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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4518_Библиотеки_им_академика_М_И_Перельмана
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22 Nasal Cavity andParanasal Sinus Cancer
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• Grading
– Hyams=includes tissue architecture, mitosis, nuclear polymorphism, bril-
lary matrix, rosettes, and necrosis.
• Locally aggressive with lymphatic and hematogenous spread.
– LR metastatic disease in 10–30% of patients.
• Cervical involvement portends an exceptionally unfavorable prognosis.
• Multimodality therapy offers optimal survival rate, especially for advanced disease: Surgery w/post-op RT or CRT followed with planned or salvage surgical
therapy.
• Multimodality therapy resulted in 8-year disease-free survival of 80% of patients.
• Long-term survival with late recurrence—follow patients for many years
• Surgical approach (endoscopic vs. craniofacial) dependent on the extent of
disease.
• Case series have shown that endoscopic resection is an effective method of
management.
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Radiation Therapy
• Early-stage disease can be treated with single-modality therapy with radiation
but due to signicant radiation side effects in this region, surgical resection most
often preferable.
• Ocular side effects from radiation therapy are common
• Dose limitations
– Lens <10Gy
– Retina <45Gy
– Brain <60Gy
– Lacrimal gland <30–40Gy
– Optic chiasm <54Gy
– Pituitary and hypothalamus <40Gy
• Compared to IMRT, proton-beam therapy decreases radiation areas further from
tumor (posterior fossa, contralateral orbit).
Surgical Treatment
• Open craniofacial resection carries a 4.7% mortality
– Morbidity 33–36%—wound 20%, systemic 5%, and orbital 1.5%
– Overall 5-year survival is approximately 50%
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• Endoscopic endonasal approach (EEA)
– Overall mortality 0.9%
– Intracranial infection 2%
– Overall morbidity 2.6%
– CSF leak rate between 4% and 6%
• The historic approach to paranasal sinus and anterior skull base malignancies has
been with open craniofacial approaches. There has been transition in recent
decades to minimally invasive approaches with extended endoscopic approaches
(EEA), which eliminates facial incision, enhances visualization, and decreases
need for large craniotomies.
• If the tumor does not involve facial skin or lateral orbit, the EEA approach
should be a primary consideration for approach without sacricing survival.
Consider addition of external approaches when tumor is extending very far
laterally within the frontal sinus (past mid-pupillary line) or has signicant
posterior extension into the intracranial cavity past the posterior table of the
frontal sinus, or if orbit needs to be taken and reconstruction will need
free ap.
• Approach ultimately based on likelihood of obtaining negative margins—most
important impact on survival.
• Early-stage disease treated with single-modality therapy, usually surgical resection with some exceptions (rhabdomyosarcoma, lymphoma, small-cell carcinoma, SNUC, metastasis)
• Advanced-stage disease
– Multimodality therapy: (±induction chemotherapy) surgical resection and
postoperative radiation±chemotherapy
• Unresectable disease: primary RT, CRT, or chemotx alone
• Role of surgery can be also be for palliation for pain or tumor debulking
• Neck management:
– N0 neck: consider elective neck dissection or radiation in higher stage SCC
and ENB tumors due to elevated risk of occult nodal metasis
– N1–3 neck
Treat for clinical neck disease
Parotid nodes will require supercial parotidectomy
• Craniofacial resection—contraindications
– Absolute
Distant metastasis
Cavernous sinus invasion
Carotid artery invasion
Prevertebral fascia involvement
Involvement of optic chiasm or both optic nerves
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– Relative (prominent skull base centers will resect for carefully selected
patients)
Dural invasion
Intracranial nerve involved by adenoid cystic
• Orbital involvement—negative prognostic factor, but management remains
controversial.
– Grade 1: erosion of the bony orbital wall
– Grade 2: involvement of orbital periosteum
– Grade 3: involvement of orbital soft tissue.
– Tumors that do not transgress periorbita or signicantly involve orbital fat/
muscle may be resectable without exenteration
– Induction chemotherapy may allow for orbital preservation without reduction
in survival.
– Indications for exenteration: orbital apex involvement, frank intraconal
involvement
• External approaches
– Midface degloving:
Lesions inferior and medial maxillary walls, difcult superior exposure, if
alveolus or hard palate involved then endoscopic approach not an option
No facial incisions
– Lateral rhinotomy
Standard incision for open medial maxillectomy
Exposure for ethmoid, sphenoid, nasal cavity, medial orbital wall, maxillary wall
Endoscopic approaches easily access all these regions, so typically only
now useful for tumors involving the above structures as well as anterior
soft tissues.
– Fascial translocation
Wide exposure of middle cranial base, pterygopalatine fossa, nasopharynx
Endoscopic approaches easily access all these regions, so more historic,
used only rarely
– Weber-Fergusson
Lateral rhinotomy+lip split to connect with sublabial incision
Exposure for total maxillectomy, if alveolus or hard palate involved then
endoscopic approach not an option
– Transpalatal approach
Floor of nose or inferior maxilla
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– Infratemporal fossa
Preauricular with extension via hemicoronal and cervical incisions
Endoscopic approaches access the infratemporal fossa, but how far laterally tumor extends would dictate if external or endoscopic approach more
efcient
• Resections
– Medial maxillectomy
Lateral nasal wall+medial maxilla
– Inferior maxillectomy
Maxillary sinus inferior to the infraorbital nerve
– Total maxillectomy
Includes entire bone of the maxilla, up to its articulations with the frontal,
sphenoid, and ethmoid bones.
– Radical maxillectomy
Total maxillectomy+orbital exenteration
• Reconstruction of skull base defects/CSF leaks (watertight closure of skull base
and dural defect is the goal)
– Endoscopic
Vascularized pedicled
• Nasoseptal ap—based on posterior septal branch of sphenopalatine
artery (introduction reduced recurrent CSF leaks from 30% to <5%
with endoscopic resection)
• Inferior turbinate ap—inferior turbinate branch of sphenopalatine artery
• Middle turbinate ap—middle turbinate branch of sphenopalatine artery
• Vascularized non-pedicled (random based rotational aps, i.e., Lateral
nasal wall ap)
Nonvascularized
• Tensor fascia lata
• Free mucosal graft
• Fat
• Temporalis fascia
• Bone grafts
• Cadaveric bone or tissue
• Synthetic implants (e.g., Medpore and Duraform)
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– Transfacial
Regional aps
• Temporoparietal fascial ap—supercial temporal artery. Can be tunneled endoscopically through opening in lateral wall of maxillary sinus
for endoscopic placement via small incision above zygoma.
• Pericranial ap—supraorbital and supratrochlear artery. Can be tunneled endoscopically through nasotomy and modied Lothrop cavity
Free aps: De-epithelialized anterolateral thigh, rectus myofascial ap,
radial forearm free ap bula, iliac crest, or scapula for reconstruction of
maxilla. Obturator in cases where reconstruction is contraindicated
• Complications
– CSF leak
– Intracranial infection
– Osteitis
– Epiphora
– Orbital complications
– Cerebrovascular occlusion
– Hemorrhage
– Tension pneumocephalus
– Cranial nerve injury
– Anosmia/Hyposmia/Parosmia/Phantosmia
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Further Reading
1. Janfaza P, Nadol JB, Galla RJ, Fabian RL, Montgomery WW. Surgical anatomy of the head
and neck. 1st ed. Cambridge, MA: Harvard University Press; 2011.
2. Krouse JH. Development of a staging system for inverted papilloma. Laryngoscope.
2000;110(6):965–8.
3. Busquets JM, Hwang PH. Endoscopic resection of sinonasal inverted papilloma: a metaanalysis. Otolaryngol Head Neck Surg. 2006;134(3):476–82.
4. Oikawa K, Furuta Y, Nakamaru Y, Oridate N, Fukuda S.Preoperative staging and surgical
approaches for sinonasal inverted papilloma. Ann Otol Rhinol Laryngol. 2007;116(9):674–80.
5. Lee CH, Hur DG, Roh H-J, Rha K-S, Jin H-R, Rhee C-S, etal. Survival rates of sinonasal
squamous cell carcinoma with the new AJCC staging system. Arch Otolaryngol Head Neck
Surg. 2007;133(2):131–4.
6. Bristol IJ, Ahamad A, Garden AS, Morrison WH, Hanna EY, Papadimitrakopoulou VA, etal.
Postoperative radiotherapy for maxillary sinus cancer: long-term outcomes and toxicities of
treatment. Int J Radiat Oncol Biol Phys. 2007;68(3):719–30.
7. Hanna EY, Cardenas AD, DeMonte F, Roberts D, Kupferman M, Weber R, etal. Induction chemotherapy for advanced squamous cell carcinoma of the paranasal sinuses. Arch Otolaryngol
Head Neck Surg. 2011;137(1):78–81.
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8. Laskin JJ, Savage KJ, Voss N, Gascoyne RD, Connors JM.Primary paranasal sinus lymphoma:
natural history and improved outcome with central nervous system chemoprophylaxis. Leuk
Lymphoma. 2005;46(12):1721–7.
9. Lupinetti AD, Roberts DB, Williams MD, Kupferman ME, Rosenthal DI, DeMonte F, etal.
Sinonasal adenoid cystic carcinoma: the M.D. Anderson cancer center experience. Cancer.
2007;110(12):2726–31.
10. Van Gerven L, Jorissen M, Nuyts S, Hermans R, Vander PV. Long-term follow-up of 44
patients with adenocarcinoma of the nasal cavity and sinuses primarily treated with endoscopic resection followed by radiotherapy. Head Neck. 2011;33(6):898–904.
11. Lee KJ.Essential otolaryngology: head and neck surgery. 12th ed. NewYork: McGraw-Hill
Professional; 2019.
12. Mendenhall WM, Mendenhall CM, Werning JW, Riggs CE, Mendenhall NP.Adult head and
neck soft tissue sarcomas. Head Neck. 2005;27(10):916–22.
13. Terada T, Kato T.Sinonasal-type hemangiopericytoma of the nasal cavity and paranasal sinus.
Int J Clin Oncol. 2012;17(2):169–73.
14. Kadish S, Goodman M, Wang CC.Olfactory neuroblastoma—a clinical analysis of 17 cases—
Kadish—2006—Cancer—Wiley Online Library. Cancer. 1976;37:1571–6.
15. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, et al.
Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800
patients. J Neurosurg. 2011;114(6):1544–68.
16. Le QT, Fu KK, Kaplan MJ, Terris DJ, Fee WE, Gofnet DR.Lymph node metastasis in maxillary sinus carcinoma. Int J Radiat Oncol Biol Phys. 2000;46(3):541–9.
17. Ganly I, Patel SG, Singh B, Kraus DH, Bridger PG, Cantu G, etal. Craniofacial resection for
malignant paranasal sinus tumors: report of an international collaborative study. Head Neck.
2005;27(7):575–84.
18. Robbins KT, Ferlito A, Silver CE, Takes RP, Strojan P, Snyderman CH, etal. Contemporary
management of sinonasal cancer. Eisele DW, editor. Head Neck. 2010;33(9):1352–65.
19. Albonette-Felicio T, Rangel GG, Martinéz-Pérez R, Hardesty DA, Carrau RL, Prevedello
DM.Surgical management of anterior skull-base malignancies (endoscopic vs. craniofacial
resection) [published online ahead of print, 2020 Feb 4]. J Neuro-Oncol. 2020;150(3):429–36.
https://doi.org/10.1007/s11060- 020- 03413- y.
20. Suárez C, Ferlito A, Lund VJ, Silver CE, Fagan JJ, Rodrigo JP, etal. Management of the orbit
in malignant sinonasal tumors. Head Neck. 2008;30(2):242–50.
21. Turri-Zanoni M, Lambertoni A, Margherini S, etal. Multidisciplinary treatment algorithm for
the management of sinonasal cancers with orbital invasion: a retrospective study. Head Neck.
2019;41(8):2777–88.
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Chapter 23
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Vascular Malformations andTumors
BenjaminM.Laitman, EitanPrisman, BrettA.Miles, andMohemmedKhan
Pearls
• Vascular anomalies are primarily categorized as malformations or tumors based
on the presence of a clonal population of cells.
• Sclerotherapy may be utilized for lymphatic malformations and is more effective
for macrocystic lesions; microcystic lesions often require surgical excision if
feasible.
• Hemangiomas are generally treated conservatively with medical therapy and
often spontaneously regress.
• Juvenile nasopharyngeal angiobromas are histologically benign but locally
destructive tumors that occur most commonly in adolescent males; diagnosis is
made with endoscopy and imaging and rarely should require a biopsy.
• Angiosarcoma is commonly seen in elderly white patients involving the scalp
and has an extremely poor (20% 5-year) survival; excision is frequently associated with dermal spread and positive margins.
B. M. Laitman · M. Khan (*)
Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at the
Mount Sinai Hospital, New York, NY, USA
e-mail: Benjamin.laitman@mountsinai.org; mohemmed.khan@mountsinai.org
E. Prisman
Otolaryngology Head and Neck Surgery, Microvascular Reconstruction, Trans-Oral Robotic
Surgery, Endocrine Surgery, Vancouver General Hospital, Vancouver, BC, Canada
B. A. Miles
Otolaryngology Head and Neck Surgery, Oral and Maxillofacial Surgery, Northwell Health
System, New Hyde Park, NY, USA
e-mail: bmiles4@northwell.edu
© Springer Nature Switzerland AG 2023
F. Y. Lin, Z. M. Patel (eds.), ENT Board Prep,
https://doi.org/10.1007/978-3-031-26048-3_23
423
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• Kasabach–Merritt phenomenon presents with severe thrombocytopenia that can
occur in Kaposiform hemangioendotheliomas or tufted angiomas.
• Osler–Weber–Rendu syndrome is an autosomal dominant disease of small ves-
sels presenting with recurrent nasal or nasopharyngeal bleeding, often treated
with laser coagulation combined with endoscopic techniques. Bevacizumab is a
VEGF inhibitor used to reduce epistaxis.
B. M. Laitman et al.
Classication
Vascular anomalies can be classied as:
• Malformations: error in development of vascular embryologic tissue; usually
present at birth. Can contain multiple cell types.
• Tumors: have neoplastic characteristics including proliferation of a specic
cell type
Can also be categorized in regards to malignant potential
• Benign
– Vascular malformations
– Hemangiomas
– Juvenile nasopharyngeal angiobroma (JNA)
– Kaposiform hemangioendothelioma and Tufted Angiomas
• Malignant
– Angiosarcoma
– Hemangiopericytoma
– Kaposi sarcoma
• Vascular anomalies associated with syndromes:
– PHACES (Posterior fossa, Hemangioma, Arterial, Cardiac, Eye, Sternal
clefting)
– Osler–Weber–Rendu
– Sturge–Weber
– Maffucci
– Von Hippel–Lindau
Vascular Malformations
Epidemiology
• Always present at birth, although may not be realized for months to years later
• Generally grows proportionally with patient
• May increase with trauma, infection, and hormonal changes
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Classication
• Low ow—capillary, lymphatic, venous, or other combinations
• High ow—arterial, arteriovenous, or other combinations
Pathology
• Not associated with cellular hyperplasia but rather hypertrophy of existing cells
• Normal endothelial cell turnover and mast cells
Capillary Malformation (CM)
• Low ow malformations frequently seen in mid/upper face
• Commonly known as port wine stains
• Present at birth and become darker with age and may be associated with soft tissue hypertrophy and hamartomatous nodule formation
• Arise from cutaneous supercial vascular plexus
• Equal Male: Female incidence
• Associated with Sturge–Weber syndrome when present in the upper face/eye-
lid region
• Capillary malformation involving eye, skin, and leptomeninges
• Treated with serial pulse-dye laser therapy (585nm)
Lymphatic Malformation (LM)
• Collections of abnormally dilated lymphatic vessels and sac
• Soft doughy nontender mass, commonly found in the head and neck
• Can cause respiratory distress/airway compression
Epidemiology
• Most common pediatric head and neck vascular malformation
• 60% detected by ultrasound in utero
• 90% detected prior to 2years of age
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Categorization
• Macrocystic (cysts >2cm)
• Microcystic (cysts <2cm)
• Mixed (>50% of lesion is macrocystic)
Imaging
• Nonenhancing low signal on T1-weighted MRI
• Nonenhancing high signal without feeding/draining vessels on T2-weighted MRI
• Absence of ow voids
• CT: nonenhancing uid density areas
Staging System Based onAnatomic Position
• I—unilateral infrahyoid
• II—unilateral suprahyoid
• III—unilateral suprahyoid and infrahyoid
• IV—bilateral suprahyoid
• V—bilateral suprahyoid and infrahyoid
Pathology
• Collections of abnormally dilated lymphatic vessels and sacs
Treatment
• Microcystic disease as well as stage II–V is less responsive to treatment
• Observation can be appropriate for unilocular lesions, especially if not involving airway
• May spontaneously regress
• Medical
– Sclerotherapy
– More useful for macrocystic disease
– OK-432 (Picibanil)—lyophilized, low virulence strain of Streptococcus pyo-
genes, lower toxicity, and less associated brosis; not commercially available
in the US.
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