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SECTION II — Diseases of Nose and Paranasal Sinuses
TABLE 38.2 SOURCE AND ROUTE OF INFECTION
IN CAVERNOUS SINUS THROMBOSIS
Source Disease Route
Nose and danger
area of face
Ethmoid sinuses Orbital cellulites or
Sphenoid sinus Sinusitis Direct
Frontal sinus Sinusitis and
Orbit Cellulitis and
Upper lid Abscess Angular vein and
Pharynx Acute tonsillitis
Ear Petrositis Petrosal venous
Furuncle and
septal abscess
abscess
osteomyelitis of
frontal bone
abscess
or peritonsillar
abscess
Pharyngeal plexus
Ophthalmic veins
Supraorbital and
ophthalmic veins
Ophthalmic veins
ophthalmic veins
Pharyngeal plexus
sinuses
clinical Features. Onset of cavernous sinus thrombophlebitis is abrupt with chills and rigors. Patient is acutely ill. Eyelids get swollen with chemosis and proptosis of
eyeball. Cranial nerves III, IV and VI which are related
to the sinus get involved individually and sequentially
causing total ophthalmoplegia. Pupil becomes dilated
and fixed, optic disc shows congestion and oedema with
diminution of vision. Sensation in the distribution of V1
(ophthalmic division of CN V) is diminished. CSF is usually normal. Condition needs to be differentiated from
orbital cellulitis (Table 38.3). CT scan is useful for this.
TABLE 38.3 DIFFERENCES BETWEEN ORBITAL
CELLULITIS AND CAVERNOUS SINUS THROMBOSIS
Cavernous sinus
Orbital cellulitis
Source Commonly ethmoid
sinuses
Onset Slow; starts with
oedema of eyelids
the inner canthus
→ chemosis →
proptosis
Cranial nerve
involvement
Laterality Often involves one
Involved concurrently
with complete
ophthalmoplegia
eye
thrombosis
Nose, sinuses, orbit,
ear or pharynx
• Abruptwithhigh
fever and chills
with near signs of
toxaemia
• Oedemaof
eyelids, chemosis
and proptosis
Involved individually
and sequentially
Involves both eyes
1. Otitis media (acute or chronic).
2. Pharyngitis and tonsillitis. Hypertrophy of lateral
lymphoid bands behind the posterior pillars (lateral
pharyngitis) is indicative of chronic sinusitis. It may
be unilateral and affect the side of the involved sinus.
Chronic sinusitis may also cause recurrent tonsillitis or
granular pharyngitis.
3. Persistent laryngitis and tracheobronchitis. Sinusitis
may be associated with recurrent laryngitis, bronchiectasis and asthma but the latter are not necessarily
caused by sinusitis.
treatment. It consists of i.v. antibiotics and attention
to the focus of infection, drainage of infected ethmoid or
sphenoid sinus. Blood culture should be taken before starting antibiotic therapy. Role of anticoagulants is not clear.
IV. DESCENDING INFECTIONS
In suppurative sinusitis, discharge constantly flows into
the pharynx and can cause or aggravate:
V. FOCAL INFECTIONS
The role of sinus infection to act as focus of infection is
doubtful. A few conditions such as polyarthritis, tenosynovitis, fibrositis and certain skin diseases may respond to
elimination of infection in the sinuses. However, sinus
infection, if present in these cases, is treated on its own
merit.
Chapter 39
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Benign and Malignant Neoplasms
of Nasal Cavity
Both benign and malignant tumours of the nasal cavity
(Table 39.1) per se are uncommon. Very often their sepa-
ration from tumours of paranasal sinuses is difficult except in early stages. In addition to primary tumours, nasal
cavity can be invaded by growths from paranasal sinuses,
nasopharynx, cranial or buccal cavity.
Benign lesions are usually smooth, localized and covered with mucous membrane. Malignant ones are usually
friable, have a granular surface and tend to bleed easily.
BENIGN NEOPLASMS
1. squamous papilloma. Verrucous lesions similar to
skin warts can arise from the nasal vestibule or lower part
of nasal septum. They may be single or multiple, pedunculated or sessile (Figure 39.1). Treatment is local excision
with cauterization of the base to prevent recurrence. They
can also be treated by cryosurgery or laser.
2. inVerted papilloma (transitional cell papil-
loma or ringertZ tumour or schneiderian pap-
illoma). It is a tumour of the nonolfactory mucosa of
nose (Schneiderian membrane) and paranasal sinuses.
Most common site of origin is lateral wall of nose in the
middle meatus; less commonly it arises from the maxillary, frontal or sphenoid sinus (Figures 39.2 and 39.3).
It is so named because hyperplastic papillomatous tissue
grows into the stroma rather than in exophytic manner
(Figure 39.4). Human papilloma virus is thought to be
responsible for its aetiology. Clinically, men are affected
more than women in the age group of 40–70. It is almost
always unilateral and presents with nasal obstruction,
nasal discharge and epistaxis. It can invade sinuses or
orbit. Orbital involvement causes proptosis, diplopia and
lacrimation.
On examination of nose or endoscopy, it presents as a
pale polypoidal mass resembling a simple nasal polypus
or polypi.
Computed tomography (CT) and magnetic resonance
imaging (MRI) show the location and extent of the lesion. MRI also helps to differentiate associated secretions
in sinus from the actual tumour mass. Biopsy is essential
for diagnosis.
Care should be taken as simple nasal polypi may be
associated with it or even the patient might have been
operated for their removal.
Treatment. Medial maxillectomy is the treatment
of choice. It can be performed by lateral rhinotomy or
sublabial degloving approach. These days endoscopic
approach is preferred. In 10–15% of cases, it is associated
with malignancy.
Wider external surgical approaches may be required
for tumour extending to the frontal sinus or orbit. Recurrence can occur. Radiotherapy is not advised as it may
induce malignancy.
3. pleomorphic Adenoma. Rare tumour, usually arises
from the nasal septum. Treatment is wide surgical excision.
4. schwannoma. Schwannoma is an uncommon benign
tumour arising from the nose or paranasal sinuses. The
latter include ethmoid, maxillary and sphenoid sinuses.
It arises from the Schwann cells of nerve sheath.
Clinically it presents a rounded mass, firm in consistency, yellowish in colour and may show blood vessels
running on its surface. It can cause pressure necrosis of
TABLE 39.1 TUMOURS OF NASAL CAVITY
Benign Malignant
• Squamouspapilloma
• Invertedpapilloma
• Pleomorphicadenoma
• Schwannoma
• Meningioma
• Haemangioma
• Chondroma
• Angiobroma
• Encephalocele
• Glioma
• Dermoid
Figure 39.1. Squamous papilloma nose, left side.
• Carcinoma
• Squamous cell carcinoma
• Adenocarcinoma
• Malignantmelanoma
• Esthesioneuroblastoma
• Haemangiopericytoma
• Lymphoma
• Solitaryplasmacytoma
• Varioustypesofsarcoma
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SECTION II — Diseases of Nose and Paranasal Sinuses
the surrounding bones. Imaging techniques, CT and MRI,
are useful to show the extent. Diagnosis is made on biopsy. Treatment is surgical excision. They can be removed
by endoscopic surgery or by external approaches.
5. meningioma. It is an uncommon tumour found intranasally. Treatment is surgical excision by lateral rhinotomy.
6. haemangioma. It may be:
(a) Capillary haemangioma (bleeding polypus of the sep-
tum). It is a soft, dark red, pedunculated or sessile tumour arising from the anterior part of nasal septum
(Figure 39.5). Usually it is smooth but may become
ulcerated and present with recurrent epistaxis and nasal obstruction. Treatment is local excision with a cuff
of surrounding mucoperichondrium.
(b) Cavernous haemangioma. It arises from the turbi-
nates on the lateral wall of nose. It is treated by
surgical excision with preliminary cryotherapy.
Extensive lesions may require radiotherapy and surgical excision.
7. chondroma. It can arise from the ethmoid, nasal cavity or nasal septum. Pure chondromas are smooth, firm
and lobulated. Others may be mixed type fibro-, osteoor angiochondromas. Treatment is surgical excision. For
recurrent or large tumours, wide excision should be done
because of their tendency to malignant transformation
after repeated interference.
8. angioFibroma. It is included in nasal tumours because its primary site of origin is supposed to be posterior
part of nasal cavity near the sphenopalatine foramen (see
p. 279).
9. intranasal meningoencephalocele. It is herniation of brain tissues and meninges through foramen caecum or cribriform plate. It presents as a smooth polyp in
Figure 39.3. An inverted papilla masquerading as a simple polyp.
Figure 39.2. (A) Inverted papilloma in a 79-year-old male (right side). (B) CT scan of the same.
Figure 39.4. A histological section of a Schneiderian papilloma
showing ribbons of thickened epithelial proliferations growing downwards into the stroma (H&E, ×40).
Chapter 39 — Benign and Malignant Neoplasms of Nasal Cavity
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Figure 39.5. A bleeding polypus arising from the right side of the
nasal septum.
the upper part of nose between the septum and middle
turbinate, usually in infants and young children. The
mass increases in size on crying or straining. Unless
care is taken, it may be misdiagnosed as a simple polyp
and mistakenly avulsed, resulting in cerebrospinal fluid
rhinorrhoea or meningitis. For the same reason biopsy
should not be taken. CT scan is essential to demonstrate
a defect in the base of skull. Treatment is frontal craniotomy, severing the stalk from the brain, and repair of dural
and bony defect. Intranasal mass is removed as secondary
procedure after cranial defect has sealed (endoscopic).
10. gliomas. Of all the gliomas, 60% are extranasal,
30% are intranasal and 10% both intra and extranasal.
They are seen in infants and children. An intranasal glioma presents as a firm polyp sometimes protruding at the
anterior nares.
11. nasal dermoid. It presents as widening of upper
part of nasal septum with splaying of nasal bones and
hypertelorism. A pit or a sinus may be seen in the midline
of nasal dorsum with hair protruding from the opening.
MALIGNANT NEOPLASMS
1. carcinoma oF nasal caVity. Primary carcinoma per
se is rare. It may be an extension of maxillary or ethmoid
carcinoma. Squamous cell variety is the most common,
seen in about 80% of cases. Rest may be adenoid cystic
carcinoma or an adenocarcinoma.
(a) Squamous cell carcinoma. It may arise from the vesti-
bule, anterior part of nasal septum or the lateral wall
of nasal cavity. Most of them are seen in men past
50 years of age.
(i) Vestibular. It arises from the lateral wall of na-
sal vestibule and may extend into the columella,
nasal floor and upper lip with metastases to parotid nodes.
(ii) Septal. Mostly arises from mucocutaneous junc-
tion and causes burning and soreness in the nose.
It has often been termed “nose-picker’s cancer.”
Usually, it is of low-grade malignancy.
229
(iii) Lateral wall. This is the site most commonly in-
volved. Easily extends into ethmoid or maxillary
sinuses. Grossly, it presents as a polypoid mass
in the lateral wall of nose. Metastases are rare.
Treatment is combination of radiotherapy and
surgery.
(b) Adenocarcinoma and adenoid cystic carcinoma. They
arise from the glands of mucous membrane or minor
salivary glands and mostly involve upper part of the
lateral wall of nasal cavity.
2. malignant melanoma. Usually seen in persons about
50 years of age. Both sexes are equally affected. Grossly,
it presents as a slaty-grey or bluish-black polypoid mass.
Within the nasal cavity, most frequent site is anterior
part of nasal septum followed by middle and inferior turbinate. Amelanotic varieties are nonpigmented. Tumour
spreads by lymphatics and blood stream. Cervical nodal
metastases may be present at the time of initial examination. Treatment is wide surgical excision. Immunological
defences of the patient play a great role in the control of
this disease. Radiotherapy and chemotherapy suppress the
immune processes and are avoided. A 5-year survival rate
of 30% can be expected after wide surgical excision.
3. esthesioneuroblastoma (syn. olFactory neu-
roblastoma). Also called olfactory placode tumour
as it arises from the olfactory epithelium in the upper
third of nose. Bimodal peaks of incidence at 10–20 and
50–60 years are seen. Most common symptoms are unilateral nasal obstruction and epistaxis. When tumour
invades orbit and the surrounding structures, other
symptoms like proptosis, headache, epiphora, diplopia
and blurred vision can also arise. Lymph node metastases
in the neck can occur in 10–15%.
Intranasal or endoscopic examination of nose reveals
a friable cherry-red, polypoidal mass in the upper third of
nasal cavity. It is a vascular tumour and biopsy should not
be immediately attempted unless imaging studies have
been done.
High-resolution CT scan shows the extent of lesion. It
may show destruction or erosion of the cribriform plate
or orbital wall. MRI with enhancement will reveal extension into the orbit or intracranially.
Biopsy of tumour reveals true nature of the tumour.
It may be low grade with formation of pseudorosettes or
high grade with nuclear pleomorphism but no rosette
formation. It may require special staining to differentiate
from other tumours.
It should be differentiated from lymphoma, melanoma, plasmacytoma, rhabdomyosarcoma, undifferentiated
carcinoma and neuroendocrine carcinoma.
Treatment. Treatment protocols differ between institutions. They are:
(a) Craniofacial resection with adjuvant radiation.
(b) Preoperative radiation followed by craniofacial resection.
(c) Preoperative chemotherapy and radiation followed
by craniofacial resection for advanced lesions extending to orbit, cribriform plate and intracranially. Neck
nodes if present are also radiated.
Craniofacial resection is done by osteoplastic flap exposing the anterior cranial fossa while facial approach is
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Figure 39.6. Rhabdomyosarcoma of the nose in a 2.5-year-old male
child.
SECTION II — Diseases of Nose and Paranasal Sinuses
the capillaries. It is usually seen in the age group of 60–70
and presents with epistaxis. Brisk bleeding may occur on
biopsy. The tumour may be benign or malignant but it
cannot be distinguished histologically. Treatment is wide
surgical excision. Radiotherapy is used for inoperable or
recurrent lesions.
5. lymphoma. Rarely a non-Hodgkin lymphoma presents on the septum.
6. plasmacytoma. Solitary plasmacytoma without
generalized osseous disease may be seen in the nasal
cavity. It predominantly affects males over 40 years.
Treatment is by radiotherapy followed 3 months later
by surgery if total regression does not occur. Longterm follow-up is essential to exclude development of
multiple myeloma.
through lateral rhinotomy or midfacial degloving. Enblock removal of tumour can thus be accomplished. Defect in the base of skull is repaired by pericranial flap.
4. haemangiopericytoma. It is a rare tumour of vascular origin. It arises from the pericyte—a cell surrounding
7. sarcomas. Osteogenic sarcoma, chondrosarcoma,
rhabdomyosarcoma (Figure 39.6), angiosarcoma, malignant histiocytoma are other rare tumours affecting the
nose.
Chapter 40
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Neoplasms of Paranasal Sinuses
Paranasal sinuses may be affected by both benign and
malignant neoplasms but the latter are much more common.
BENIGN NEOPLASMS
1. osteomas. They are most commonly seen in the frontal
sinus followed in turn by those of ethmoid and maxillary
(Figure 40.1). They may remain asymptomatic, being discovered incidentally on X-rays (Figure 40.2). Treatment is
indicated when they become symptomatic, causing obstruction to the sinus ostium, formation of mucocele, pressure
symptoms due to their growth in the orbit, nose or cranium.
2. Fibrous dysplasia. In this condition, bone is replaced by fibrous tissue; mostly involves maxillary but
sometimes the ethmoid and frontal sinuses. Patient seeks
advice for disfigurement of the face, nasal obstruction and
displacement of the eye. Treatment is surgical resculpturing of the involved bone to achieve a good cosmetic and
functional result (Figure 40.3).
3. ossiFying Fibroma. Seen in young adults. The tumour can be shelled out easily.
4. ameloblastoma (adamantinoma). It is a locally
aggressive tumour that arises from the odontogenic tissue and
invades the maxillary sinus. Treatment is surgical excision.
Other rare tumours include inverted papilloma, meningi-
oma and haemangioma (see Chapter 39).
MALIGNANT NEOPLASMS
1. incidence. Cancer of nose and paranasal sinuses
constitutes 0.44% of all body cancers in India (0.57% in
males and 0.44% in females). Most frequently involved
are the maxillary sinuses followed in turn by ethmoids,
frontal and sphenoid.
2. aetiology. Cause of sinus malignancy is largely unknown. People working in hardwood furniture industry,
nickel refining, leather work and manufacture of mustard
gas have shown higher incidence of sinunasal cancer.
Cancer of the maxillary sinus is common in Bantus of
South Africa where locally made snuff is used, which is
found rich in nickel and chromium.
Workers of furniture industry develop adenocarcinoma of the ethmoids and upper nasal cavity, while those
engaged in nickel refining get squamous cell and anaplastic carcinoma.
Figure 40.1. A frontoethmoidal osteoma with invasion of the orbit
(arrow).
Figure 40.2. Osteoma right frontal sinus (arrow).
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SECTION II — Diseases of Nose and Paranasal Sinuses
Figure 40.3. Fibrous dysplasia of maxilla in a 13-year-old girl. (A) As seen externally. (B) After retraction of the lip.
3. histology. More than 80% of the malignant tumours
are of squamous cell variety. Rest are adenocarcinoma, adenoid cystic carcinoma, melanoma and various types of
sarcomas (Figures 40.4 and 40.5).
CARCINOMA OF MAXILLARY SINUS
It arises from the sinus lining and may remain silent for
a long time giving only vague symptoms of “sinusitis.” It
then spreads to destroy the bony confines of the maxillary sinus and invades the surrounding structures.
Clinical Features (Figure 40.6)
Disease is common in 40–60 age group with preponderance in males.
1. Early features of maxillary sinus malignancy are nasal
stuffiness, blood-stained nasal discharge, facial paraesthesias or pain and epiphora. These symptoms may be
missed or simply treated as sinusitis.
2. Late features will depend on the direction of spread
and extent of growth.
3. Medial spread to nasal cavity gives rise to nasal obstruc-
tion, discharge and epistaxis. It may also spread into
anterior and posterior ethmoid sinuses and that is
why most antral malignancies are antroethmoidal in
nature.
4. Anterior spread causes swelling of the cheek and later
invasion of the facial skin.
5. Inferior spread causes expansion of alveolus with
dental pain, loosening of teeth, poor fitting of dentures, ulceration of gingiva and swelling in the hard
palate.
6. Superior spread invades the orbit causing proptosis,
diplopia, ocular pain and epiphora.
7. Posterior spread is into pterygomaxillary fossa, ptery-
goid plates and the muscles causing trismus. Growth
may also spread to the nasopharynx, sphenoid sinus
and base of skull.
8. Intracranial spread can occur through ethmoids,
cribriform plate or foramen lacerum.
9. Lymphatic spread. Nodal metastases are uncom-
mon and occur only in the late stages of disease.
Figure 40.4. Photomicrograph showing adenocarcinoma having
glandular pattern with neoplastic epithelial cells lining them. The cells
contain intracytoplasmic mucin (black arrow) (H&E, x200).
Figure 40.5. Photomicrograph showing well-differentiated squamous cell carcinoma with pearl formation (H&E, x200).
Figure 40.6. Antroethmoidal carcinoma left side. Note (A) swelling of left cheek and (B) expansion of alveolus and palate.
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Submandibular and upper jugular nodes are enlarged.
Maxillary and ethmoid sinuses drain primarily into
retropharyngeal nodes, but these nodes are inaccessible to palpation.
10. Systemic metastases are rare. May be seen in the lungs
(most commonly) and occasionally in bone.
Chapter 40 — Neoplasms of Paranasal Sinuses
233
Diagnosis
1. Radiograph of sinuses. Opacity of the involved sinus
with expansion and destruction of the bony walls.
2. Computed tomography (CT) scan. If available, this is
the best noninvasive method to find the extent of disease. CT scan should be done both in axial and coronal
planes. It also helps in the staging of disease.
3. Biopsy. If growth presents in the nose or mouth, biop-
sy can be easily taken. In early cases, with suspicion of
malignancy, sinus should be explored by Caldwell–Luc
operation. Direct visualization of the site of tumour in
the sinus also helps in staging of the tumour.
Endoscopy of the nose and maxillary sinus will provide detailed examination. An accurate biopsy can also be
taken. This route is preferred to Caldwell-Luc approach.
Classification
There is no universally accepted classification for maxillary carcinoma.
1. Ohngren’s classification. An imaginary plane is
drawn, extending between medial canthus of eye and
the angle of mandible (Figure 40.7). Growths situated
above this plane (suprastructural) have a poorer prog-
nosis than those below it (intrastructural).
2. AJCC (American Joint Committee on Cancer) classi-
fication (Tables 40.1–40.3). AJCC classification is only
for squamous cell carcinoma and does not include
nonepithelial tumours of lymphoid tissue, soft tissue,
cartilage and bone. Histopathologically, squamous cell
carcinoma is further graded into:
(a) Well-differentiated,
(b) Moderately differentiated and
(c) Poorly differentiated.
In histopathology, note should also be made of vascu-
lar or perineural invasion.
Figure 40.7. Ohngren’s line extends from medial canthus of eye to
the angle of mandible. Growths anteroinferior to this plane (infrastructural) have a better prognosis than those posterosuperior to it (suprastructural).
3. Lederman’s classification (Figure 40.8). It uses two
horizontal lines of Sebileau; one passing through the
floors of orbits and the other through floors of antra,
thus dividing the area into:
(a) Suprastructure. Ethmoid, sphenoid and frontal
sinuses and the olfactory area of nose.
(b) Mesostructure. Maxillary sinus and the respiratory
part of nose.
(c) Infrastructure. Containing alveolar process. This
classification further uses vertical lines, extending down the medial walls of orbit to separate
ethmoid sinuses and nasal fossa from the maxillary sinuses.
The student may note here that suprastructure and in-
frastructure of Lederman’s classification is not the same as
in Ohngren’s classification.
Treatment
Histologically, nature of malignancy is important in deciding the line of treatment as is the location and extent
of disease.
Early cases with Stage I and II squamous cell carci-
nomas are treated with surgery (Figures 40.9 and 40.10)
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SECTION II — Diseases of Nose and Paranasal Sinuses
TABLE 40.1 TNM CLASSIFICATION AND STAGING SYSTEM OF CANCER OF MAXILLARY SINUS
Maxillary sinus
T
1
T
2
T
3
T
4a
T
4b
Regional lymph nodes (N)
N
x
N
0
N
1
N
2
N
2a
N
2b
N
2c
N
3
Distant metastasis (M)
M
x
M
0
M
1
Source: AJCC, Cancer Staging Manual, fifth ed. Chicago, 2002.
Tumour limited to maxillary sinus mucosa with no erosion or destruction of bone.
Tumour causing bone erosion or destruction including extension into the hard palate and/or middle nasal
meatus, except extension to posterior wall of maxillary sinus and pterygoid plates.
Tumour invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues,
floor or medial wall of orbit, pterygoid fossa and ethmoid sinuses.
Tumour invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform
plate, sphenoid or frontal sinuses.
Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other
than maxillary division of trigeminal nerve (V2), nasopharynx or clivus.
Regional lymph nodes cannot be assessed.
No regional lymph node metastasis.
Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension.
Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest
dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in
bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.
Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest
dimension.
Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension.
Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.
Metastasis in a lymph node, more than 6 cm in greatest dimension.
Distant metastasis cannot be assessed.
No distant metastasis.
Distant metastasis.
TABLE 40.2 STAGE GROUPING OF CANCER OF
MAXILLARY AND ETHMOID SINUSES
Stage I T1 N0 M
Stage II T2 N0 M
Stage III T3 N0 M0T1 or T2 or T3 with N1 M
Stage IV A T4 N0 M0T4 N1 M
Stage IV B Any T N2 M0Any T N3 M
Stage IV C Any T Any N M
Regional lymph nodes and distant metastasis. They are divided in the
usual manner into N0, N1, N2 & N3 (see p. 256) and M0, M1.
0
0
0
0
0
1
TABLE 40.3 CLASSIFICATION OF CANCER OF NASAL
CAVITY AND ETHMOID SINUSES (AJCC, 2002)
T
1
T
2
T
3
T
4a
T
4b
Tumour restricted to any one subsite, with or without
bony invasion
Tumour invading two subsites in a single region or
extending to involve an adjacent region within the
nasoethmoidal complex, with or without bony invasion
Tumour extends to invade the medial wall or floor of
the orbit, maxillary sinus, palate or cribriform plate
Tumour invades any of the following: anterior orbital
contents, skin of nose or cheek, minimal extension to
anterior cranial fossa, pterygoid plates, sphenoid or
frontal sinuses
Tumour invades any of the following: orbital apex,
dura, brain, middle cranial nerves other than (V2),
nasopharynx or clivus
or radiation with equal results. T3 and T4 lesions are
treated by combined modalities of radiation and surgery.
Radiation in such cases may be given preoperatively or
postoperatively. Preoperative dose of radiation is 5500
cGy. Similarly postoperative dose of radiation used is
Figure 40.8. Lederman’s classification.
5000–5500 cGy. Now three-dimensional conformal radiotherapy and intensity-modulated techniques of radiotherapy cover larger tumour volumes and help to reduce
side effects of radiation to optic nerves and lens by providing accurate and homogenous radiation dose.
Chemoradiation, i.e. chemotherapy and radiation
concomitantly has also been used for large and inoperable tumours by different workers with 5 year survival of
more than 60%. Intra-arterial infusion of 5-Fu or cisplatin
and 5-Fu with concomitant radiation has also been used
with good results in preference to deformities created by
extensive surgery associated with advanced malignancy.
Figure 40.9. Weber–Fergusson’s incision used in maxillectomy.
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Prognosis
Survival diminishes with the stage of tumour. Overall
5 year survival is about 40–50%. However, advances are
being made in the multimodal therapy with improved
techniques of radiation delivery with the hope to improve results and protect injury to lens and optic nerve.
Chapter 40 — Neoplasms of Paranasal Sinuses
3. Nodal involvement is not common. Upper nodes may
be involved.
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Treatment
CT scan is essential to know the extent of disease and
intracranial spread. In early cases, treatment is preoperative radiation, followed by lateral rhinotomy and total
ethmoidectomy. If cribriform plate is involved, anterior
cranial fossa is exposed by a neurosurgeon and total exenteration of the growth in one piece is accomplished by
what is called craniofacial resection.
Prognosis
Five-year-cure rate of about 30% can be expected.
ETHMOID SINUS MALIGNANCY
Ethmoid sinuses are often involved from extension of the
primary growth of the maxillary sinus. Primary growth of
ethmoid sinuses per se is not common.
Clinical Features
1. Early features include nasal obstruction, blood-stained
nasal discharge and retro-orbital pain.
2. Late features are broadening of the nasal root, lateral
displacement of eyeball and diplopia (Figure 40.11).
Extension through cribriform plate may cause men ingi tis.
Figure 40.11. Carcinoma ethmoid.
Figure 40.10. (A) Maxillectomy with orbital exenteration on the right side. (B) Same patient after rehabilitation with a maxillary prosthesis and
an artificial eye.
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