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39 Neoplasms oftheLarynx andLaryngopharynx
455
in assessment of cartilage and tongue base
involvement, paraglottic and preepiglottic space
extension of tumour. MRI is also more useful in
the detection of recurrent carcinoma [13].
A chest X-ray is done to screen for distant
metastasis, while a CT chest is indicated in
patients with advanced stage tumours to evaluate
the mediastinum and detect second primary
tumours. Positron emission tomography (PET)
imaging is not routinely used in the evaluation
and treatment planning of early cases, and its role
is increased in the staging of more advanced cancers [14]. Surgery and radiation therapy change
the normal laryngeal anatomy and may cause
oedema, brosis and scarring making diagnosis
of recurrent carcinoma with CT or MRI more difcult. PET scan is valuable in posttherapy monitoring, distinguishing recurrence from these
alterations. It is done at least 3months following
completion of treatment. PET/CT combines PET
and CT into one scanner, with fusion of anatomic
and metabolic data higher diagnostic accuracy is
provided [7].
Pretreatment endoscopy under anaesthesia,
with the use of microscopic and endoscopic techniques, is recommended in all patients.
Endoscopic evaluation with 0, 30, and 70° telescopes provide better inspection of the anterior
commissure, ventricles and the subglottis.
Paralysis of the cord is differentiated from
arytenoids xation by palpation and manipulation of the arytenoid cartilage. In laryngopharyngeal cancer bilateral pyriform fossae, lateral and
posterior walls of the laryngopharynx, and the
postcricoid region are examined. The distal
extent of tumour should be determined, if the
endoscope can be passed through the tumour; the
rest of the oesophagus is examined to rule out the
presence of synchronous tumours. Bronchoscopy
may be performed to detect the presence of tracheal invasion [12].
Biopsy is needed to conrm the diagnosis
because the gross appearance of sarcoidosis or
Wegener granulomatosis can mimic advanced
carcinoma. Deep biopsies obtained from the
tumour should reach stroma or muscle to diagnose an invasive squamous cell carcinoma. Small
lesions are completely excised with a small cuff
of normal appearing submucosa to detect the
depth of invasion. Biopsy is recommended for
any other suspicious area discovered during
endoscopy [7]. To avoid a tracheostomy, that
could lead to tumour seeding and stomal recurrence, laser is used to debulk large tumours partially obstructing the airway.
39.4 Treatment ofEarly Cancer
Larynx
Treatment of early cancer larynx should aim to
completely remove the tumour, prevent recurrence and preserve laryngeal function by a single
modality with the least morbidity. Treatment
options include radiotherapy, transoral laser
microsurgery or open surgery. The choice of
treatment should be made depending on tumour
primary site, extension and accessibility, surgeon’s experience as well as patient’s lifestyle
and preference.
39.4.1 Treatment ofEarly Glottic
Cancer
Early glottic cancer refers to tumours ranging
from Tis to T2 lesions. Transoral laser microsurgery has become an established treatment modality for early glottic cancer larynx [15]. It is
associated with minimal bleeding, absence of
post-operative oedema, less patient morbidity,
short hospital stay, high local control rates, preservation of function and excellent re-treatment
options for local failure. Tracheostomy is rarely
required. The tumour is transected and removed
piecemeal; this allows for exposure of the dissection plane and precise visualization of the interface between tumour and the underlying normal
tissue. Using the magnication and good illumination of the operating microscope makes this
feasible. Obtaining an adequate surgical exposure of anterior commissure lesions in endoscopic laser surgery is difcult but not impossible
[16]. In case of suspected cartilage involvement,
endoscopic cartilage resection may be performed
but is technically challenging. Combined laser
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I. Zohdi et al.
endoscopic and open technique may be a better
alternative treatment choice. Extent of voice
affection after surgery depends on the depth of
resection. If limited to the supercial layer of the
lamina propria and the vocal ligament resection
usually results in near normal voice production.
Resections extending to the vocalis muscle can
cause post-operative phonatory function decits.
After a post-operative period of total voice rest to
facilitate healing, patients require voice therapy
to maximize voice outcome. If needed reconstruction after endoscopic laser surgery is performed by augmentation using cordal injection or
medialization thyroplasty [17].
Radiation therapy and conservation surgery
are almost equally effective treatments for early
glottic carcinoma. Endoscopic laser resection is
recommended over radiation therapy for the
well-dened supercial lesion located in the middle third of the vocal cord. Because the surgical
management of larger lesions requires the
removal of greater amounts of tissue, radiation is
usually the preferred initial treatment for those
tumours. Older patients with greater comorbidity
are selected for radiation therapy. Primary standard radiation therapy is delivered at 2Gy per
fraction per day, 5days a week over 7weeks for
a total dose of 70Gy. It produces a control rate of
85–95% for T1 tumours, 70–80% for T2 tumours,
and an ultimate local control rate including
salvage laryngectomy of up to 100%.
Radiotherapy, however, is a time-consuming procedure necessitating several weeks; there is also a
risk of radiogenic carcinoma specially in younger
patients. Because the amount of normal tissue in
the treatment port for early T1 or T2 glottic carcinoma is small, radiation for these lesions is associated with mild side effects. Voice disturbance
may be a result of radiation induced mucositis,
atrophic changes and brosis [18]. Continued
smoking during treatment increases tissue susceptibility to radiation injury.
Larger more inltrating T2 tumours with posterior extension or anterior commissure involvement may require open procedures, vertical
hemilaryngectomy or supracricoid resection, that
have a greater local control rate. Patients usually
need a temporary tracheostomy after open partial
surgery. The vertical partial hemilaryngectomy
includes resection of the corresponding thyroid
ala along with tumour at the glottic level. Lesions
involving the anterior commissure are treated
with frontolateral hemilaryngectomy or supracricoid laryngectomy. Frontolateral partial laryngectomy removes a vocal fold, anterior
commissure, anterior third of the contralateral
vocal fold, and the overlying medial thyroid cartilage. Supracricoid laryngectomy involves resection of both true and false vocal folds, the thyroid
cartilage, both paraglottic spaces, and one partial
or full arytenoid, but preserves at least one cricoarytenoid unit (arytenoid associated musculature,
plus the superior and recurrent laryngeal nerve)
and cricoid cartilage. Contraindications to this
surgical procedure include bilateral arytenoid
involvement, posterior commissure disease,
hyoid bone involvement, and subglottic extension beyond the upper margin of the cricoid ring.
Reconstruction is performed with cricohyoidoepiglottopexy [19]. Supracricoid laryngectomy
for T1b and T2 carcinomas results in high local
control rates. It also plays an important role in the
surgical salvage of selected radiation failures in
patients in whom the recurrent tumour has not
extended beyond its original site.
39.4.2 Treatment ofEarly
Supraglottic Cancer
Early supraglottic cancer refers to tumours ranging from T1 to T2 lesions. The treatment options
for early supraglottic lesions include radiotherapy, supraglottic laryngectomy (open or transoral laser microsurgery) or supracricoid
laryngectomy. Patients with T1–2 lesions have a
20–30% incidence of occult nodal metastasis
and a higher frank nodal disease at presentation.
It carries therefore a somewhat poorer prognosis
than glottic cancer. For early supraglottic
tumours, the clinically N0 neck needs to be
addressed due to the high risk of microscopic
AL GRAWANY
39 Neoplasms oftheLarynx andLaryngopharynx
457
lymph node metastasis. Elective treatment of the
neck is performed by either radiotherapy or
selective neck dissection (unilateral or bilateral)
depending on the initial line of treatment [20].
The general recommendation is to irradiate
patients with T1 and small exophytic T2 lesions,
as well as patients with poor pulmonary function, with poor access for surgery or high risk for
general anaesthesia. The target volume for
radiation treatment includes the primary tumour
and lymph nodes bilaterally (Level II–IV).
In a supraglottic laryngectomy, the larynx is
resected between the preepiglottic space and the
ventricles, with preservation of both true vocal
folds and both arytenoids. Tumour extension
below the laryngeal ventricle and substantial cartilage involvement contraindicates this surgical
procedure. Swallowing can be temporary affected
with variable degrees of aspiration. Dietary modications and compensatory techniques as
Mendelsohn manoeuvre, supraglottic swallow
and effortful swallow can be used to improve
swallowing. Patients indicated for supraglottic
partial laryngectomy require adequate pulmonary reserve. Advance aged patients are poor candidates for this procedure [21].
Endoscopic laser resection of supraglottic
tumours is recently gaining more ground.
Patients complain of less post-operative dysphagia and rapidly recover normal swallowing.
This improved outcome and better functional
recovery of swallowing in contrast to open supraglottic laryngectomy are mostly due to the
preservation of the superior laryngeal nerve [22].
Patients with trismus, projecting teeth or cervical
spine deformity are not suitable for endoscopic
laser resection. Inserting the largest possible
laryngoscope or bivalved laryngoscope into the
patient increases the visibility and accessibility
of these tumours to transoral excision. The local
control rates with laser excision appear to be
equal to open procedures for T1 and T2 lesions.
Extended procedures may include resection of
the tongue base, arytenoid, aryepiglottic fold, or
superior medial pyriform wall. Transoral robotic
surgery has emerged as a new, safe, useful proce-
dure in the management of supraglottic tumours
[23]. Advantages of robotic surgery include
improved optics, three-dimensional viewing,
increased instrument freedom of motion and
modulating tremor. A supraglottic partial laryngectomy is feasible in selected patients, with
early supraglottic cancer, who have failed initial
treatment with radiotherapy. Supracricoid laryngectomy with cricohyoidopexy is used for
selected T2 supraglottic carcinomas that have
extension from the supraglottis to the glottic
level.
Key Points
• Early laryngeal cancer can be treated
with single modality.
• Treatment options include radiotherapy,
transoral laser microsurgery or open
surgery.
• Endoscopic laser resection is recently
gaining more ground.
• To maximize voice outcome, reconstruction may be needed.
• Treatment of the neck for occult metastatic disease must be considered for
early supraglottic cancer.
39.5 Treatment ofSubglottic
Carcinoma
Early subglottic carcinoma is treated with radiation therapy. More advanced disease is treated by
total laryngectomy with bilateral paratracheal
node dissection, and ipsilateral or total thyroidectomy and adjuvant post-operative radiation or
chemoradiation therapy if indicated.
39.6 Treatment ofAdvanced
Cancer Larynx
Advanced laryngeal carcinoma (T3–4) carry
long-term survival rates ranging from 30 to 60%
depending on the site and stage of the tumour.
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I. Zohdi et al.
They were treated with total laryngectomy and
adjuvant radiation or chemoradiation therapy.
Some cases of T3 glottic or supraglottic cancers
can be treated by endoscopic resection, but these
patients need thorough preoperative evaluation
and strict post-operative follow-up. Supraglottic
cancers staged as T3 (invasion of the preepiglottic space with intact ventricles and vocal folds)
can be treated by open supraglottic laryngectomy
with resection of the hyoid bone. The supracricoid laryngectomy plays an important role in
treatment of some selected advanced tumours
(T3 or early T4) and early postradiotherapy failure. This is achieved with preserving physiologic
speech, and respiration without the need for a
permanent tracheostoma. In supraglottic tumours,
with paraglottic space invasion causing vocal
cord xation, supracricoid laryngectomy with
cricohyoidopexy may be the alternative to total
laryngectomy. Glottic tumours with supraglottic
extension can be treated by supracricoid laryngectomy with cricohyoidoepiglottopexy [19].
The high local control rate of this procedure is
achieved by the wide resection of the paraglottic
space, the thyroid cartilage and inferior portion
of the preepiglottic space.
Radiation therapy alone is used if patients are
medically unt to undergo surgery. It results in
lower local control rates, and many patients may
need total laryngectomy for salvage. Side effects
from radiation increase with larger elds, as in
patients requiring extensive nodal irradiation. It
may be associated with severe acute and longterm side effects, such as skin problems, dry
mouth, mucositis, difcult swallowing, tooth
decay, chondronecrosis, hypothyroidism,
oesophageal stricture and oedema requiring tracheostomy in some cases. Using radiation therapy causes difculty in detecting local recurrence
due to laryngeal oedema, and increased postoperative complications if surgery is required for
salvage. Radiation efcacy is improved with
accelerated and hyperfractionated schemes.
Intensity modulated radiation therapy uses
advanced technology to provide higher target
volume and to minimize the dose delivered to
surrounding structures such as the spinal cord,
salivary glands, and swallowing apparatus hence
limiting the side effects of treatment [24].
Due to the discouraging outcomes of treating
advanced laryngeal carcinoma with radiotherapy
alone, chemoradiation began to be used. Organ
preservation strategies using chemoradiation protocols is now the standard treatment option for
most T3 and T4a tumours without extensive cartilage invasion. A major advantage of chemoradiation is the synergistic effect on the tumour and
the eradication of micrometastases. Induction
chemotherapy with cisplatin plus 5-uorouracil
is evaluated after 2 or 3cycles by CT or MRI
with contrast. In cases of complete response or
partial response with tumour size reduction to
50% or more, denitive radiotherapy is given.
Induction chemotherapy followed by radiation
therapy allows preservation of the larynx in over
60% of patients. In case there is no response or
insignicant reduction of tumour size the patient
is subjected to surgery. Concurrent radiation therapy and cisplatin 100mg/m2 on days 1, 22 and 43
achieves higher rates of organ preservation and
better loco-regional control compared to radiation therapy alone or induction chemotherapy
followed by radiation therapy. Chemotherapy is
better tolerated when given sequentially than
concurrently with radiotherapy. Concurrent
chemoradiation has been associated with acute
and long-term toxicity [24].
Patients with more advanced laryngeal carcinoma, with bulky tumours, destruction of the thyroid or cricoid cartilage, penetration through the
cartilage, extralaryngeal soft tissue spread and
extension beyond the posterior third of the base
of tongue are treated by total laryngectomy [25].
Indications for post-operative radiation or chemoradiation therapy include close or positive margins, extracapsular extension, multiple positive
nodes, invasion of the soft tissues of the neck,
perineural invasion and vascular spread. It should
start within 6 weeks of surgery [26]. Using
chemoradiation protocols alone in these more
advanced cases results in poor functional preservation, high failure rates and increased postoperative complications if surgery is required for
salvage.
AL GRAWANY
39 Neoplasms oftheLarynx andLaryngopharynx
Fig. 39.4 Diagram
showing the extent of
resection in different
types of laryngectomy.
(1) Horizontal partial
laryngectomy
(supraglottic
laryngectomy), (2)
Supracricoid
laryngectomy, (3) Total
laryngectomy
459
12 3
In total laryngectomy the larynx is resected
from the vallecula to the upper trachea, including
the vocal folds, hyoid bone, epiglottis, thyroid
and cricoid cartilages and a few tracheal cartilage
rings (Figs.39.4 and 39.5). Parts of the pharyngeal mucosa of pyriform sinus or lateral pharyngeal wall are resected ensuring adequate resection
margins but enough mucosa should be preserved
for later closure. The airway is interrupted, and
patients respirate through a tracheal stoma. Postlaryngectomy rehabilitation is required to achieve
intelligible speech and restore swallowing function and oral feeding. Post-laryngectomy patients
communicate by oesophageal speech, articial
larynx, or creation of a tracheoesophageal stula
with insertion of vocal prosthesis. The voice
Fig. 39.5 Specimen of total laryngectomy (the cricoid
lamina is incised showing advanced tumour in the left
glottic area)
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I. Zohdi et al.
prosthesis allows air from the lungs to pass into a
narrow pharyngoesophageal segment that
vibrates to produce sound. Tracheoesophageal
speech is now the preferred form of voice rehabilitation as it achieves longer phonation time,
greater volume and better intelligibility [27].
Results of treatment in advanced laryngeal
cancer patients are affected by the presence of
cervical lymph node metastases, which may
amount to an overall 30% incidence of occult
neck metastasis. There is an inverse relation
between the extent of neck disease and ultimate
local control. Patients with supraglottic and
advanced glottic cancer with N0 necks should
undergo elective treatment of the neck by either
neck dissection or radiotherapy. In supraglottic
tumours, with more incidence of bilateral neck
metastasis, necks should be bilaterally managed.
The option of treatment of the primary decides
the method used to treat the neck. If surgery is
chosen for the primary tumour, neck dissection
should include levels II, III and IV (Fig.39.6).
Patients with N1 involvement with a complete
clinical response after chemoradiation should be
closely observed. Those with incomplete clinical
response require neck dissection. A planned neck
dissection is recommended for patients with N2
disease or greater, regardless of response to
chemoradiotherapy [28].
Treating patients with combined modalities
have improved local-regional control, but overall
Fig. 39.6 Specimen of total laryngectomy with left
selective and right radical neck dissection (back view)
survival has remained unchanged as result of distant metastases and second primary tumours.
Overall, local and regional failures after treatment occur in about 30% of patients, and distant
metastases in 10–30% of patients depending on
cancer location. About 50% of patients die of
second primary tumours or other intercurrent
illness.
Follow-up care after laryngeal cancer treatment is mandatory, it includes regular physical
examinations and medical tests. Follow-up visits
aim to detect recurring cancer or second primary
cancer and manage late side effects of treatment.
A common follow-up schedule after treatment is
every 2months for the rst year, every 3months
for the second year, every 4months for the third
year, every 6months for the fourth and fth year,
and once a year after that. It is important to identify early recurrence and start salvage treatment
before the disease reaches more advanced stages.
PET/CT scan may be used for surveillance
purposes. It gained a role in the detection of local
and regional recurrences, even if CT and MRI fail
to diagnose them [7].
Surgery remains the gold standard treatment
in loco-regional recurrence. Salvage surgery is
mostly performed by total laryngectomy.
Supracricoid laryngectomy is an appropriate
treatment option in selected patients, in whom
the recurrent tumour has not extended beyond its
original site.
Patients radiologically staged N0 by CT imaging are not submitted to neck dissection, as they
most probably are free from occult neck metastases. Post-operative complication rates reach more
than 50%, pharyngocutaneous stula being the
most encountered local complication [
29].
Chemotherapy or chemoradiation may be used,
especially if surgery is not amenable, to help control local and distant disease. Immunotherapy is
recently under trial among some cases. Palliative
care is interdisciplinary care that provides support for the physical and psychological suffering
of patients.
AL GRAWANY
39 Neoplasms oftheLarynx andLaryngopharynx
Key Points
• Advanced cancer larynx is treated with
combined modality, either surgery with
adjuvant radiotherapy or initial
chemoradiation.
• Laryngeal cartilage penetration is an
indication for laryngectomy.
• Tracheoesophageal speech is now the
preferred form of voice rehabilitation.
• Treatment of the neck for palpable or
occult metastatic disease is indicated for
all advanced laryngeal cancer.
39.7 Treatment
ofLaryngopharyngeal
Carcinoma
Early stage laryngopharyngeal cancer may be
managed with either surgery or radiotherapy with
equally good results. Choice of treatment depends
on site, inferior and superior extent, circumferential involvement and laryngeal spread of the
tumour [30]. Surgical procedures include open
partial pharyngectomy or laryngopharyngectomy
and transoral laser surgery in conjunction with
staged or synchronous neck dissection. Transoral
robotic surgery that aims at less invasiveness and
functional preservation is becoming popular.
Radiotherapy is usually the treatment of choice in
patients who are medically unt or cannot tolerate early post-operative aspiration and in early
lesions involving pyriform sinus apex or postcricoid region.
Tumours of the laryngopharynx with gross
thyroid cartilage destruction, advanced tumours
of the postcricoid region or of the pharyngeal
wall with circumferential involvement are managed with total pharyngolaryngectomy along
with uni- or bilateral selective neck dissection
with the removal of levels II–IV lymph nodes.
The presence of cervical nodal metastasis
requires modied radical neck dissection.
Extension into the oesophagus necessitates
pharyngo- oesophagectomy, paraesophageal and
461
paratracheal lymph node dissection with
hemithyroidectomy. Laryngopharyngeal cancer
patients commonly suffer from malnutrition
increasing the risk of post-operative complications. Complete resection of the tumour is followed by appropriate reconstruction and
post-operative adjuvant treatment. Prevertebral
musculature or cervical spine involvement, massive mediastinal nodal enlargement and carotid
artery involvement are contraindications to surgery [31].
Reconstruction after resection of tumours
ensures proper wound healing and recovery of
swallowing function. After partial pharyngectomy for tumours limited to the pyriform fossa,
the pectoralis major myocutaneous ap is applied
as a patch repair to reconstruct the pharynx. For
reconstruction of circumferential pharyngectomy
defects free ap surgery, as tubed skin aps and
visceral aps, is performed by microvascular surgical technique. The tubed radial forearm fasciocutaneous free ap is reliable due to the large
vascular pedicle calibre. Microvascular anastomosis is performed under magnication to suitable recipient vessels in the neck. Ease of harvest,
immediate reconstruction, limited donor site
morbidity, radiation tolerance, high ap reliability
and good swallowing outcome are all advantages
of the radial forearm free ap [32]. The free jejunal ap is harvested through an upper midline
laparotomy and transferred to the neck. The
advantages of using visceral aps include lower
incidence of pharyngocutaneous stula and stricture formation at the site of anastomosis [33].
After pharyngolaryngoesophagectomy the stomach, fashioned into tube-like conguration, is
pulled up through the retrosternal plane to the
neck and anastomosed to the oropharynx.
Laparoscopic gastric pull-up is recently indicated
to minimize the morbidity of the open technique.
In cases when gastric pull-up is not feasible, pedicled jejunum or colonic interposition is used.
Combined chemoradiotherapy has become
now the standard of care for a vast majority of
patients with advanced laryngopharyngeal cancer, among them are also patients, who are unt
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for or refuse surgery. This treatment modality
achieves organ preservation without compromising survival. Surgery for laryngopharyngeal
cancer is on the retreat. In very advanced lesions
T4b, not amenable for resection, chemoradiation is the only option. Intention of this treatment is mostly palliative. Combined modality
therapies include concurrent chemoradiotherapy, induction chemotherapy followed by radiotherapy and sequential therapy with induction
chemotherapy followed by concurrent chemoradiotherapy [31].
Despite some improvement inlocal and functional outcomes with the advent of organ laryngeal preservation, overall survival for patients
with laryngopharynx cancer remains poor. The
average rates lies between 25 and 40% 5 years
survival. Prognosis is considered to be the worst
among all head and neck sites. Up to 95% of all
recurrences occur in the rst 36months and over
half of the rst recurrences are distant
metastases.
Key Points
• In early laryngopharyngeal cancer, transoral laser microsurgery and robotic surgery show good oncological benets.
• In advanced cases, organ preservation
by chemoradiation took ground from
surgery and adjuvant chemoradiation.
• Radical surgery (pharyngolaryngectomy) has a role in the non-functioning
larynx, in advanced volume disease and
in salvage surgery.
• Treatment of the neck is determined
according to tumour location and neck
stage.
I. Zohdi et al.
Take Home Messages
• True benign tumours constitute 5% or
less of all laryngeal tumours. The most
common benign tumour of the larynx is
papilloma.
• Hoarseness lasting longer than 3weeks
and persistent odynophagia or dysphagia in elderly patients are warning
symptoms suggesting cancer, and
should be thoroughly investigated.
• Preoperative evaluation is essential for
planning treatment; it includes history,
examination, endoscopy and imaging.
• Early laryngeal and laryngopharyngeal
cancer can be treated with single modality either conservation surgery or
radiotherapy.
• Laryngopharyngeal carcinomas have a
worse prognosis, as most of the patients
have advanced stage disease when rst
diagnosed.
• Organ preservation strategies using
chemoradiation protocols is now the
standard treatment option for a vast
majority of patients with advanced
laryngeal and laryngopharyngeal
cancer.
• Treatment of the neck for palpable or
occult metastatic disease must be considered for all supraglottic, laryngopharyngeal and advanced laryngeal
cancer.
• Follow-up care after cancer treatment is
mandatory, salvage treatment is less
successful once the disease reaches the
advanced stages.
• Surgery remains the gold standard treatment inloco-regional recurrence.
AL GRAWANY
39 Neoplasms oftheLarynx andLaryngopharynx
463
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Cancer oftheNasal Cavity
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
andParanasal Sinuses
AhmedEldaly, MohammedHassab,
andAliAl Ansari
40
40.1 Introduction
Cancers of the nasal cavity and paranasal sinuses
are rare. They comprise about 3% of head and
neck malignancies and less than 1% of all human
malignancies [1]. The estimated annual incidence
is about 0.56–1:100,000 of population. The
male–female ratio is about 2:1 with an average
age at presentation between 50 to 60years [2].
The maxillary sinus is the most common site
of origin (55%) followed by the nasal cavity
(23%) and the ethmoid sinus (20%) [3]. Primary
tumors of the sphenoid and the frontal sinus are
exceedingly rare. However, extension of paranasal sinus malignancies to involve the sphenoid
and frontal sinuses occurs frequently because of
the anatomic contiguity of the paranasal sinuses
and because a signicant number of tumors may
involve more than one site at the time of initial
diagnosis making it difcult to ascertain the primary site of origin.
A. Eldaly · M. Hassab (*)
Otolaryngology-Head and Neck Surgery,
University of Alexandria, Tharwat, Alexandria, Egypt
A. Al Ansari
Otolaryngology-Head and Neck Surgery,
Hamad Medical Corporation, Doha, Qatar
40.2 Pathology andBiology
Paranasal sinus malignancies include a heterogeneous group of tumors with widely varying histology and prognosis. The World Health
Organization classication of tumors includes
more than 40 unique histopathological types for
malignancies of the nasal cavity and paranasal
sinuses [4].
These etiologies are broadly subclassied into
epithelial or nonepithelial malignancies.
Epithelial neoplasms constituted more than twothirds of all malignant neoplasms in the sinonasal
tract [5].
The distribution of those tumors varies from
one geographical region to another however
globally; Squamous cell carcinoma (SCC) and
glandular malignancies are the most common
epithelial tumors whereas rhabdomyosarcoma
and lymphomas are well-known nonepithelial
tumors that occur in this region.
Squamous cell carcinoma is the most common
malignancy of the sinonasal tract occurring with
a frequency between 36% and 58% of all paranasal sinus cancers. These tumors have a peak incidence between 60 to 70years of age and occur
more commonly in males [6].
The maxilla is the most common site of origin
within the sinonasal region followed by the nasal
cavity and the ethmoids [7, 8]. Associations
between the development of paranasal SCC and
working in nickel rening industry have been
© Springer Nature Switzerland AG 2021
A. Al-Qahtani et al. (eds.), Textbook of Clinical Otolaryngology,
https://doi.org/10.1007/978-3-030-54088-3_40
AL GRAWANY
465
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