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314

S. Ganesan et al.

27.6 Revision Surgery

Despite the progress in the FESS techniques and the technological advances, 10–15% of the patients will undergo revision surgery [21, 69,

70]. Major complications after revision FESS

rate was 0.46% and was found to be similar to primary cases [1].

Take Home Messages

• The best management of complications is avoidance, and in order to avoid complications, surgeons should have good anatomical knowledge.

• Study preoperative imaging thoroughly.

• Training in hands-on cadaveric dissection courses.

• It is always safer to abort the procedure and plan elective second surgery if proper hemostasis cannot be achieved.

• Informed consent and documentation for medicolegal purpose.

• Remember learning curve.

• Know your limitations and call for help.

• The percentage of signicant complications between 0.3% and 22.4% (median

7.0%).

• The most common complication of sinus surgery is synechiae formation.

• The most common orbital complication of the endoscopic sinus surgery is a trauma of the lamina papyracea.

• Meningitis is the most frequent intracranial complication in paranasal sinus surgery.

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Neoplasms oftheSinonasal Cavity

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AndrewTassler, CharlesA.Riley, ChetanSa, andMichaelG.Stewart

Key Points

• Majority of malignant tumors of the sinonasal cavity come from the maxillary sinus (50–70%), followed by nasal cavity (15–30%), ethmoid cavity (10– 20%), and rarely the frontal and sphenoid sinuses.

• Nasal endoscopy and cross-sectional imaging to determine vascularity of lesions and invasion of vital structures such as orbit and brain.

• CT is helpful in determining bony erosion while MRI can assess for perineural spread, vascular anatomy, and dural invasion.

• Unilateral paranasal sinus disease and polyposis could be an indication of a neoplastic process.

• Squamous cell carcinoma is the most common paranasal sinus malignancy and accounts for approximately 75% of cases.

• Most sinonasal malignancies will require multimodality therapy.

A. Tassler · C. A. Riley · C. Sa · M. G. Stewart (*) Department of Otolaryngology—Head and Neck Surgery, Weill Cornell Medical College and NewYork-Presbyterian Hospital, New York, NY, USA e-mail: ant9025@med.cornell.edu;

mgs2002@med.cornell.edu

https://doi.org/10.1007/978-3-030-54088-3_28

28.1 Introduction

Though sinonasal neoplasms are not routinely encountered, the differential diagnosis for these lesions can be vast. Most sinonasal masses present with similar symptoms of nasal obstruction, epistaxis, nasal discharge, and/or facial pain. Additionally, due to limited anatomic real estate, both benign and malignant lesions can cause compressive effects leading to orbital and intracranial complications as well as possible regional cervical metastases. Diagnostic workup for each lesion will be slightly varied but ultimately will comprise of some combination of nasal endoscopy, CT, MRI, and/or biopsy via an endoscopic or image guided approach. Furthermore, treatment for these lesions will involve a combination of surgical therapy, chemotherapy, and or radiation therapy.

28.2 Sinonasal Cavity Tumor

1. Uncommon tumors with wide range of

2. Most common malignancy is squamous cell

Epidemiology

histopathology. (a) Congenital malformations to benign

tumors to high-grade malignancies.

carcinoma (SCCA). (a) Scca of sinonasal cavity is a rare malig-

nancy which occurs with the frequency of

317

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approximately 1:200,000 in the United States.

3. Malignant tumors of the sinonasal cavity represent less than 1% of all cancers, and about 3% of cancers of the upper aerodigestive tract.

4. Majority of malignant tumors of the sinonasal cavity come from the maxillary sinus (50– 70%), followed by nasal cavity (15–30%), ethmoid cavity (10–20%), and rarely the frontal and sphenoid sinuses.

28.3 History andPresentation

1. Causative factors (a) SCCA

• Nickel, aatoxin, mustard gas, hydrocarbons

• Fibers found in wood and textile industries

(b) Adenocarcinoma

• Woodworking, furniture making, leather- related occupational exposure

co-factor (d) Chronic infection/inammation (e) Previous radiation

2. History (a) Sinonasal tumors can be a diagnostic

challenge because they present with symptoms that mimic common inammatory sinonasal disease

(b) Results in delayed diagnosis and higher

stages at presentation

obstruction, nasal discharge, facial pain, congestion, epistaxis, smell disturbance, epiphora, hypesthesia, pain, aural fullness, hearing loss, otalgia, and neck swelling

3. Physical exam (a) Nasal cavity mass, midface and perior-

bital edema, proptosis, middle ear effusion, loose dentition, trismus, malocclusion, cranial nerve decits including CN I, II, III, IV, V1, V2, and VI

4. Nasal endoscopy (a) Evaluate extent of tumor (b) Determine origin/base

• Expansion of tumor suggests intracranial extension

5. Biopsy (a) Tumors may be biopsied during nasal

endoscopy, unless there is concern for intracranial extension or increased vascularity

(b) Consider diagnostic imaging such as

computed tomography (CT) or magnetic resonance imaging (MRI) prior to biopsy

• Evaluate for intracranial (i.e., encephalocele) or vascular lesions

operating room (OR)

• Allows frozen section conrmation of adequate specimen

• Controlled airway and facilitates control of bleeding

(d) Nodal disease warrants ne-needle aspi-

ration to assess for regional spread

28.4 Imaging

1. Computed tomography (a) Evaluate tumor involvement of paranasal

sinuses, bony skull base, and retro-orbital/

orbital apex region (b) CT denes bony invasion (c) CT does not dene soft tissue well (d) Malignant tumors cause bony destruction;

benign tumors cause tissue remodelling

and hyperostosis

2. Magnetic resonance imaging (a) Claries tumor versus inammatory

mucosa/secretions

• Tumor typically is bright on T1 and enhances with contrast

• Inammatory mucosa/secretions are bright on T2

(b) Assess for perineural spread (c) Denes vascular anatomy (d) Helpful to determine dural invasion,

infratemporal and intracranial extension

(e) CT and MRI are complimentary, particu-

larly in the workup of sinonasal malignancies

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319

3. Positron Emission Tomography (PET) (a) Assesses regional and distant disease for

malignant tumors

28.5 Dierential Diagnosis

ofNeoplasms

1. Benign (a) Osteoma

• Most commonly found in frontal > ethmoid > maxillary sinus

• Benign, slow growing, usually asymptomatic

• Manage with observation typically, unless it is obstructing sinus outow tract

• Multiple osteoma lesions associated with Gardner syndrome

– Malignant degeneration of intesti-

nal polyp

(b) Fibrous dysplasia

• Hamartomatous lesion in which medullary bone is replaced by bro-osseous tissue

• Slow growing, painless

• Destroys bone, with eggshell-thin cortex from destruction of cortical bone

• Ground-glass expansive mass on CT

• May obliterate sphenoid or frontal sinuses

• Treatment of asymptomatic disease involves observation with serial imaging

• Arises from proliferation of cells in Schneiderian mucosa

– Associated with HPV 6, 11 and

Epstein–Barr Virus (EBV)

– Benign pathology but locally

aggressive

• More common in males, in sixth to seventh decades of life

• Symptoms.

– Unilateral polyp, unilateral nasal

congestion/obstruction, epistaxis, rhinorrhea

• Histopathology

– Endophytic growth of epithelium

• On CT imaging, hyperostotic bone can be identied at site of origin

• Approximately 10% risk of transformation to SCCA (highest risk in smokers)

• Krouse Staging System

– Stage T1—limited to one area of

the nasal cavity

– Stage T2—involvement of the

medial wall of the maxillary or ethmoid sinuses and/or osteomeatal unit

– Stage T3—involvement of the supe-

rior, inferior, posterior, anterior, or lateral walls of the maxillary sinus

– Stage T4—tumors with extra-sino-

nasal spread or malignancy

(d) Juvenile Nasopharyngeal Angiobroma

(JNA)

• Most common vascular mass in nose

• Benign but aggressive; slow growing, may spread intracranially but does not metastasize

• May have hormonal component

• Most common presentation is unilateral epistaxis in teenage male; other symptoms include rhinorrhea, congestion/obstruction, anosmia, headache, facial swelling, and proptosis

• Endoscopy demonstrates vascular lesion emanating from sphenopalatine area; avoid biopsy

• Staging System—Radkowski

– Stage 1A—limited to nose or

nasopharynx

– Stage 1B—extension into at least

one paranasal sinus

– Stage 2A—minimal extension

through the sphenopalatine foramen; includes minimal part of medial pterygomaxillary fossa

– Stage 2B—full occupation of ptery-

gomaxillary fossa with HolmanMiller sign; lateral or anterior displacement of maxillary artery branches; may have superior extension with orbital bone erosion

– Stage 2C—extension through pter-

ygomaxillary fossa into the cheek,

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temporal fossa, or posterior to the pterygoids

– Stage 3A—skull base erosion

with minimal intracranial extension

– Stage 3B—skull base erosion with

minimal intracranial extension, involving cavernous sinus

• University of Pittsburgh Medical Center Staging System for JNA

– Stage 1—within the nasal cavity,

medial pterygoid fossa

– Stage 2—Within paranasal sinuses,

lateral pterygoid fossa; no residual vascularity

– Stage 3—Skull base erosion, orbit,

or infratemporal fossa; no residual vascularity

– Stage 4—Skull base erosion, orbit,

or infratemporal fossa; residual vascularity

– Stage 5—Intracranial extension,

residual vascularity

M—medial extension L—lateral extension

• Expansion of pterygopalatine fossa present on CT/MRI

– Holman-Miller sign—anterior bow-

ing of posterior wall of maxillary sinus

– Findings are pathognomonic for

JNA

• Very vascular tumor

– Primary blood supply from internal

maxillary artery from external carotid artery

– Also receives blood supply from

internal carotid artery, ethmoid arteries, contralateral arteries

– Do not biopsy in clinic

• Treatment includes embolization before surgical resection

– Endoscopic, midface de-gloving,

and transfacial approaches can be performed

– Success with resection is dependent

on surgeon preference

– Recurrence rates with the various

approaches are about equal

2. Malignant (a) Squamous cell carcinoma

• Approximately 75% of all paranasal sinus malignancies

• Smoking exposure is a risk factor

• Overall low (<10%) risk for occult neck disease

• AJCC Paranasal sinus cancer staging

– Maxillary

Ohngren’s line

• Imaginary angled sagittal plane from medial canthus of eye to the angle of the mandible

• Infrastructural lesions, anterior/inferior, have better outcomes; more amenable to resection

• Suprastructural lesions, posterior/superior, present at more advanced stages, more likely to involve skull base and perineural invasion; less amenable to resection

T1—tumor limited to maxillary sinus mucosa without bone involvement T2—tumor causing erosion of bone such as hard palate; extension of tumor into middle meatus T3—tumor invades of the following: posterior wall of maxillary sinus, orbital floor, subcutaneous tissues, pterygopalatine fossa, ethmoid sinuses T4a—moderately advanced local disease

• Tumor invades orbit, skin of face, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid sinus, frontal sinus

• T4b—advanced local disease

• Tumor invades orbital apex, dura, brain, nasopharynx, clivus

– Ethmoid sinus T stage

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321

T1—Tumor within one subsite without bony invasion T2—Tumor invading two adjacent subsites or extending into nasoethmoid complex T3—Tumor invades orbital oor, medial orbital wall, maxillary sinus, palate, or cribriform plate T4a—Moderately advanced local disease.

• Tumor invades orbit, skin of face, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid sinus, or frontal sinus

T4b—advanced local disease.

• Tumor invades orbital apex, dura, brain, nasopharynx, clivus

(b) Intestinal-Type Adenocarcinoma (ITAC)

• Risk factors – Wood-dust exposure – Leather-related occupational

exposure

• Presents more commonly in the eth-

moid sinuses

• Minor salivary gland origin in the para-

nasal sinuses

– More common in minor than major

salivary glands

– Insidious growth

• Signicant propensity to invade along

nerves, resulting in pain and paresthesia

• Distant metastases common but can be

delayed

• Good 5-year survival but poor 10-year

survival

(d) Esthesioneuroblastoma

• Rare malignancy

• Arises from olfactory epithelium

• Bi-modal frequency – Presents in teenagers and elderly

• Kadish System – A—tumors limited to the nasal

cavity

– B—extension into paranasal sinuses

– C—extension beyond paranasal

sinuses

– D—Metastatic disease

• Hyams histopathologic grading system

– Grading is based on mitosis, necro-

sis, pleomorphism, and type of tissue architecture

– Grade 1 and 2—Homer-Wright

pseudorosettes

– Grade 3 and 4—Flexner–

Wintersteiner rosettes

• Most common treatment includes surgical resection with postoperative radiation

(e) Lymphoma

• Risks

– Irradiation, EBV, immunosuppres-

sion

• Symptoms

– Nodal mass, fever, night sweats,

nasal obstruction, epistaxis, exophthalmos

• Workup

– Imaging and biopsy – Maintain index of suspicion

• Treatment

– Non-surgical: chemotherapy, radia-

tion therapy

(f) Malignant mucosal melanoma

• Sinonasal cavity is most common site of mucosal melanoma

• Very aggressive and high grade

– All lesions are at least T3 and Stage

III

• Surgery and radiation are mainstays of treatment

• Poor 2-year survival, around 25%.

• Local recurrence and distant metastasis are common

• Less aggressive or palliative surgical approach can be used given poor prognosis

(g) Nasopharyngeal Carcinoma (NPC)

• Causes of NPC

– Genetic factors

Family clusters: 15% of NPC patients have a rst-degree family member with NPC

AL GRAWANY

322

A. Tassler et al.

HLA-B, C, and D haplotypes are associated with increased risk

– Environmental factors

High-nitrosamine diet of salted sh, eggs, and vegetables

– Epstein–Barr virus (EBV)

Elevated IgA Viral capsid antigen (VCA) and IgA Early Antigen (EA) EBV DNA is useful screening tool for early asymptomatic NPC

• Earlier detection and better outcomes

• Demographics – 75% male – Highest world incidence if in

Guangzhou, China

Southern China, Northern Africa, Southeast Asia at higher risk

– 99% of patients with NPC have

symptoms at diagnosis

• Symptoms – Neck mass—level V and level II – Otitis media with effusion and/or

Eustachian tube dysfunction – Unilateral hearing loss – Hemoptysis – Nasal congestion – Cranial nerve palsy

CN V>VI>XI > X>XII

• World Health Organization Classication of NPC

– Type I—keratinizing SCC

5-year survival is 35%

– Type II—nonkeratinizing carci-

noma (EBV+)

– Type III—undifferentiated carci-

noma (EBV+)

5-year survival is 60%

• Workup

– MRI to evaluate tumor extent and

skull base involvement – PET to evaluate distant disease – Audiogram – EBV serology

IgA VCA—highly sensitive

28.6 Factors Associated

1. Histological ndings of primary tumor

2. T stage

3. Presence/Extent of intracranial involvement

4. Positive margins

5. Prior radiation

6. Nodal disease

7. Distant disease

28.7 Treatment

1. Benign sinonasal tumors

IgA EA—highly specic

• Staging for NPC – T1—Conned to nasopharynx or

extends to oropharynx or nasal cavity

– T2—Tumor extends to the parapha-

ryngeal space

– T3—Tumor involves sinuses and/or

skull base

– T4—Intracranial or infratemporal

involvement, or cranial nerve or

orbital involvement – N0—No nodal disease – N1—Unilateral cervical lymph

nodes <6 cm, or retropharyngeal

nodes <6 cm above the supracla-

vicular fossa – N2—Bilateral cervical LN <6 cm

above supraclavicular fossa – N3a—Lymph node >6cm – N3b—Supraclavicular lymph node

• Treatment options – Stage I-II: Radiation alone – Stage III–IV: Chemoradiation – Persistent disease: Salvage surgery – Recurrent disease: Reirradiation or

salvage surgery

withSurvival

(Table28.1) (a) Worst: melanoma (b) Best: minor salivary gland tumors

(a) Dependent on extent of disease and

pathology

28 Neoplasms oftheSinonasal Cavity

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

323

Table 28.1 Overall survival based on histopathologic

diagnosis

Histopathology 5-Year OS Squamous cell carcinoma 30–50% Intestinal-type adenocarcinoma 60–70% Adenoid cystic carcinoma Esthesioneuroblastoma 78% Mucosal melanoma <30% Undifferentiated carcinoma 75% Neuroendocrine carcinoma 65%

OS overall survival

≈60%

(b) Observation, partial resection, complete

resection with margins

surgery not possible

2. Malignant sinonasal tumors (a) Consideration of nearby neurovascular

structures

• Brain, eye, important arteries and veins

(b) Oncologic outcomes and morbidity

improving over last several decades

• Low morbidity

• Comparable, if not better, outcomes in properly selected patients

• May be performed for denitive resection of disease, debulking, or palliation

• Dependent on surgeon technical skill

(d) Transfacial open approaches

• Lateral rhinotomy

– Requires external incision with

some resultant morbidity and cosmetic deformity

– Provides excellent visualization of

maxillary, ethmoid, and sphenoid sinuses as well as medial orbit

• Midface de-gloving

– Requires transxion and intercarti-

laginous incisions bilaterally with gingivobuccal incisions

– Excellent visualization for inferior

nasal cavity and medial maxillary

walls – Allows bilateral exposure – No external incisions

• Facial translocation – Used for wide exposure of middle

cranial base, infratemporal fossa, pterygopalatine fossa, and nasopharynx

(e) Low-grade cancers

• Single-modality primarily, with surgi-

cal resection for early maxillary or nasal cavity tumors versus primary radiation

– Radiation eld and dose are limited

by orbital and intracranial complications such as blindness, keratitis, and brain necrosis

(f) High-grade cancers

• Multimodal therapy with either pri-

mary radiation therapy with surgical salvage or primary surgical excision with postoperative radiation therapy

(g) Unresectable disease or non-operative

patients

• Primary radiation, chemotherapy, or

combination chemoradiation

(h) Obtaining local control is most important

factor that impacts survival

3. Management of neck disease (a) N0 neck

• Elective neck dissection is generally not indicated

• <10% of exam-negative necks contain occult disease

(b) N1–N3 Neck

• Neck dissection indicated

28.8 Complications fromTumor Treatment

1. Hemorrhage

(a) Venous vs arterial; potentially

life-threatening

(b) Increased risk in vascular tumors; con-

sider pre-operative embolization

2. Intradural vs extradural nerve injury

3. Positive margins

4. Wound infection, sinonasal mucocele, chronic

rhinosinusitis

5. Orbital complications

AL GRAWANY

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