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■ Hyposmia or anosmia
■ Headache.
Subsequently, these tumors may progress and extend to the surrounding
structures:
■ Extension to orbit or compression of optic nerve causing proptosis,
diplopia and decrease in vision.
■ Extension to pterygopalatine fossa or infratemporal fossa causing cheek
swelling and rarely trismus.
■ Extension to palate causing palatal swelling.
■ Often extension to anterior cranial fossa and cavernous sinus remain
asymptomatic.
INVESTIGATIONS
Radiology
Once clinical examination reveals a mass in the nasal cavity or suspicious
to have a mass lesion in paranasal sinus, these patients are subjected to
imaging to evaluate the characteristic of the tumor and extent of the tumor.
Radiological characteristics of dierent sinonasal tumors are discussed
separately in the radiology chapter.
Biopsy
183Chapter 13 Benign Sinonasal Tumors: Surgical Perspective
Denitive diagnosis is made from histopathological examination of the
biopsy specimen of the tumor. Imaging helps in guiding about decision of
biopsy and the site from which the biopsy has to be taken. As for example
biopsy is contraindicated in vascular lesion like juvenile nasopharyngeal
angiobroma where the diagnosis is mainly based on clinico-radiological
ndings.
PREOPERATIVE WORKUP
Workup for Fitness for General Anesthesia
ese include routine hemogram, blood sugar level, liver function test,
kidney function test, electrocardiography and chest X-ray.
Ophthalmology Evaluation
is is important for:
■ Patients who have visual complaints
■ Patients with tumors extending into orbit or optic canal without visual
complaints.
Ophthalmology evaluation should include:
■ Visual acuity
■ Field of vision
■ Fundus.
Section 3 Tumor and Tumor-like Conditions184
TREATMENT
Surgery
■ Surgery is the mainstay of treatment for all benign sinonasal tumors.
■ Goal of surgery is complete excision of the tumor.
Medical Treatment
is will be discussed later under specic tumors.
Wait and Watch Policy
is is suitable for only those asymptomatic, very slow-growing benign
tumors, e.g. asymptomatic frontal osteoma.
APPROACHES FOR SURGERY
Open Approach
Lateral Rhinotomy Incision (Fig. 13.1a)
■ Provides wide exposure of the nasal cavity, maxillary antrum, ethmoid
sinuses and sphenoid sinus.
■ Can be used for excision of benign tumors involving nasal cavity, medial
aspect of maxillary sinus, ethmoid sinus and sphenoid sinus.
■ is incision has also been used as an approach for medial maxillectomy
which is the main surgery for inverted papilloma. Medial maxillectomy
requires removal of medial part of maxilla medial to inferior orbital
foramen, inferior turbinate and infero-medial wall of orbit.
Weber-Ferguson Incision (Fig. 13.1b)
■ Provides complete exposure of the maxilla from inferior orbit to superior
alveolus.
■ is incision has been classically used for total maxillectomy.
Lynch Incision (Fig. 13.1c)
■ Provides good exposure for frontal sinus and ethmoid sinus.
■ is incision is mainly used for frontoethmoidectomy.
Midfacial Degloving Approach
■ Main advantage of this approach is avoidance of facial incision.
■ Approach is from bilateral sublabial area and requires sublabial incision
from 1st molar of one side to 1st molar of other side and intranasal
incisions.
■ Provides good exposure to nasal cavity, inferior part of maxillary sinuses,
ethmoid and sphenoid sinuses.
Transpalatal Approach (Fig. 13.2)
■ Provides adequate exposure for posterior part of nasal cavity and to some
extent pterygopalatine fossa.
185Chapter 13 Benign Sinonasal Tumors: Surgical Perspective
Fig. 13.1: (a) Lateral rhinotomy incision; (b)
Weber-Ferguson incision; (c) Lynch incision.
Fig. 13.2: Incision for transpalatine approach.
■ is approach has been mainly used for juvenile nasopharyngeal angiobroma conned to nasal cavity, sphenoid sinus and pterygopalatine
fossa.
■ Main advantage here also is avoidance of facial scar.
Endoscopic Sinus Surgery
■ Endonasal endoscopic approach can provide excellent exposure
essentially to all parts of nasal cavity and paranasal sinuses with good
magnied view except lateral part of frontal sinus and anterior maxillary
sinus.
■ It can also be used to approach pterygopalatine fossa and infratemporal
fossa.
SPECIFIC TUMOR MANAGEMENT CONSIDERATIONS
Inverted Papilloma
■ Site of origin of inverted papilloma is important as it helps in deciding
the approach of surgery. e following are the sites of origin of inverted
papilloma:
• Lateral nasal wall (82%)
• Maxillary sinus (53.9%)
• Ethmoid sinus (31.6%)
• Nasal septum (9.9%)
• Frontal sinus (6.5%)
• Sphenoid sinus (3.9%).
1
Section 3 Tumor and Tumor-like Conditions186
■ Recurrence rate as per dierent approaches are as follows:
1
• Intranasal (without endoscopy): 67.3%
• Conservative (Caldwell-Luc, external ethmoidectomy procedures):
44%
• Aggressive (lateral rhinotomy, midface degloving, maxillectomy): 18%
• Endoscopic and extended endoscopic approach: 11.8%.
■ Contraindications of endoscopic approach are:
• Massive involvement of frontal sinus mucosa or supraorbital cells
• Intradural or transorbital extension
• Concomitant presence of malignancy
• Presence of excessive scar tissue from previous surgery.
Fibro-osseous Tumors
■ Fibrous dysplasia usually stabilizes over time and has low malignancy
potential.
■ Management of brous dysplasia is mainly conservative and surgery is
indicated for:
• Symptomatic disease: Optic nerve decompression for tumors
compressing the optic nerve, partial excision of intranasal mass to
restore nasal patency.
• Cosmetic recontouring surgery, which can be achieved by partial
excision of the tumor.
■ Bisphosphonate, e.g. pamidronate has been used in brous dysplasia
and found to decrease bone pain and stimulate remineralization of
osteolytic area.
■ Out of total, 95% of sinonasal osteoma is found in frontoethmoidal region
■ Indication for surgery in osteomas are:
3
• Rapid growth
• Obstructive sinusitis or mucocele
• Compression of vital structures
• Severe pain or headache
• Facial deformity.
■ Ossifying broma is the most aggressive form of bro-osseous lesion
with high recurrence rate and treatment should be complete excision of
the tumor.
Juvenile Nasopharyngeal Angiobroma
■ Radkowski staging (Table 13.1).
■ Preoperative angiography helps in providing the information of blood
supply to the tumor, i.e. whether the tumor is receiving blood supply only
from external carotid artery branches or from both internal and external
carotid artery systems. Preoperative embolization signicantly decreases
blood loss during tumor resection.
■ Surgery is the mainstay of treatment.
4
2
Table 13.1: Radkowski staging.
Stage Tumor extent
IA Limited to nose and nasopharyngeal area
IB Extension into one or more sinuses
IIA Extension into one or more sinuses
IIB Full occupation of the pterygopalatine fossa with or without orbital erosion
IIC Infratemporal fossa extension with or without cheek or pterygoid plate
involvement
IIIA Erosion of the skull base (middle cranial fossa or pterygoids)
IIIB Erosion of skull base with intracranial extension with or without cavernous sinus
involvement
■ Endoscopic approaches are more suitable for early stage tumors (IA, IB,
IIA, IIB, and some types of IIC).
■ External approaches are more preferable for larger tumors (IIC, IIIA, IIIB).
■ Radiation therapy is mainly reserved for unresectable tumor. For
example, tumor encasing internal carotid artery and massive intracranial
extension. It can provide local control rate of 85–91%.
5
■ Preoperative antiandrogen treatment with utamide have been shown
to provide partial tumor regression especially in postpubertal patient.
6
187Chapter 13 Benign Sinonasal Tumors: Surgical Perspective
REFERENCES
1. Krouse JH. Endoscopic treatment of inverted papilloma: safety and ecacy. Am
J Otolaryngol. 2001;22(2):87-99.
2. Sayan NB, Ucok C, Karasu HA, et al. Peripheral osteoma of the oral and maxillofacial
region: a study of 35 new cases. J Oral Maxillofac Surg. 2002;60(11):1299-301.
3. Eller R, Sillers M. Common bro-osseous lesions of the paranasal sinuses.
Otolaryngol Clin North Am. 2006;39(3):585-600.
4. Radkowski D, McGill T, Healy GB, et al. Angiobroma. Changes in staging and
treatment. Arch Otolaryngol Head Neck Surg. 1996;122:122-9.
5. Blount A, Riley KO, Woodworth BA. Juvenile nasopharyngeal angiobroma.
Otolaryngol Clin North Am. 2011;44(4):989-1004.
6. akar A, Gupta G, Bhalla AS, et al. Adjuvant therapy with utamide for
presurgical volume reduction in juvenile nasopharyngeal angiobroma. Head
Neck. 2011;33(12):1747-53.
14
CHAPTER
Malignant Tumors of
Sinonasal Cavities: Imaging
Mukesh Yadav, Devasenathipathy Kandasamy
• Introduction
• Epithelial Malignancies
– Squamous Cell Carcinoma
– Adenocarcinoma
– Adenoid Cystic Carcinoma
– Sinonasal Neuroendocrine
Carcinoma and Undifferentiated
Carcinoma
• Neuroectodermal Malignancies
– Melanoma
– Ewing’s Sarcoma Family of
Tumors
• Hematolymphoid Neoplasms
– Lymphoma
– B-Cell Type Lymphoma
– Plasma Cell Neoplasm
– Granulocytic Sarcoma or
Chloroma
• Tumors of Soft Tissue, Bone and
Cartilage
– Rhabdomyosarcoma
– Osteosarcoma
– Chondrosarcoma
• Metastasis
• Miscellaneous
INTRODUCTION
■ Sinonasal (SN) malignancies represent 3% of all the malignancies in
head and neck regions.
■ Within the SN tract, the malignant tumors are more common as
compared to benign tumors.
■ e recent most World Health Organization classication for these
malignant lesions has been discussed elsewhere in this book.
■ Occupational exposure of dust, etc. signicantly increases the risk of
developing malignancies in SN area, while other predisposing conditions
are previous radiation treatment, immunosuppression, etc.
■ In addition to the primary neoplastic lesions of SN tract, there are many
masses which have primary origin in the cranium or skull base or from
the maxillary alveolus (Figs. 14.1A and B).
1
A B
Figs. 14.1A and B: Carcinoma alveolus inltrating maxillary sinus. Mass lesion centered
over the left side maxillary alveolus causing destruction of oor (arrows in A and B) and
medial wall of left maxillary sinus and soft tissue extension into maxillary antrum and left side
nasal cavity. The epicenter of the mass lesion is in the left maxillary alveolus with secondary
invasion of maxillary antrum. Also noted are the steak artifacts in the region of oral cavity.
■ Sinonasal tumors need to be dierentiated from other masses like
inammatory or infective lesions, hyperparathyroidism or osteonecrosis.
■ Common malignancies in SN area are epithelial malignancies (squamous, adeno, neuroendocrine and undierentiated carcinoma), melanoma, Ewing sarcoma (ES) family of tumors, hematolymphoid tumors
(lymphoma, plasma cell neoplasm, granulocytic sarcoma), rhabdomyosarcoma (RMS), osteosarcoma, chondrosarcoma and metastases.
189Chapter 14 Malignant Tumors of Sinonasal Cavities: Imaging
EPITHELIAL MALIGNANCIES
Squamous Cell Carcinoma
■ Most common of these malignant lesions are seen in antrum followed by
nasal cavity, ethmoid complex, sphenoid and frontal sinus in that order.
■ Squamous cell carcinomas are the most common type of malignancy in
SN area (50–80%) with highest incidence in 6th and 7th decades.
■ Small tumors may be misdiagnosed as sinusitis and other inammatory
pathologies.
Imaging Features
■ Large mass lesion with soft tissue attenuation, frequent necrosis and
bone destruction showing heterogeneous enhancement (nonspecic
appearance on imaging) (Figs. 14.2 and 14.3).
Section 3 Tumor and Tumor-like Conditions190
A
C
Figs. 14.2A to D: Maxillary sinus carcinoma––different stages. Irregular mucosal
thickening and enhancement of the left side maxillary sinus (arrow in A). Also noted is the
bone destruction seen in the walls of sinus—T2 tumor. Mass lesion inltrating into right orbit
(arrow in B) with associated bone destruction––T3 tumor. Mass lesion causing destruction of
sphenoid sinus (arrow in C)––T4a tumor. Large mass lesion causing destruction of oor of
anterior cranial fossa with intracranial extension (arrow in D)—T4b tumor.
B
D
■ Because of anatomical separation, separate staging system exists for
maxillary sinus carcinomas and ethmoidal carcinomas which are
covered in Chapter 15.
■ On T2-weighted images, it shows intermediate signal intensity, with
more hyperintense areas represented by necrosis (Figs. 14.4A to C).
■ Diusion-weighted images (DWI) and contrast imaging help in
dierentiating the solid tumor part from the inspissated secretions in the
blocked sinus cavity.
■ Intracranial extension, intraorbital extension and perineural spread
should be particularly searched for on imaging.
■ Intracranial tumor extension is best evaluated with T1-weighted fat
suppressed postcontrast imaging with thin sections and small eld of
view (FOV).
A B
Figs. 14.3A to C: Nasopharyngeal carci-
noma. Heterogeneous mass lesion (arrows
in A to C) in nasopharynx and nasal cavity
causing extensive bone destruction of the
base of skull, all the paranasal sinuses and
nasal turbinates. There is extension into bilat-
C
eral orbits also.
191Chapter 14 Malignant Tumors of Sinonasal Cavities: Imaging
A
B
Figs. 14.4A to C: Squamous cell carcinoma
of maxillary sinus. Heterogeneous mass
lesion (arrows) involving the right maxillary
sinus, infrate mporal fossa and nasal cavity.
(A) Lesion is isointense on T1w image; (B
and C) hyper intense on T2w and showing
signicant diffu sion restriction on ADC
C
image––T4aN1M0––stage 4a.
Section 3 Tumor and Tumor-like Conditions192
■ Positron emission tomography (PET) has limited role in SN tract tumor
evaluation, e.g. for assessment of early regional or distant metastatic
lesion identication.
■ Low incidence of metastatic lymphadenopathy even if the tumor is quite
bulky (~15%).
■ Treatment may be surgery, irradiation or both with 5-year survival rate of
approximately 62%.
■ Curative surgery is not attempted, if there is involvement of central
skull base, nasopharynx, pterygopalatine fossa, or regional or distant
metastasis is present.
Adenocarcinoma
■ Intestinal variety—more common in elderly, males and more associated
with occupational exposure (ethmoid sinuses and nasal vault are more
common areas).
■ Nonintestinal variety—sporadic forms, more in females and commonly
aects maxillary sinus.
Imaging Features
■ Site—related to occupation—ethmoid sinus and nasal vault; in sporadic
form, maxillary sinus.
■ Nonspecic; large heterogeneous soft tissue with or without bone
erosion.
■ Has overlapping features with squamous cell carcinoma.
■ On T2-weighted (T2w) images, it shows intermediate signal intensity,
with necrotic areas showing hyperintensity.
■ Diusion-weighted imaging and contrast imaging help in dierentiating
solid tumor from inspissated secretions.
Adenoid Cystic Carcinoma
■ Within the salivary glands, adenoid cystic carcinomas are the most common.
■ Common in 5th decade with high recurrence rates (~60%) and prone to
develop delayed recurrence (long latent period).
■ Local recurrence is highest among SN malignancies.
■ Common sites are maxillary sinus followed by nasal cavity.
■ Polypoidal in appearance with bone remodeling more common than bone
destruction.
■ High signal on T2w images (Figs. 14.5A to C).
■ Perineural spread, submucosal as well as subperiosteal spread is
common.
■ Perineural involvement is usually contiguous along the nerve and
retrograde. Magnetic resonance imaging (MRI) is the modality of choice
to detect perineural spread and it is characterized by thickening and
irregularity of the involved nerve, abnormal enhancement compared to
the normal nerve, obliteration of perineural fat and widening of neural
foramina (Figs. 14.6A to D).
2
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