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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4416_Библиотеки_им_академика_М_И_Перельмана
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MISCELLANEOUS ENTITIES
ere are several tumors which are not classied in the WHO classication
of Sinonasal tumors but they are frequently encountered clinicoradiological
entities. ese common entities are covered in this section.
Juvenile Nasopharyngeal Angiobroma (JNA)
■ JNA for instance is classied under Benign nasopharyngeal tumors in
the WHO classication system.
■ It is characterized by high vascularity, locally aggressive behavior and
high recurrence rates.
■ Almost exclusively seen in males.
■ Age: Adolescence.
■ Site of origin: Sphenopalatine foramen with extension into sinonasal
cavity, pterygomaxillary fossa and intracranially with characteristic
pattern of spread (Flowchart 12.1).
■ e combination of clinical prole, radiological ndings and risk of
bleeding obviate the need for biopsy in majority of patients. However,
tumors with aggressive behavior and atypical patterns of spread mimic
malignant lesions and may require sampling.
■ Radkowski’s classication: is is used for staging of tumors and is
detailed in Chapter 13.
1
173Chapter 12 Benign Tumors of the Nose and Paranasal Sinuses: Imaging
Flowchart 12.1:PathwaysofspreadofJuvenilenasopharyngealangiobroma.
Section 3 Tumor and Tumor-like Conditions174
A
C
Figs. 12.14A to D: Juvenile nasopharyngeal angiobroma CECT (Stage III B).
• Intensely enhancing heterogeneous mass lesion centered near right sphenopalatine
foramenextendinginto,bilateralethmoids,posteriorchoanaandnasopharynx(asterisk)
• Laterallyextensionintothepterygomaxillaryssure(arrowheadinA)
• Superiorly,erosionoflesserwingandbodyofsphenoidandplanumsphenoidale(white
arrow in B)
• Posteriorlyerosionofpterygoidbaseandwideningofinferiororbitalssure(arrowinC)
andclivus(blackarrowinB).
• Inferiorlydestructionofhardpalate(arrowinD).
B
D
■ Imaging Findings.
■ CT Scans (Figs. 12.14A to D):
• Intensely enhancing homogenous/heterogeneous mass lesions centered
near the sphenopalatine foramen, posterior choana and nasopharynx
with characteristic lateral extension into the pterygo maxillary ssure.
• Initially tumor causes bone expansion and remodeling with typical mass
eect on the posterior wall of the maxillary sinus (antral bowing or the
Holman-Miller sign). e tumor demonstrates characteristic pattern
of spread through ssures and foramina. (Figs. 12.15A to D). However,
175Chapter 12 Benign Tumors of the Nose and Paranasal Sinuses: Imaging
A
C
Figs. 12.15A to D: Juvenile nasopharyngeal angiobroma MRI (Stage II C).
• Bowing of posterior antral wall (arrow in A)
• Wideningofinferiororbitalssure(arrowheadinB)
• IntermediateSIwithprominentowvoidsonT2WI(arrowinB)andhypointenseonT1WI
• Freediffusion(brightonADCmap-asteriskinD)withintensepostcontrastenhancement
(asterisk in C)
• Large,heterogeneousmassinnasalcavity,pterygopalatinefossaandinfratemporalfossa.
B
D
it is a locally invasive tumor and can display aggressive behavior with
bone erosion.
• Bone expansion is however seen far more frequently than erosive
destruction.
• Intracranial extension is usually extradural.
■ MRI (Figs. 12.15A to D):
• e tumor shows heterogeneous signal on T1 and T2 weighted images.
It is however predominantly T2 hyperintense.
• Flow voids are often seen within the lesion.
• ere is intense enhancement with contrast.
• On diusion weighted imaging, the lesion shows free diusion with
high ADC values (2.168 ± 0.270 × 10–3 mm2/s).10 is feature aids in
dierentiating the aggressive JNAs from other malignant entities.
Hemophilic Pseudotumor
■ Uncommon complication in patients of hemophilia A and B; and rarely
seen in those without hemophilia (in other bleeding diathesis).
■ Trauma may incite the lesion.
■ Consequence of recurrent hemorrhage into soft tissue/ bones resulting
in mass lesions.
Section 3 Tumor and Tumor-like Conditions176
A B
Figs. 12.16A and B: Hemophilic pseudotumor.
• Large soft tissue mass with erosion of anterior nasal septum (asterix in A)
• Mass is predominantly hyperdense on NCCT (arrow in B)
■ Due to their tendency to enlarge and cause bone erosions due to
increasing pressure, these can mimic a malignancy.
■ Osseous forms reported in pelvis, femur, tibia and soft tissue forms in
muscles. Rare in sinonasal cavity.
■ Appearance is of a lytic lesion with irregular contour, bone erosion or
sclerosis. May appear hyperdense on CT (Figs. 12.16A and B).
■ Soft tissue component on MRI reveals hemorrhage in various stages
and surrounding brous capsule.
■ Heterogeneous enhancement may be seen.
■ High index of suspicion required for diagnosis.
Fibro-osseous Lesions
■ Although not classied as a category in WHO classication, due to
variable genetic and etiological basis, these are frequently encountered
lesions in practice.
■ ese lesions are clubbed together due to several common clinical,
radiological and histological features.
■ Tumors of osseous origin that involve the SN cavity may arise from the
bony structures within the SN cavity or from adjacent structures, such as
the anterior or central skull base, and maxillary alveolus.
■ Included in this group are ossifying broma and brous dysplasia.
■ Common points: Lesions characterized by normal bone being replaced
by a cellular, broid, stroma which over time shows variable amount of
ossication/mineralization.
■ Seen in young patients.
■ Radiologically this is reected as mixed density lesions which are expansile
with variable amounts of brous stroma vs ossied components.
Fibrous Dysplasia (FD) (Figs. 17A and B)
■ Fibrous dysplasia is not a neoplastic disorder, but a benign disorder
involving multiple bones wherein the medulla is replaced by immature
brous tissue and eventually osseous tissue.
1
A B
Figs. 12.17A and B: Fibrous dysplasia.
• Expandedleftfrontalandsphenoidboneswithintactcontour
• Ground glass density (asterisk)
• Narrowingofleftopticcanal(arrow).
■ Craniofacial bones are a frequent site of involvement, may be part of the
polyostotic form.
■ Facial appearance referred to as ‘Leontiasis Ossea’.
■ Imaging Findings:
• Involved bone is expanded. Its margins with the adjoining bone are
ill-dened, i.e. it merges imperceptibly.
• Matrix may initially appear lucent, then assume a “cotton wool”
appearance and nally evolves into “ground glass” density.
• MRI: Intermediate signal on T1 weighted images , intermediate or
low signal intensity on T2 weighted images with signicant contrast
enhancement in brous tissues.
■ Critical Issues:
• Expansion of bone causes narrowing of drainage pathways and skull
base foramina.
• Complications, such as secondary infection and malignancies.
Ossifying Fibroma
■ Based on histology ossifying broma1 is divided into two major subtypes
(conventional OF and juvenile OF).
■ Juvenile type has a more aggressive behavior, are seen in younger
patients, are larger at presentation, have less mineralization and show
more bone erosion. e juvenile type also has a higher recurrence rate.
■ Imaging Findings:
• CT (Figs. 12.18A and B): Well-dened mixed density lesion with soft
tissue component, matrix mineralization and calcication along the
periphery. e amount of soft tissue vs mineralized matrix is variable.
• Expansile lesion, occasionally bone erosion seen.
177Chapter 12 Benign Tumors of the Nose and Paranasal Sinuses: Imaging
Section 3 Tumor and Tumor-like Conditions178
• MRI (Figs. 12.19A to C): e soft tissue component of the lesion shows
heterogeneous enhancement, while the mineralized matrix/rim appear
as signal voids.
A B
Figs. 12.18A and B: Ossifying broma CT.
• Large well-dened heterogeneously enhancing expansile mass lesion nasal cavity and
bilateralmaxilla
• Mixeddensitylesionwithfewinternalbonytrabeculae(asterisksinAandB)
• Thinningofbonymarginswitherosionatplaces(arrowinB).
A B
Figs. 12.19A to C: Ossifying broma
MRI.
• Large well-dened heterogeneously
• Mixed signal intensity
• Osseous area: Hypointense on T1
• Fibrous tissue: Intermediate on T1
• Cystic area: Hyperintense on T2 and
C
enhan cing expansile mass lesion
nasalcavityandbilateralmaxilla
(A) and T2 (B) (arrows in A and B)
and T2 (asterisks in A and B)
nonenhancing(arrowheadinC).
■ e ethmoidal OFs can result in secondary mucocele of the frontal
sinuses (also see Chapter 5).
are described in Table 12.1 and illustrated in Figures 12.20A to D.
Table 12.1. Key dierentiating features between ossifying
broma and brous dysplasia.
Ossifying broma Fibrous dysplasia
• Classiedasabenigntumor • Classiedasadysplasia,hencenota
neoplasm
• Increases in size • Growthstopsafterpuberty
• Complete removal advocated
• High recurrence rate in case of
complete removal
• Biopsy required • Imagingsufcientfordiagnosis
CT:
• Expansile mass with loss of normal
shape/contourofboneoftenseenas
a soft tissue mass
• Mixedsofttissuewithbonedensity,
thickbonywallsmaybeseen
• Sharplydenedmargins(vs
osteosarcoma/chondrosarcoma)
• Contrast: Mild enhancement
MRI:
• T1WI
• Osseous area: Hypointense
• Fibrousarea:Intermediateintense
• T2WI: Osseous area—Hypointense
(profound)
• Fibroustissue:Hypointense
• CEMR:Fibrousareaenhance
• “Waitandwatch”policyadoptedwith
surgeryonlyforreliefofspecicpressure
symptoms
CT:
• Boneexpandedbutbasicshapeand
contour intact
• Characteristic ground glass appearance
• Maybedened/mergeintosurrounding
tissue
MRI:
• Similar signal characteristics depending
ondegreeofossication
179Chapter 12 Benign Tumors of the Nose and Paranasal Sinuses: Imaging
suggest a secondary ABC
HPE:
• COF:Fibrous+Mineralizedtissue
• Sharp margin from healthy tissue
• Mineralizationpatternvariable
HPE:
• Ill-dened
• Homogenous
Section 3 Tumor and Tumor-like Conditions180
A
C
Figs. 12.20A to D: Ossifying broma (OF) (A and C) versus brous dysplasia (FD) (B
and D).
• ExpansilemassinOF;BoneexpandedwithintactcontourinFD
• MixedsofttissuewithbonedensityinOF;GroundglassappearanceinFD
• BonymargininOF;MarginmergingwithsurroundingtissueinFD.
B
D
CONCLUSION
Most benign sinonasal tumors show bone expansion and remodelling,
several can show aggressive behaviour simulating malignant masses. e
approach to sinonasal masses is detailed in Chapter 28.
REFERENCES
1. Sen S, Chandra A, Mukhopadhyay S, et al. Sinonasal tumors computed
tomography and MR imaging features. Neuroimag Clin N Am. 2015;25: 595-618.
2. Krouse JH. Development of a staging system for inverted papilloma. Laryngoscope. 2000;110(6): 965-8.
3. Lombardi D, Tomenzoli D, Butta L, et al. Limitations and complications of
endoscopic surgery for treatment for sinonasal inverted papilloma: a reassessment after 212 cases. Head Neck. 2011;33(8):1154-61.
4. Whyte A, Chapeikin G. Opaque maxillary antrum: a pictorial review. Australasian
Radiology. 2005:49;203-13.
5. Desai SV, Spinazzi EF, Fang CH, et al. Sinonasal and ventral skull base inammatory pseudotumor: a systematic review. Laryngoscope. 2015;125(4):813-21.
6. Chihani M, Aljalil A, Touati M, et al. Glomangiopericytoma: an uncommon
sinonasal perivascular tumor with particular characteristics. Egyptian J Ear,
Nose, roat, Allied Sciences. 2011;12(3):167-70.
7. Jung WS, Yoo CY, Park Y-J, et al. Hemangioma of the maxillary sinus presenting
as a mass: CT and MR features. Iran J Radiol. 2015;12(2):e6923.
8. Dubey RB, Tara NP, Desai SM. Giant cell tumor of sinonasal cavity an uncommon
location for a common bone tumor. Indian J Radiol Imaging. 2003;13:13-14.
9. Sidani CA, Karam AR, Bruce JH, et al. Osteoblastoma of the frontal sinuses
presenting with headache and blurred vision: case report and review of the
literature. Radiology Case. 2010;4(6):1-7.
10. Das A, Bhalla As, sharma R, et al. Can diusion weighted imaging aid in dierentiating benign from malignant sinonasal masses: a useful adjunct. Pol J Radiol.
2017;82:345-55.
181Chapter 12 Benign Tumors of the Nose and Paranasal Sinuses: Imaging
13
CHAPTER
Benign Sinonasal Tumors:
Surgical Perspective
Chirom Amit Singh, Suresh C Sharma
• Introduction
• Clinical Presentation
• Investigations
– Radiology
– Biopsy
• Preoperative Workup
– Workup for Fitness for General
Anesthesia
– Ophthalmology Evaluation
• Treatment
– Surgery
– Medical Treatment
– Wait and Watch Policy
• Approaches for Surgery
– Open Approach
▪ Lateral Rhinotomy Incision
▪ Weber-Fergusson Incision
▪ Lynch Incision
– Midfacial Degloving Approach
– Transpalatal Approach
– Endoscopic Sinus Surgery
• SpecicTumorManagement
Considerations
– Inverted Papilloma
– Fibro-osseous Tumors
– Juvenile Nasopharyngeal
Angiobroma
INTRODUCTION
World Health Organization classies the sinonasal tumors into benign and
malignant epithelial tumors, soft tissue tumors, tumors of bone and cartilage,
hematolymphoid tumors, neuroectodermal and germ cell tumors. Out of
these, hematolymphoid and neuroectodermal tumors do not have any benign
entity. Mature teratomas of the sinonasal cavity are rare. is chapter will
discuss the commoner benign tumors of sinonasal cavity namely inverted papilloma, bro-osseous tumors and juvenile nasopharyngeal angiobroma.
CLINICAL PRESENTATION
Initially, when the tumors are conned to the nose and paranasal sinuses,
the patients may present with:
■ Nasal obstruction
■ Nasal discharge which may be blood stained
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