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P. Surda et al.
• Sinonasal melanoma is rare but melanotic forms may
demonstrate high signal on T1-weighted images.
• T cell lymphomas characteristically affect the nasal septum, whilst B cell lymphomas arise more laterally and
may demonstrate tumour on either side of the maxillary
sinus wall.
• Olfactory neuroblastoma which tend to arise in the superior nasal fossa and may be associated with peritumoural
cysts when extending into the anterior cranial fossa.
Staging
• MRI is particularly useful to delineate the intrasinus
extent of tumour relative to (increased T2 signal) inam-
matory change and obstructed secretions. Extrasinus
extension to the intracranial compartment, orbit and infratemporal fossa is dened.
• In particular, pial enhancement, nodular dural enhancement and dural thickening of more than 5mm have been
found to be predictive of dural invasion, whilst brain
parenchymal signal abnormality suggests brain invasion.
• Post-contrast MRI sequences are particularly helpful to
evaluate for perineural spread.
• High-resolution T2w signal coronal images are useful to
dene invasion since they delineate the periosteum and
periorbita (Fig.41.4).
Fig. 41.4 Depicting pathology: sinonasal tumours and mimics. (a) Coronal T2w image demonstrating low T2w signal expansion of the right
ethmoid air cells, which is related to dense fungal concretions and metallic contents (star). (b) Axial CT image in the same patient demonstrating
the utility of CT to depict the high-density fungal material within the ethmoid labyrinth (arrow). (c) Axial CT in a patient with granulomatous
polyangiitis (GPA) with extensive bony destruction presenting as an ‘autorhinectomy’ and a single central cavity, together with marked osseoneogenesis. (d) Axial CT demonstrating a dentigerous cyst, expanding into the left maxillary antrum. Note the ‘double line’ (arrows), which
indicate an alveolar/dental origin to the expansile mass. (e) Axial CT revealing calcied matrix within a chondrosarcoma of the nasal septum
(arrow). (f) Axial T2w image revealing the ‘cerebriform’ pattern of a right antronasal inverted papilloma (arrow). (g) Coronal T1w+ contrast
sequence demonstrating an enhancing mass within the nasopharynx and extending to the right pterygoid base (arrow) compatible with a juvenile
angiobroma. (h) Axial T1w+ contrast sequence demonstrating perineural spread of a right maxillary antral squamous cell carcinoma (star) along
the vidian canal posteriorly (arrow). (i) Coronal T1w+ contrast fat-saturated sequence demonstrating dural enhancement and thickening (black
arrow) corresponding to dural invasion at the anterior skull base. There is also invasion of the right orbit (white arrow). (j) Coronal T1w+ contrast
fat-saturated sequence demonstrating extensive intracranial extension of an olfactory neuroblastoma with its characteristic peritumoural cysts
(arrow). (k) Coronal FLAIR sequence demonstrating a hyperintense expansile left ethmoid mucocele (star). (l) Coronal CT demonstrating a calcic abnormality within the right nasal cavity consistent with a rhinolith (arrow). (m) Coronal T2w sequence demonstrates gliotic brain tissue
(arrow) extending through a left sphenoid defect with an extensive sphenoid sinus and subcranial meningocele
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a
d
g
bc
e
h
f
i
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41.5 Principles ofTreatment
Sinonasal malignancies are infrequent entities, therefore
their treatment, especially for the advanced cases is usually
best coordinated by high volume centres with well-established head and neck and skull base multidisciplinary teams.
After staging and discussion, probably the most important
factor is to decide whether the treatment will be administered
with a curative or palliative intent. In the latter, the choice of
the therapeutic approach and the vigour with which they are
pursued will be driven by the desire to improve the patient’s
quality of life, rather than by its oncological outcomes.
When it comes to curative approaches for sinonasal cancers, these can vary greatly according to the histology of the
tumour and to its extent at presentation. Surgery is still the
treatment of choice; adjuvant treatment is recommended
based on a risk stratication algorithm, and neoadjuvant regimens have been shown to improve outcomes in certain
aggressive tumours presenting at an advanced stage.
Table 41.5 is a summary of the treatment for specic
histologies:
Depending on degree of invasion, the relative contraindications for endoscopic approach include involvement of
(Fig.41.5):
• Brain parenchyma
• Palate
• Anterior face and lateral portion of frontal sinus
• Nasal bones
• Soft tissues
Conversely, there is almost a consensus on the inoperabil-
ity (with curative intent) of a patient who presents with:
• Extensive involvement of the orbital apex
• Inltration of the cavernous sinus
• Encasement of the internal carotid artery
41.5.1 Management ofOrbital Invasion
Recent advances in management of sinonasal neoplasms led
to orbital preservation surgery, which should be indicated if
the resection is considered achievable from oncological perspective. Data suggest that orbital preservation does not
reduce survival or local control. In extensive cases, surgical
management is combined with neoadjuvant chemotherapy
with aim to downstage the extent of the mass and allow
resection with preserving eye function. In general, malignancies with bone wall erosion and periorbita and/or focal extraconal fat invasion are considered suitable for eye preservation
surgery. Invasion of orbital contents such as medial rectus
muscle, optic nerve, ocular bulb and palpebral skin is an
indication for orbital exenteration. Orbital apex invasion was
reported to have dismal outcome and is considered uncurable
(Fig.41.5) [26].
Table 41.5 Histology-driven strategy
Treatment
Squamous Cell Ca
[14]
Adenoid Cystic Ca
[13]
AdenoCa • Endoscopic approach (if no contraindication) is the gold standard [16]
ONB • Open, endoscopic or combined craniofacial resection encompassing at least dura of anterior skull base and
SNUC Tailored approach with induction chemotherapy [23]
Mucosal Melanoma • The treatment of choice is surgery, with curative or palliative intent
Used with permission of authors: Castelnuovo P, Turri-Zanoni M, Battaglia P, Antognoni P, Bossi P, Locatelli D.Sinonasal Malignancies of
Anterior Skull Base: Histology-driven Treatment Strategies. Otolaryngol Clin North Am. 2016 Feb;49(1):183–200. doi: 10.1016/j.
otc.2015.09.012. PMID: 26614837 [25]
• Similar oncological outcomes for open (maxillectomy, craniofacial resection) vs endoscopic approach [12, 15]
• Adjuvant IMRT always considered [17, 18]
Consider induction chemotherapy for poorly differentiated T3–T4 lesions [19]
• Standard treatment is surgical resection with clear margins followed by adjuvant radiotherapy
Palliative resection of the primary is considered also in metastatic disease considering the often-long-term survival
• Open or combined approach only when endoscopic contraindicated (mainly in the form of craniofacial resection)
• Intestinal-type: because of widespread eld change, even in the presence of unilateral disease, exenteration of the
whole ethmoid complex is indicated [7, 17]
• RT can be avoided in T1–T2, low-grade ITAC [18]
• Adjuvant radiotherapy: consider it in high-grade, high-stage malignancies (IMRT preferred) [18]
• Elective neck treatment not necessary as low risk of nodal spread (7%) [1]
ipsilateral olfactory bulb [19]
• Better survival with Endoscopic vs open approach [20]
• Post-operative RT always considered (improved OS irrespective of stage) [21, 22]
Neck metastasis 20–25% at presentation, therefore some evidence to elective treatment of the neck, but consider neck
irradiation in patients with intracranial extension of the primary tumour [21]
• Evidence of improved survival using endoscopic, minimally invasive approach [24]
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Fig. 41.5 (a, b) Relative
contraindications of
endoscopic resection. FS
frontal sinus; P palate; O
orbita; BP brain parenchyma;
NB nasal bones. (c)
Approaches to anterior skull
base. A transfrontal; B
transcribriform; C transplanar;
D transsellar; E transclival; F
craniocervical
a
b
c
41.6 Endoscopic Resection ofSinonasal
Neoplasms
41.6.1 Surgical Considerations Based
onTumour Location
Malignant tumours, by their nature, do not respect anatomical boundaries and will evade and escape the normal contours of the sinonasal cavity. Therefore, once the MDT has
approved the plan to operate with curative intent, a surgeon
must be prepared to be exible in their operative approach
and be prepared to adapt to the individual tumour and the
structures involved.
We would therefore advocate a modular or ‘building
block’ strategy to oncologic endoscopic surgery. Individual
modules of dissection are outlined below, describing
approaches to anatomical subunits such as the maxillary
sinus, orbit and skull base. Each of the modules of dissection
can then be combined as tailored to the individual characteristics of a tumour and patient. For example, one patient may
need medial maxillectomy alone; another patient may need
medial maxillectomy plus ethmoidectomy plus clearance of
the orbital oor and lamina papyracea ,and a further patient
may need medial maxillectomy plus access to the infratemporal fossa via the pterygopalatine fossa. Rather than seeing
these as three completely different procedures, each opera-
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tion can be built up using the required modules of dissection.
This building block approach allows a surgeon to be exible
and yet methodical—whilst each tumour has its own characteristics and may be extensive or involve extra-sinus structures, a surgeon can plan each required step of dissection by
choosing the appropriate modules.
41.6.1.1 Case Example ofaModular Approach
toDissection
This example demonstrates a complete surgical approach
that successfully resected an extensive tumour using the following modules:
• Medial maxillectomy
• Removal of lamina papyracea
• Wide sphenoidotomy
• Modied Lothrop
41.6.2 Preoperative Considerations
Strategies of surgical eld optimisation:
• 15–20° reverse Trendelenburg position that increases
venous drainage without compromising cerebral
perfusion.
• Hypotensive anaesthesia for optimal surgical eld; sys-
tolic mean arterial blood pressure of circa 90mmHg and
a pulse rate below 70bpm have been shown to decrease
surgical bleeding without affecting cerebral blood ow,
provided a patient does not have underlying cardiovascular disease.
• Total intravenous anaesthesia/Desurane (at low concen-
tration only) and remifentanil combined (avoids the need
BIS monitoring) provide good a surgical eld.
• Topical decongestion using Moffat’s solution (cocaine
and adrenaline +/− sodium bicarbonate).
– Co-phenylcaine and lignocaine (Co-phenylcaine) or
Oxymetazoline can be also used.
• Intraoperatively, neuropatties soaked with vasoconstrict-
ing agents, haemostatic agents such as Gelfoam® and
Floseal®, warm saline irrigations and cautery are used.
Image guidance technology is used in complex cases
where it provides enhanced anatomical localisation. CT/
MRI is valuable addition visualising soft tissue structures
surrounding the tumour. In cases requiring preoperative
embolisation, we recommend using CT after intervention as
the presence of coils may improve the understanding of the
tumour position in relation to surrounding vascular
structures.
41.6.3 Lesions Limited toMaxillary Sinus
andExtending toMiddle Meatus (T1/
T2) (Fig.41.6)
Approaches to maxillary sinus include the following:
• Large antrostomy
• Pre-lacrimal approach to maxillary sinus
• OR endoscopic medial maxillectomy and inferior
turbinectomy
When managing benign neoplasms, inferior turbinectomy
and medial maxillectomy can be avoided using pre-lacrimal
approach, which preserves the structure and function of the
lateral nasal wall. In malignant tumours, medial maxillectomy and turbinectomy is almost always necessary to obtain
clear margins.
41.6.3.1 Antrostomy, Inferior Turbinectomy
andMedial Maxillectomy
Initially, an uncinectomy is performed to identify the natural
maxillary ostium and enlarged up to the posterior maxillary
sinus wall. Posteriorly located lesions can be accessed using
mega-antrostomy. Tumours with lateral extension require
medial maxillectomy including these steps (Fig.41.7.):
• Medialisation of the inferior turbinate and crushing with
Tilley forceps (or artery clip) up to posterior end.
• Resection of the inferior turbinate along the crushed area
using turbinectomy scissors.
• Scalpel or Colorado needle is used to perform mucosal
incision.
• Bone is cut along mucosal incisions using sharp chisel or
osteotome.
• Lacrimal duct is sharply cut with scissors.
• Once the medial wall is removed, tumour can be easily
removed. Anterior wall extension might require an angled
scope for better visualisation.
• If more exposure is required, the anterior wall of maxil-
lary sinus is drilled down.
Tumours extending beyond middle meatus require anterior and posterior ethmoidectomy and sphenoidotomy.
Tumour clearance and level of extension can be assessed
with frozen biopsies. If necessary, middle turbinate and
superior turbinate can be removed to achieve clearance of
anterior skull base region.
ab
Lateral nasal w
resection line of IT
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Fig. 41.6 T1 lesion localised within maxillary sinus (a) and T2 lesion extending beyond maxillary sinus into middle meatus (b)
Fig. 41.7 Illustration of
medial maxillectomy,
mucosal and bony incisions
all
Maxillary antrum
Mucosal incision
MT
IT
“Crush” and
Nasal floor
424
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SPA a. &
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41.6.4 Lesions Invading Posterior Wall
ofMaxillary Sinus, Floor or Medial Wall
ofOrbit, Pterygoid Fossa, Ethmoid
Sinuses (T3) (Fig.41.8)
Approaches to lesions invading oor or medial wall of orbit,
pterygoid fossa, ethmoid sinuses include the following:
• Transmaxillary access to pterygopalatine fossa
• Resection of lamina papyracea +/− periorbita
• Ethmoidectomy
41.6.4.1 Transmaxillary Access
toPterygopalatine Fossa (Fig.41.9)
Access to pterygopalatine fossa is usually preceded by large
antrostomy and medial maxillectomy; therefore, the posterior wall is widely exposed. The next step is to elevate
mucosa from the posterior maxillary sinus wall. Prior to
bone removal, the sphenopalatine artery is ligated/cauterised
with bipolar forceps. Kerrison punch (3mm, 45°) is used to
remove the bony wall of the posterior maxillary sinus and
expose the anterior face of PPF.
The anterior compartment contains fat and blood vessels,
but the posterior compartment contains neural structures.
The maxillary artery is in the lateral and inferior portion of
the PPF along the anterior margin of the lateral pterygoid
muscle. Neurovascular structures and fat are covered with
the fascia. In most of cases, we do not have to enter these soft
tissues but only mobilise them laterally, which allows suf-
P. Surda et al.
Fig. 41.8 Maxillary T3 lesion extending into middle meatus and
invading medial and inferior wall of orbit
foramen
MT
Maxillary
sinus
PNS
Fig. 41.9 Transpterygoid approach, mucosal dissection line (left),
contents of pterygopalatine fossa (right). MT middle turbinate; PNS
postnasal space; SPA sphenopalatine artery; PP ganglion pterygopala-
foramen
Vidian n.
MT
Maxillary
PNS
tine ganglion; IMA internal maxillary artery; GDP n. greater descending palatine nerve; PPF pterygopalatine fossa
sinus
PP ganglion
GDP n.
IMA
PPF
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cient access to posterior wall of PPF. To do so, SPA and
Vidian bundle must be cauterised as these structures prevent
the mobilisation.
When exposing PPF contents, crucial is to leave the periosteum intact. This way further dissection will be avascular,
and PPF contents are protected. Complete removal of posterior wall allows access laterally to the infratemporal fossa.
41.6.4.2 Management ofOrbital Invasion
Tumours invading the medial or inferior orbital walls are
often well dened and can be successfully removed leaving
periorbita intact. Management of medial wall invasion
includes removal of bulla ethmoidalis followed by removal
of invaded lamina papyracea but leaving periorbita.
In cases of resectable tumours with extension into extraconal space, it is difcult to identify the lateral margin and
normal tissue planes using direct transnasal route through
the tumour. Therefore, we adopted the combined transorbital
and transnasal approach [27]. This technique allows:
• Early identication of the lateral extent and clear demar-
cation of uninvolved tissue planes at the orbital
interface.
• AEA and PEA can be identied and cauterised to reduce
the vascularity of the mass prior to resection.
• Transorbital placement of the customisable protective
Silastic® sheet between orbital contents and tumour
ensures that tissue plane is not lost once approaching the
tumour transnasally. It also allows a clear protective bar-
rier of the orbital contents from the transnasal endoscopic
approach.
Tumours that involve medial wall, retrocaruncular
approach is indicated. When orbital oor is also invaded, we
recommend combination of transconjunctival and retrocaruncular approach with lateral canthotomy extension.
41.6.4.3 Retrocaruncular Approach (Medial
Orbital Corridor)
1. Upper and lower eyelids are retracted in their medial por-
tion with traction sutures.
2. Caruncle is retracted medially with atraumatic ne
forceps.
3. Incision is placed immediately lateral to the caruncle
through the conjunctiva of the plica semilunaris.
4. Fibrous layer is dissected until Horner’s muscle is
encountered and followed medially to the posterior lacrimal crest.
5. Globe is gently retracted laterally.
6. Orbital periosteum is incised and elevated at level of
orbital rim.
7. AEA and PEA are identied and discontinued.
8. Silastic® implant cut into U-shaped sheet can be inserted
as a preventive measure to protect the orbital contents
during the transnasal part.
41.6.4.4 Transconjunctival Approach (Inferior
Orbital Corridor) andLateral
Canthotomy (Lateral Orbital Corridor)
(Fig.41.10)
1. Procedure is initiated with lateral canthotomy.
2. A pointed scissor is inserted horizontally into the outer lid
angle laterally so that the instrument contacts the underlying bone of the lateral orbital rim (approximately 7–10mm).
3. Lateral palpebral ssure is cut horizontally including the
skin, the orbicularis oculi muscle and the conjunctiva.
4. Conjunctival incision is placed from laterally to medially
in the depth of the fornix.
5. Lower lid is retracted downwards, and periorbita is
incised parallel but just posterior to the infraorbital rim.
6. Periosteum is then incised and elevated. Subperiosteal
dissection follows, and medial orbital wall is identied.
Once the lateral margin of the tumour is identied, we
continue with transnasal approach and removal of the tumour.
41.6.4.5 Transnasal Approach (Removal
oftheTumour)
1. If accessible, a sphenopalatine artery ligation is performed with bipolar cauterisation
2. Tumour debulking is performed until Silastic® implant is
easily identied within the nasal cavity, demarcating to
the surgeon the lateral limit of dissection while preventing orbital fat prolapse.
41.6.4.6 Closure andReconstruction
Silastic® implant can be removed endonasally or transorbitally depending on the size of lamina papyracea defect.
Minimal bony resection such as isolated orbital wall (lateral or medial) or small orbital oor defects do not require
any kind of reconstruction. Subtotal resection of medial
orbital wall with visible fat prolapse can be repaired using
slightly oversized perforated PDS sheet. Fat prolapsing into
perforations ensures that sheet will not dislodge. If the fat
was resected, there is a risk of muscle entrapment; hence,
non-perforated sheet should be used.
Larger defects of the orbital oor can be repaired using a
thick fascial sling tightly secured to the margins of the bony
defect or customised titanium/medpore plate depending on
whether radiotherapy is planned. With subtotal or total oor
defects (>75% surface area, orbital oor and 1 or more
walls), rigid reconstruction is advisable. Furthermore, it is
important to reconstruct extensive orbital defects primarily
because established secondary defects are difcult to repair.
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Retracted
orbital fat
Inferior
orbital
fissure
Infraorbital
canal
Fig. 41.10 Transconjunctival approach (inferior orbital corridor) and lateral canthotomy (lateral orbital corridor), endoscopic view of the orbital
oor containing fracture (bottom)
In our experience, customised titanium/medpore plate is
used. Plate is attached to the inferior orbital rim with screws.
Mesh must be sitting on the posterior ledge in the posterior
third of the orbita to avoid enophthalmos.
apex, inltration of the cavernous sinus and encasement of
the internal carotid artery. In cases of invasion of soft tissues
of the check or palate, endoscopic assisted or pure open
approach is indicated. Non-oncologic approaches of surgical
Orbital
floor fr
debulking of the tumour may be performed either for palliation or, occasionally, adjuvant proton beam radiotherapy.
41.6.5 Tumour Invades Any oftheFollowing:
Anterior Orbital Contents, Skin
ofCheek, Infratemporal Fossa,
Pterygoid Plates, Cribriform Plate,
Sphenoid or Frontal Sinuses (T4a)
Orbital Apex, Dura, Brain, Middle
Cranial Fossa, Cranial Nerves Other
Than Maxillary Nerve
A purely endoscopic approach with curative intent is contraindicated in cases of extensive involvement of the orbital
41.6.5.1 Endoscopic Approaches toAnterior
Skull Base (Cribriform Fossa, Frontal
Sinus)
Firstly, we must identify the stalk of the tumour, which is
followed by central debulking using microdebrider to achieve
better mobilisation. During this phase, it is crucial to leave
the margins intact.
Before we commence resection of the tumour, a wide surgical eld must be created allowing good manoeuvrability
and visualisation. This usually includes the following:
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• Posterior septotomy, resection of rostrum sphenoidale
allowing visualisation of important landmarks: opticocarotid recess and planum sphenoidale
• Haemostasis by sphenopalatine artery cauterisation
• Maximal ventrocranial exposure usually requires Draf III
frontal sinotomy (outside in technique) allowing visualisation anterior border of anterior skull base
Subsequently, centripetal resection of tumour is per-
formed. Tumour is mobilised from lateral margins towards
the centre of anterior skull base.
Tumour that is inltrating lamina papyracea is resected
together with invaded bone leaving periorbita. All efforts
should made to remove anterior tumour in one monobloc.
Margins are sent for frozen sections to conrm complete
clearance.
41.6.5.2 Resection ofAnterior Skull Base (Bony
Structures, Dural Involvement, Brain
Parenchyma)
This module can be further built upon with endoscopic
resection of anterior skull base. First step involves coagulation of anterior and posterior ethmoidal artery, which is followed by removal of invaded skull base using diamond drill.
The crista galli can be carefully removed using scissors with
blunt tip. Adherence of dura to the orbital roof may signify
invasion. Dural resection extends from posterior frontal
region to optic chiasm (if needed). Laterally, it is crucial to
leave few millimetres wide rim of dura that will facilitate
reconstruction.
Falx cerebri can be clipped to prevent bleeding from sinus
sagittalis. Arachnoidea that lies above the tumour is separated from brain parenchyma, and bulbus olfactorius is
resected if indicated. Residual tumour containing bone of
anterior skull base, dura mater and bulbus olfactorius is
removed in toto transnasally. Dural edges are sent for frozen
sections to ensure completeness of resection.
3. Reconstruction is supported with small pieces of fat
placed between bone of anterior skull base and second
layer.
4. The third layer is either fascia lata or mucoperiostal/
mucoperichondrial ap (nasoseptal ap), which has
mainly supportive role.
5. Small pieces of absorbable dressing are placed over the
reconstruction.
First and second layer of fascia lata can be stitched
together. Stitch has a square shape of the size of dural defect.
This way, reconstruction is more robust, and fascia lata is
less likely to dislodge.
Post-Operative Care in Large Dural Reconstruction
1. Bed rest for 5 days; horizontal position with increased
upper body by 30°.
2. Regular neurological monitoring.
3. Do not lift objects that are heavier than 3kg for 3weeks.
Avoid any activity where you hold your breath and push,
for example, weightlifting, lifting or moving heavy
objects or straining during bowel movements for the rst
3weeks.
4. Open mouth sneezing to avoid increase of intracranial
pressure.
5. General rule is not to touch the nose for 2 weeks to the
prevent cerebrospinal uid (CSF) leak.
6. After 2weeks, patient will start to regularly ush the nose
with saline douches as instructed.
7. Patient can start to gently blow your nose after 2weeks.
8. Patients usually return to the work between the fourth to
sixth weeks after surgery with increasing work hours. We
will specify when you can go back to work.
9. There are no specic restrictions to sexual activity.
41.6.5.4 Approach toParapharyngeal Space
andInfratemporal Fossa (Fig.41.11)
Initial steps of this approach include these modules:
41.6.5.3 Dural Reconstruction
Reconstruction is performed endonasally in multilayer fashion, preferably using autologous material. We recommend
fascia lata. When adjuvant radiotherapy is planned, cartilage
must be avoided due to the risk of necrosis.
Multilayer Technique
1. Fascia lata is used as rst intracranial and intradural layer
and should be at least 30% larger than defect. Anterior
portion can be split, which makes positioning around falx
cerebri easier.
2. Second layer of fascia lata is placed intracranially but
extradurally; in between anterior skull base rim and dura
mater.
• Nasoseptal ap harvest
• Posterior septotomy
• Sphenopalatine artery ligation and division
• Medial maxillectomy and inferior turbinectomy
• Removal of posterior maxillary sinus wall
For larger resections, contralateral nasoseptal ap is harvested at the beginning. During the dissection, it can be
stored in the sphenoid sinus and at the end used for reconstruction of the defect.
For purposes of planning, positions of vidian canal and
foramen rotundum are excellent landmarks to determine area
of dissection depending on tumour location (Fig.41.12) [29].
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