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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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213Chapter 16 Radiation and Chemotherapy in Management of Malignant Sinonasal Tumors
A
D
Figs. 16.1A to F: Comparative plan with photon beam intensity-modulated radiotherapy
(IMRT) and double scatter proton beam therapy for adjuvant radiation of a nasal
melanoma. The upper and lower panel shows photon IMRT and proton plan, respectively.
The target coverage is comparable with both techniques, but proton beam is capable of
excellent normal tissue sparing. The low dose isodose lines clearly separate from each other.
Courtesy: Rahul R Parikh, Rutgers Cancer Institute of New Jersey.
B
E
C
F
Complications and Sequelae of Treatment
■ Chemotherapy and radiation are potentially toxic and should be used
adequately and judiciously.
■ Potential complications of radiation are mainly divided into acute and
late radiation toxicity.
■ Common acute toxicities are radiation dermatitis, nasal, oropharyngeal,
laryngeal and esophageal mucositis; facial and nasal hair loss, loss of
eyebrow and eyelash, congestion of eye, dryness of mouth, dysphagia,
etc.
■ Most acute radiation toxicities are symptomatically managed and usually
start resolving weeks after radiation completion.
■ Potential long-term side eects are mainly cataract, neuropathy, damage
to optic structures, retinopathy, xerostomia, chronic dry eye syndrome,
permanent loss of hair and soft tissue injury.
■ Osteoradionecrosis (ORN), though not common with lower dose,
can occur with higher dose. Mandible is the most common site but
radionecrosis of other facial bones is also reported (Figs. 16.2A to D).
■ Temporal lobe necrosis when dose to temporal lobe is very high.
■ Both ORN and temporal lobe radionecrosis can pose challenge diagnostic
dilemma with recurrence.
■ Late sequelae are mostly dose and volume dependent and uncommon
with modern radiation techniques in high volume academic centers.
Section 3 Tumor and Tumor-like Conditions214
A
C
Figs. 16.2A to D: Osteoradionecrosis as a complication. (A and B) Axial bone window
images. Irregular lytic-sclerotic destruction of mandible (arrows). Associated soft tissue
(asterisks); (C) Sagittal bone window image (arrow); and (D) VRT image. Destruction of the
angle and body of mandible extending till the alveolar margin.
B
D
CONCLUSION
■ Sinonasal tumors are uncommon.
■ Most present with advanced disease.
■ Outcome is modest even with aggressive therapy.
■ Surgical resection with adjuvant radiation and/or chemotherapy is
standard for most tumors.
■ Survival outcome has not changed signicantly over the years; however,
treatment related toxicity has been reduced providing better quality of
life.
■ Intensity-modulated radiotherapy should be the standard of care for
radiation to sinonasal tumors.
■ New modalities like proton beam therapy has provided hope to better
tumor control and survival.
REFERENCES
1. Ang KK, Jiang GL, Frankenthaler RA, et al. Carcinomas of the nasal cavity.
Radiother Oncol. 1992;24:163-8.
2. Le QT, Fu KK, Kaplan MJ, et al. Lymph node metastasis in maxillary sinus
carcinoma. Int J Radiat Oncol Biol Phys. 2000;46:541-9.
3. Corry J, Peters LJ, Costa ID, et al. e ‘QUAD SHOT’—a phase II study of
palliative radiotherapy for incurable head and neck cancer. Radiother Oncol.
2005;77(2):137-42.
4. Robin TP, Jones BL, Gordon OM, et al. A comprehensive comparative analysis of
treatment modalities for sinonasal malignancies. Cancer. 2017;123(16):3040-9.
5. Dirix P, Vanstraelen B, Jorissen M, et al. Intensity-modulated radiotherapy for
sinonasal cancer: improved outcome compared to conventional radiotherapy.
Int J Radiat Oncol Biol Phys. 2010;78(4):998-1004.
6. Hoppe BS, Stegman LD, Zelefsky MJ, et al. Treatment of nasal cavity and paranasal sinus cancer with modern radiotherapy techniques in the postoperative
setting—the MSKCC experience. Int J Radiat Oncol Biol Phys. 2007;67(3):
691-702.
215Chapter 16 Radiation and Chemotherapy in Management of Malignant Sinonasal Tumors
Section
Trauma
17. Imaging in Sinonasal Trauma
18. Imaging of Cerebrospinal Fluid Leaks
19. Sinonasal Trauma and Cerebrospinal Fluid
Rhinorrhea: Surgical Aspects
4
17
CHAPTER
Imaging in Sinonasal Trauma
Manisha Jana, Ashu Seith Bhalla
• Introduction
• Classication, Anatomy
– Key Concepts of Maxillofacial
Trauma
• Specic Fractures
– Complex Facial Injuries
▪ Le Fort Fractures
– Other Complex Fractures
▪ Naso-orbitoethmoid Complex
Fractures
▪ Zygomaticomaxillary Complex
Fractures
– Fractures Involving Single Bone
or Single Buttress
▪ Frontal Sinus Fractures
▪ Nasal Bone Fractures
▪ Maxillary Sinus Fractures
▪ Orbital Blowout Fractures
• Complications of Sinus Fractures
• Illustrative Case in a Reporting
Format
INTRODUCTION
■ Maxillofacial trauma encompasses a wide range of complex injuries.
is chapter connes itself to those involving the sinonasal structures.
■ Facial fractures may occur following blunt or penetrating trauma.
■ Multidetector computed tomography is the modality of choice for
delineating the complete extent of injury as well as the associated
complications. It has currently replaced plain radiographs in this setting.
CLASSIFICATION, ANATOMY
Key Concepts of Maxillofacial Trauma
Classication is based on the concept of buttresses or pillars (Tables 17.1
and 17.2) which constitute the basic support of the facial form. is concept
governs the surgical reconstruction. ese buttresses are there both in
horizontal and vertical planes.
1,2
Section 4 Trauma220
Table 17.1: Horizontal buttresses (Figs. 17.1A and B).
Upper transverse maxillary buttress Nasofrontal suture > along inferior margin of
orbit > zygomatic bone > zygomaticotemporal
sutures > continues posteriorly as the oor of
orbit
Lower transverse maxillary buttress Runs along the maxillary alveolar process
extending posteriorly to hard palate
Upper transverse mandibular buttress Mandibular alveolar process > ramus> posterior
margin
Lower transverse mandibular buttress Inferior mandibular margin
A B
Figs. 17.1A and B: Horizontal buttresses. (1: Upper transverse maxillary buttress; 2: Lower
transverse maxillary buttress; 3: Upper transverse mandibular buttress; 4: Lower transverse
mandibular buttress).
Table 17.2: Vertical buttresses (Figs. 17.2A and B).
Medial maxillary buttress Nasofrontal suture > lateral border of pyriform aperture
> maxillary alveolar process > extends posteriorly including
medial walls of orbit and maxillary sinus
Lateral maxillary buttress Zygomaticofrontal suture> along lateral wall of orbit > body
of zygomatic bone > maxillary alveolar process near the
alveolus > extends posteriorly along lateral walls of orbit and
maxillary sinus
Posterior maxillary buttress Pterygoid plates > connects skull base (sphenoid) to maxilla
221Chapter 17 Imaging in Sinonasal Trauma
A
B
Figs. 17.2A and B: Vertical buttresses. (1: Medial maxillary buttress; 2: Lateral maxillary
buttress; 3: Posterior maxillary buttress).
SPECIFIC FRACTURES
Sinonasal fractures may be part of more complex facial fractures involving
multiple buttresses (Le Fort fractures); or occur as less severe isolated injuries.
Complex Facial Injuries
Complex facial injuries include Le Fort fractures, nasoorbitoethmoid (NOE)
fractures, and zygomaticomaxillary complex fractures.
Le Fort Fractures (Table 17.3 and Figs. 17.3 to 17.8)
■ ese are complex maxillofacial fractures involving multiple facial bones,
and often occur as a consequence of high impact force on the midface.
■ A combination of dierent types may be seen on two sides of the face
(Figs 17.7 and 17.8).
Section 4 Trauma222
Table 17.3: Types of Le Fort fractures (Figs. 17.3 to 17.8).
Type 1/Guerin
fracture
Floating plate
(Fig. 17.4)
Type 2/Pyramidal
(Fig. 17.5)
Type 3/
Crani ofacial
dissociation
(Fig. 17.6)
Horizontal fracture
Inferior maxillary buttress
(hard palate) separated
from rest of the face and
skull base
Maxillary fragment
pyramidal in shape with
apex at nasofrontal suture
May move independent of
rest of face
Complete separation of
face from skull base
Maxillary sinus wall
(anterior, medial and
lateral)
Pyriform aperture
Nasal septum
Pterygoid plates
Medial orbital wall
Floor of orbit
Zygomaticomaxillary
suture
Zygomatic bone
spared
Nasofrontal suture
> medial orbital wall
> lateral orbital wall
> zygomatic bone
Only type to involve
lateral orbital wall and
zygomatic bone
• Coronal
• 3D images
• Axial
• Coronal
oblique
• Axial
• Coronal
Fig. 17.3: Types of Le Fort fractures.
A B
Figs. 17.4A and B: Le Fort type 1 fracture. Fracture line through inferior maxillary buttresses
(arrows) and hemosinus (asterisk).
223Chapter 17 Imaging in Sinonasal Trauma
A B
Figs. 17.5A and B: Le Fort type 2 fracture. (A) Fracture line through inferior orbital rim (arrow),
(B) lateral maxillary wall (arrowhead) and anterior maxillary wall (block arrow).
A B
Figs. 17.6A and B: Le Fort type 3 fracture. Fracture line through lateral orbital wall (arrows),
and the zygomatic bone (block arrow).
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