Maxillary sinus

Neoplasms of the Nose and Paranasal Sinuses : Neoplasms of the Nose and Paranasal Sinuses Kevin Katzenmeyer, MD Anna Pou, MD June 7, 2000

Sinonasal Neoplasms : Sinonasal Neoplasms 3% of aerodigestive malignancies 1% of all malignancies 2 to 1 males Sixth to seventh decades Symptomatology difficult

Sinonasal Neoplasms : Sinonasal Neoplasms Nasal cavity (benign = malignant) Benign - inverting papilloma Malignant - SCCA Sinuses (malignant) SCCA Maxillary most common

Epidemiology : Epidemiology Occupational exposure in >40% nickel workers - SCCA hardwood dust & leather tanning - adenoca Viral - HPV Cigarettes & alcohol

Presentation : Presentation Similar sx to common problems 6 to 8 month delay in diagnosis Cranial neuropathies & proptosis RARE

Presentation : Presentation Oral - 30% tooth pain, trismus, palatal fullness, erosion Nasal - 50% obstruction, epistaxis, discharge, erosion Ocular - 25% diplopia, proptosis, tearing, pain, fullness Facial V2 numbness, asymmetry, pain Auditory - CHL

Advanced Disease : Advanced Disease Classic Triad facial asymmetry tumor bulge in oral cavity nasal mass All three - 40-60% One - 90%

Diagnosis : Diagnosis Physical exam Nasal endoscopy Biopsy Radiography

Computed Tomography : Computed Tomography Bone erosion orbit, cribiform plate, fovea, post max sinus wall, PTPF, sphenoid, post wall of frontal sinus 85% accuracy ? Tumor vs. inflammation vs. secretions

MRI : MRI Superior to CT multiplanar no ionizing radiation Inflammatory tissue & secretions - intense T2 Tumor - intermediate T1 & T2 94% accuracy 98% accuracy with gadolinium

Schneiderian Papillomas : Schneiderian Papillomas Fungiform (50%) - septum Cylindrical (3%) - lateral nasal wall Inverting (47%) - lateral nasal wall recurs, locally destructive, malignant potential men, 6th-7th decades, unilateral SCCA - 2-13% Recurrence - 0-80%

Inverting Papilloma : Inverting Papilloma

Osteomas : Osteomas Benign, slow-growing 15 to 40 years frontal > ethmoid > maxillary local excision

Fibrous Dysplasia : Fibrous Dysplasia Normal bone replaced by collagen, fibroblasts, and osteoid material < 20 years ground-glass appearance treatment? No irradiation

Neurogenic tumors : Neurogenic tumors Schwannomas surface of nerve fibers no malignant degeneration along trigeminal & ANS Neurofibromas within nerve fibers von Recklinghausen’s disease malignant degeneration in 15% Complete excision

SCCA : SCCA Most common - 80% Max > nasal cavity > ethmoids Males Sixth decade 90% have eroded walls of sinuses

Adenoid Cystic Carcinoma : Adenoid Cystic Carcinoma Palate > major salivary glands > sinuses Resistant to tx Multiple recurrences, distant mets Perineural spread Long-term followup necessary

Slide 18 : Mucoepidermoid Carcinoma rare, widespread local invasion Adenocarcinoma 2nd most common, 5-20% ethmoids occupational exposures

Hemangiopericytoma : Hemangiopericytoma Uncommon pericytes of Zimmerman 80% of sinonasal tumors in ethmoids resembles nasal polyps average in 55 yo excision, XRT for (+) margins

Melanoma : Melanoma 1% originate in sinonasal cavity 5th-8th decades anterior septum maxillary antrum polypoid mass, pigmentation? 5 yr = 38% 10 yr = 17%

Olfactory Neuroblastoma : Olfactory Neuroblastoma Neural crest origin no urinary VMA or HVA bimodal distribution at 20 and 50 locally aggressive rosettes are hallmark Kadish staging local recurrence 50-75% metastasis 20-30%

Slide 22 : Osteogenic Sarcoma most common primary bone tumor only 5% in H & N, mandible most involved sunray appearance Fibrosarcoma rarely seen in sinuses

Slide 23 : Chondrosarcoma 3rd-5th decades histologic dx difficult slow erosion of skull base, (+) margins Rhabdomyosarcoma most common in children 35-45% in H&N, 8% in sinuses embryonal, alveolar, pleomorphic triple tx

Slide 24 : Lymphoma bimodal presentation NHL irradiation +/- chemo Extramedullary plasmacytoma 40% in paranasal sinuses/nose “benign” must r/o myeloma excision or irradiation

Metastatic tumors : Metastatic tumors Renal cell carcinoma lungs breasts urogenital tract gastrointestinal tract Palliation necessary

Ohngren’s Line : Ohngren’s Line Suprastructure Infrastructure

Staging : Staging AJCC - Maxillary sinus carcinoma

Treatment : Treatment T3 and T4 60% local recurrence Surgery Irradiation Chemotherapy

Surgical resection : Surgical resection Unresectability (Sisson) extension to frontal lobes invasion of prevertebral fascia bilateral optic nerve involvement cavernous sinus extension

Surgical resection : Surgical resection Endoscopic excision WLE medial maxillectomy total maxillectomy radical maxillectomy +/- exenteration craniofacial resection

Orbital Preservation : Orbital Preservation Harrison - proptosis, limitation of EOM, bony erosion of orbit = exenteration Conley - save eye whenever possible Sisson - preoperative XRT, decreased exenterations without change in survival Stern - nonfunctional eye without inf/med support = exenteration

Orbital preservation : Orbital preservation UVA - McCary & Levine 50 Gy preop XRT to orbit periorbital bx resect (+) periorbita functional eye

Pterygopalatine Fossa : Pterygopalatine Fossa 10-20% involvement Som - PTPF invasion = unresectable lesion Craniofacial resection (MCF) Postop XRT

Neck Dissection : Neck Dissection Retropharyngeal and jugulodigastric nodes 10% (+) necks neck dissection palpable nodes radiographic evidence of disease 40% cervical mets at 4 yrs

Radiation therapy : Radiation therapy Primary tx only for palliation 10-15% improved 5 year survival XRT = 23% vs. Surgery + XRT = 44% preoperative vs. postoperative protection of CNS and globe XRT 12-20% unilateral visual loss, 0-8% bilateral visual loss Surgery 10-20% useless globes, 2X with XRT

Chemotherapy : Chemotherapy Palliation, unresectable disease (+) margins, perineural spread, surgical refusal, ECS Intraarterial chemotherapy Robbins - 86% response of T4 lesions Lee - 91% satisfactory response