TUMOURS OF NASAL CAVITY

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TUMOURS OF NASAL CAVITY PARANASAL SINUSES

• Col Shoaib Ahmed
• Consultant ENT Head Neck Surgeon
• MBBS (Honours) FCPS(Pakistan) FRCS(Glasgow)

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Review of Anatomy

• Paranasal sinuses are air filled cavities that
  communicate with the nasal cavity
• There are close anatomical relations with orbit
  skull base
• Cranial nerves 1st, 2nd, 3rd ,4th , 5th and 6th
  are in close vicinity

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Unique Features of Sinonasal Tumours

• Relatively rare of head neck tumours
• Present late
• Large air filled sinuses with no vital
  structure in immediate vicinity ? remain
  clinically silent
• Highly non specific early symptoms
  (rhinorrhea nasal obstruction) ? receive scant
  attention
• Wide variety of pathological lesions
• Extension to anatomically critical areas
• Generally advanced disease with poor clinical
  outcome

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Classification

• BENIGN
• Epithelial
• Inverted papilloma
• Non epithelial
• Fibroma
• Chondroma
• Hemangioma
• Nerve sheath tumour

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Classification contd.

• MALIGNANT
• Epithelial
• Squamous cell carcinoma
• Adenocarcinoma
• Adenoid cystic carcinoma
• Mucoepidermoid carcinoma
• Olfactory neuroblastoma / Esthesioneuroblastoma
• Non epithelial
• Sarcomas
• Lymphoma
• Giant cell tumour

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Environmental Factors associated with sinonasal
malignancy

• Wood dust
• Nickel
• Hydrocarbons
• Chromium
• Organic oils
• Isopropyl oil

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Clinical Features

• EARLY
• Nasal obstruction
• Rhinorrhea
• LATE
• Epistaxis
• Proptosis
• Facial pain / swelling
• Cranial nerve dysfunction
• Trismus

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How to identify early on ?

• Can be readily mimicked by common respiratory
  conditions (e.g. Sinusitis )
• ?
• Unilaterality of symptoms signs
• Persistent progressive symptoms
• No improvement with antibiotics / anti
  histamines
• Unilateral facial pain / numbness / fullness
• Short span of symptoms suggests a malignant
  tumour

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Clinical Examination

• Thorough ENT head neck examination
• ?
• Trismus
• Orbit
• Neurological exam (cranial nerves 1st to 6th)
• Cervical lymph nodes

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Diagnosis

• Clinical
• Imaging (X rays, CT , MRI , PET )
• Biopsy
• Always done after imaging
• (highly vascular lesion, or intra cranial)
• Generally under LA

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Radiological ImagingPlain X rays have lesser
value !
45 degrees Occipitomental projection X ray
PNS
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Plain X- rays - Findings

• Unilateral findings
• Opaque sinus
• Gross bone destruction

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CT scans

• Initial investigation of choice
• Shows bony details
• Areas of bone destruction
• Extension into adjacent areas

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Normal CT scan
Frontal sinus
Ethmoid sinuses
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CT scan

• Unilateral sinonasal mass
• Bony erosion of lateral nasal wall and skull
  base

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Inverted papilloma
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Olfactory neuroblastoma in a 14 year old
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MRI

• Better soft tissue detail
• Useful to detect intracranial extension
• Able to distinguish nasal secretions from
  tumour
• Indicates extension into dural venous sinuses

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Positron Emission Tomography (PET scan)

• Routine evaluation for recurrent disease
  after primary tumour
• Mainly used for squamous cell carcinoma
• Very expensive modality

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TREATMENT OPTIONS

• Surgery
• Radiotherapy
• Combined surgery radiotherapy
• Chemotherapy
• Palliation
• Lymphomas

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Olfactory Neuroblastoma in a young lady
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CONCLUSION

• These are rare tumours with poor survival are
  generally advanced at presentation
• Comprise of several histologic types with varying
  biological behaviour
• Early diagnosis requires being alert for any
  persistent unilateral symptoms
• Diagnosis is based on CT, MRI and biopsy
• For cure, extensive mutilating surgery followed
  by reconstruction is often required

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• DEPARTMENT OF ENT HEAD NECK SURGERY
• COMBINED MILITARY HOSPITAL
• RAWALPINDI

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Any Questions ?