiated from
JNA by position on septum
and predilection for females
Commonly confused with
ossifying broma.
Ossifying broma has a
better dened, dense
eggshell rim on CT scan.
Both conditions are
surgically challenging with
high recurrence rates
Intervention dependent
upon symptoms; some may
advocate a wait and watch
policy depending on site
and symptoms
41 Endoscopic Resection ofNasal andParanasal Sinus Neoplasms
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Table 41.2 Malignant sinonasal neoplasms according to the 4th edition of the WHO Classication of Head and Neck Tumours (2017)
Carcinomas Malignant soft tissue tumours
Keratinizing squamous cell carcinoma Fibrosarcoma
Non-keratinizing squamous cell carcinoma Undifferentiated pleomorphic sarcoma
Spindle cell squamous cell carcinoma Leiomyosarcoma
Lymphoepithelial carcinoma Rhabdomyosarcoma, NOS
Sinonasal undifferentiated carcinoma Embryonal rhabdomyosarcoma
NUT carcinoma Alveolar rhabdomyosarcoma
Neuroendocrine carcinomas Pleomorphic rhabdomyosarcoma, adult type
Small cell neuroendocrine carcinoma Spindle cell rhabdomyosarcoma
Large cell neuroendocrine carcinoma Angiosarcoma
Adenocarcinomas Malignant peripheral nerve sheath tumour
Intestinal-type adenocarcinoma Biphenotypic sinonasal sarcoma
Non-intestinal type adenocarcinoma Synovial sarcoma
Teratocarcinosarcoma Haematolymphoid tumours
Extranodal NK/T-cell lymphoma
Borderline/low-grade malignant soft tissue tumours Extraosseous plasmacytoma
Desmoid-type bromatosis
Sinonasal glomangiopericytoma Neuroectodermal/melanocytic tumours
Solitary brous tumour Ewing sarcoma/primitive neuroectodermal tumour
Epithelioid haemangioendothelioma Olfactory neuroblastoma
Mucosal melanoma
415
Table 41.3 Main characteristics of malignant sinonasal tumours
% of
sinonasal Ca Exposure
Squamous
Cell Ca [5]
Adenoid
Cystic Ca
[6]
AdenoCa [7] 10–20 Wood dust 5–7 Ethmoid
ONB 2–6 Mainly
SNUC <5 Similar to
Mucosal
Melanoma
Sarcoma <1 Mainly
60 Nickel, wood
dust, leather
dust.
2–18 Mainly
unknown
unknown
SCC
<5 Mainly
unknown,
formalin
described
unknown
% of nodal
metastases
20 Maxillary
3.6 70 Slow growth, perineural spread (trigeminal branches) and
20–25 Olfactory
21 Ethmoid/
16 Lateral
25 Specic to
Area of
origin
sinus
sinuses
plate
maxillary
sinuses
nasal wall
subtype
41.4 Diagnosis
41.4.1 Clinical Symptomatology
The typical clinical symptoms of sinonasal cancer can often
be non-specic and difcult to distinguish from benign disease—for example, nasal blockage, epistaxis and rhinor-
5years
OS (%) Notes
50 Prognosis stage dependent. 30% related to occupational
exposures
propensity for bone invasion, lifelong risk of systemic
metastases
60 Non-intestinal type (low-grade and high-grade) and
intestinal-type (consider metastasis from colorectal [8]).
44% related to exposures
70 Histological grade, independent prognostic factor [9],
bimodal age distribution [10, 11]
35 Poor prognosis and lack of cell markers
35 Poor prognosis, tendency to recur and metastasize
regardless the radicality of the treatment, consider always
systemic imaging and opinion from Melanoma team
Variable Most common type of paediatric sinonasal malignancy
(rhabdomyosarcoma), main distinction between soft tissue
sarcomas and Ewing’s sarcoma, always multimodality
management within a Sarcoma team
rhoea. These symptoms in themselves are often insufcient
to raise suspicion. However, a clinician must be alarmed
when these occur in conjunction with some subtle but specic symptoms of malignancy—serosanguinous discharge,
facial numbness, loose dentition, enopthalmos, neck lump—
and should be treated with utmost seriousness [12]. Advanced
stage tumours may present with signs of orbital invasion
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Fig. 41.2 Blue box depicts the most common area of
origin of SCC and green box illustrates the most
P. Surda et al.
Most commonly
affected region by
adenocarcinoma
Most commonly affected region by SCC
such as proptosis and diplopia or neurological symptoms
including cranial nerve palsies or even personality change
(Fig.41.2). The relatively non-specic presentation of sinonasal tumours is frequently associated with a delay in diagnosis. The consequences of this delay in diagnosis depend
largely on the specic tumour biology. For example, nearly
30% of sinonasal SCC are associated local lymphatic metastasis a presentation but less than 10% of adenocarcinoma
[13]. Distant metastases are uncommon at presentation,
although may occur if disease progresses to a terminal stage.
41.4.2 Diagnostic Process
Evaluation for patients should begin with a thorough medical
history including not only the presenting symptoms but also
occupational history, tobacco and alcohol use, social support
and an estimation of performance status. The clinician should
then perform a complete ear, nose and throat (ENT) exploration, including examination of the cranial nerves and palpation of the neck. Anterior rhinoscopy generally provides
limited information, and therefore, nasal endoscopy with
optics at 0° or 45° is mandatory. Flexible nasendoscopy is
commonly used, but the ability to capture high-quality
images with a 0, 30, or 45° rigid endoscope is a very valuable
tool if available. If malignancy is suspected, both CT imaging and MRI must be performed prior to obtaining histological specimen/debulking. Bleeding and/or inammation
following biopsy may confound the imaging and result in
incorrect staging of the tumour [1].
Any multidisciplinary head and neck/skull base team will
have dedicated pathologists who are remarkably familiar
with the constellation of the different malignant histologies
that can be found in the sinonasal area; however, a clinician
who deals with nasal and paranasal sinus neoplasms should
Symptoms and signs
Endoscopy
Imaging:
1. CT with contrast +
2. MRI with gadolinium
Biopsy
Staging + MDT
discussion
Fig. 41.3 Management algorithm for malignant sinonasal tumours
also be familiar with the most encountered tumours and the
appropriate diagnostic and staging process (Fig.41.3) [1, 6].
41.4.3 Imaging
The workhorse of sinonasal imaging is the CT of the sinus,
and many patients with a sinus neoplasm will undergo this as
their rst line investigation. If malignancy is suspected, then
both CT imaging and MRI must be performed. These two
imaging modalities are complimentary in their assessment of
bony and soft tissue involvement and the precise anatomical
details of tumour localisation and extension, which are critical in determining operability and in planning radiotherapy
(Table41.4). MRI is the standard imaging modality for postoperative surveillance.
41 Endoscopic Resection ofNasal andParanasal Sinus Neoplasms
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Table 41.4 Main characteristics of CT and MRI and its role in sinonasal neoplasms diagnosis
CT
Isolated sinus
opacication
Isolated nasal polyp Consider a meningo- encephalocele if
Bony attenuation of
sinonasal structures
MRI
T1w high signal Usually, due to proteinaceous secretions (e.g.
T2w high signal Usually, inammatory although occasionally
Gadolinium
enhancement
Consider a neoplasm, fungal disease or (in
the maxillary sinus) an odontogenic source
extending to anterior skull base
Maybe due to pressure de-ossication from
benign disease or bony erosion from
aggressive disease
in a mucocele). Also, due to haemorrhage (or
rarely melanoma)
can be seen in tumours (e.g. salivary gland
tumours or chondroid tumours)
Useful to delineate extent of tumours and to
assess intracranial and perineural spread
Correlate with endoscopic appearances and possibly MRI
Consider MRI prior to biopsy
Look for any evidence of bony remodelling or expansion which
indicates benign process such as mucocele or polyps. Some thin
structures (such as the anterior skull base) may be poorly seen if
there is adjacent soft tissue
Always look at pre and post gadolinium sequences to distinguish
high T1w proteinaceous secretions from enhancement
T2w is a useful sequence to distinguish high T2 signal inammation
from the extent of intermediate T2w signal (cellular) tumours. Note
that very low T2w signal is seen in benign fungal disease
Note that enhancement due to dural inammation or physiological
perineural enhancement should not be confused with tumour
invasion
417
The role of PET-CT in the assessment of sinonasal
tumours continues to evolve, and its use in staging certain
tumours such as mucosal melanoma is reasonably well
established. However, for more common tumours such as
SCC and adenocarcinoma, it seems that PET-CT is likely to
take a similar role as other squams of the head and neck—
that is, it adds value for patients with T4 disease and those
with suspected recurrence or distant metastases. For the
majority of patients, however, CT and MRI will be the two
key imaging techniques and offer sufcient detail to stage
according to the current Union for International Cancer
Control (UICC) classication system.
41.4.3.1 Sinonasal Neoplasms
• Whilst biopsy will usually be required for denitive diag-
nosis, imaging plays a role in alerting the clinician to
those occasions when biopsy would be ill advised (e.g.
cephalocele, highly vascularised tumours, aneurysm).
• All efforts should be made to perform biopsy after imag-
ing as bleeding or inammation may confound ndings.
• Diagnostics should include CT and magnetic resonance
imaging MRI.
• On MRI, there is a characteristic convoluted, cerebriform
pattern.
Vascular Lesions
• These include haemangioma, haemangiopericytoma,
angiomatous polyp and the juvenile nasal angiobroma
(JNA). Vascular nature may be indicated by the nding of
ow voids and avid enhancement.
• The location of the lesion is an important feature of the
JNA, which characteristically expands and erodes the
sphenopalatine foramen. Bowing of the posterior maxillary sinus wall is recognised as the Holman-Miller sign.
The UPMC staging system also requires angiography
after embolisation; residual vascularity will upstage the
tumour with accordant increase in surgical risk.
Bone and Cartilage Tumours
• Osteomas are typically found in the frontoethmoid region
and appear as dense cortical bone but may have lower
density elements. Fibro-osseous lesions (brous dysplasia or ossifying broma) are usually recognizable on CT
due to typical ground-glass elements.
41.4.3.3 Malignant Sinonasal Tumours
41.4.3.2 Benign Sinonasal Tumours
Inverting Papilloma
• A unilateral mass most commonly originating in the lateral nasal wall and involving middle meatus and maxillary sinus.
• CT features include internal calcication and bony erosion or bowing. A focal hyperostotic spur may correlate
with the origin of this neoplasm, and its identication is
important for surgical planning.
Imaging Appearances
• The more aggressive malignant sinonasal tumours such as
the common sinonasal carcinoma and aggressive neuroendocrine tumours (e.g. SNUC and SNEC) demonstrate
frank bony erosion without bony remodelling or displacement on CT.
• Adenoid cystic carcinoma has a propensity for perineural
spread, which can be detected on MRI as asymmetric
thickening of enhancement of neural structures.
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