Nasal cavity Neoplasms

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Neoplasms of the Nasal cavity : 

Neoplasms of the Nasal cavity 137 BATCH MAMATA MEDICAL COLLEGE 1

Neoplasms of NASAL CAVITY : 

Neoplasms of NASAL CAVITY Cancers of nose and sinuses occupy less than 1% of all malignancies and about 3% of all head & neck cancers. Delay in diagnosis due to similarity to benign conditions Nasal cavity ½ benign ½ malignant 2

Etiology : 

Etiology Predominately of older males. Exposure: Wood, nickel-refining processes. Industrial fumes, leather tanning. Cigarette and Alcohol consumption No significant association has been shown. Aflotoxin,mustard gas genetics,polycyclic hydrocarbons,chronic sinusitis. 3

Presentation : 

Presentation Oral symptoms: 25-35% Pain, trismus, alveolar ridge fullness, erosion Nasal findings: 50% Obstruction, epistaxis, rhinorrhea Ocular findings: 25% Epiphora, diplopia, proptosis Facial signs Paresthesias, asymmetry 4


PATTERN OF SPREAD LOCAL: Anterior- skin of the face Lateral – maxillary sinus Superior – anterior cranial fossa,frontal sinus Inferior – palate Posterior – sphenoid sinus,naso pharynx Regional: Submandibular,jugulo dagastric lymphnodes Distant : Brain,lung,liver,bone,skin 5



Benign Lesions : 

Benign Lesions Papillomas Osteomas Fibrous Dysplasia Neurogenic tumors Pleomorphic adenoma Hemangioma Chondroma Angiofibroma Glioma Dermoid Encephalocele 7

Papilloma : 

Papilloma Vestibular papillomas Schneiderian papillomas derived from schneiderian mucosa (squamous) Fungiform: 50%, nasal septum Cylindrical: 3%, lateral wall/sinuses Inverted: 47%, lateral wall 8

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Inverted Papilloma (or)Ringertz tumour : 

Inverted Papilloma (or)Ringertz tumour 4% of sinonasal tumors Site of Origin: lateral nasal wall(middle meatus)* Unilateral Malignant degeneration in 2-13% (avg 10%) ETIOLOGY: Not exactly known but viruses like HPV 6,11,16,18 are implicated but there is no core relation.

Pathology : 

Pathology GROSSLY: Look like a polyp but it is firmer and more granular and malberry type appearance Red or grey mass which may be translucent & edematous Histo pathology Thickened epithelial covering with extensive invasion of hyperplastic epithelium into stroma

Clinical features : 

Clinical features Symptoms: Nasal obstruction hypo nasal speech,rhinorrhea,epistaxis, proptosis,diplopia,facial swelling. Signs: Polyp like mass bleed on touch, evidence of bony erosion D/D: antrochoanal polyp,allergic or fungal sinusitis,scc,adeno carcinoma 12


STAGING by KROUSES Limited to N.C Limited to ethmoid,medial and superior portion maxillary sinuses. Limited to lateral and inferior aspect of maxillary sinus or extension into frontal or spheniod sinus Spread out side the confined of nose and sinuses 13


INVESTIGATIONS Hemogram X-ray of naso pharynx X-ray of PNS CT scan Diagnostic nasal Endoscopy 14


TREATMENT Initially via transnasal resection: 50-80% recurrence Medial Maxillectomy via lateral rhinotomy: Gold Standard 10-20% Endoscopic medial maxillectomy: Key concepts: Identify the origin of the papilloma Bony removal of this region Recurrent lesions (22%): Via medial maxillectomy vs. Endoscopic resection 6000 rads 6weeks radiotherapy 15


HEMANGIOMA CAPILLARY TYPE (bleeding polyp): Soft,dark red,pedunculated or sessile tumour araising from anterior part of nasal septum(littles area)* SYMPTOMS: Recurrent epistaxis,nasal obstruction TREATMENT: Local excision of with cuff of surrounding muco perichondrium. 16

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CAVERNOUS TYPE: SITES- turbinate's of lateral wall Treatment: Surgical excision with preliminary cryotherapy 17


CHONDROMA Sites-ethamoid,nasal cavity,nasal septum Gross features-smooth,firm,lobulated mass(pur type) Mixed type- fibro,osteo,angio varities Treatment- surgical excision 18


INTRA NASAL MENINGO ENCEPHALOCELE Herniation of brain tissue & meninges through foramen caecum or cribriform plate Presentation: -as a smooth polyp in upper part of nose between septum and middle turbinate,usually in infans and young childrens Mass increase in size on crying or straining 19

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INVESTIGATIONS: biopsy-contra indicated CT scan to demonstrate defect in skul base TREATMENT: Frontal craniotomy in first procedure Intra nasal mass excision in 2nd procedure 20

Neurogenic tumors : 

Neurogenic tumors 4% are found within the paranasal sinuses Schwannomas Neurofibromas Treatment via surgical resection Neurogenic Sarcomas are very aggressive and require surgical excision with post op chemo/XRT for residual disease. When associated with Von Recklinghausen’s syndrome: more aggressive (30% 5yr survival). 21

Malignant lesions : 

Malignant lesions Squamous cell carcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Adenocarcinoma Hemangiopericytoma Melanoma Olfactory neuroblastoma Osteogenic sarcoma, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma Lymphoma Metastatic tumors Sinonasal undifferentiated carcinoma Bcc Plasmacytoma,chordoma 22

Squamous cell carcinoma : 

Squamous cell carcinoma Most common tumor (80%) Location: Maxillary sinus (70%) Nasal cavity (20%) 90% have local Invasion by presentation Lymphatic drainage: retropharyngeal nodes. 23

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VESTIBULAR: From lateral wall of vestibule which may extend upto columella and upper lip Metastasis to parotid nodes SEPTAL: Mostly at mucocutaneous junction causes burning and soreness in nose,called as NOSE PICKERS cancer. LATERAL WALL: Most common rarely metastasis. 24


TREATMENT Surgery or radio therapy: 88% present in advanced stages (T3/T4) Surgical resection with postoperative radiation Complex 3-D anatomy makes margins difficult Indications for radio therapy Extensive tumours Tumour presents as bilateral neck nodes after dissection 25

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COMPLICATIONS: atrophic rhinitis cataract, loss of vision RECONSTRUCTION: fore head flap, naso labial flap or prosthesis. 26

Adeno Cystic Carcinoma : 

Adeno Cystic Carcinoma 27 Arises from minor salivary glands of nasal cavity maxillary sinus. LOW GRADE: uniform and glandular with less incidence of perineural invasion / metastasis. HIGH GRADE: solid growth pattern with poorly defined margins,30% present with metastasis.

Adenocarcinoma : 

Adenocarcinoma Arises from mucous membrane of upper nasal cavity and ethmoid sinus SUBTYPES Sessile Mucoid(most agressive) Papillary (least aggressive) Intestinal(often associated with wood) Neuro endocrinal 28

Mucoepidermoid Carcinoma : 

Mucoepidermoid Carcinoma Extremely rare Widespread local invasion makes resection difficult, therefore radiation is often indicated 29

Hemangiopericytoma : 

Hemangiopericytoma Arises from Pericytes ( Zimmerman) of outer capillary wall Present as rubbery, pale/gray, well circumscribed lesions resembling nasal polyps 30

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HISTOPATHOLOGY: Proliferation of capillaries surrounded by connective tissue sheath Silver stain blackens the sheath of capillaries allowing accurate demonstration of malignant cells at periphery Treatment is surgical resection with postoperative XRT for positive margins but radio resistant (recurrence 10-60%) 31

Melanoma : 

Melanoma Originates from melanocytes commonly present in mucosa & submucosa of nasal cavity & PNS SITES:most common is inferior turbinate anterior aspect GROSS FEATURES:bluish black polypoid mass (pigmented), non pigmented in amelolotic melanoma HISTOPATHOLOGY: dopa reaction reveals melanin granules in the cytoplasm of the cells Pigment is capable of bleached by permanganate oxalate method 32


TREATMENT Wide surgical excision Radio and chemo therapy are avoided because they supress the immune system 33

Olfactory NeuroblastomaEsthesioneuroblastoma : 

Olfactory NeuroblastomaEsthesioneuroblastoma Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells. Known to cause PNS by secreting polypeptides(cushing syndrome,HTN) Kadish Classification A: confined to nasal cavity B: involving the nasal cavity & PNS C: extending beyond nose & PNS D: cervical lymphnode or distant metastasis 34

Olfactory NeuroblastomaEsthesioneuroblastoma : 

Olfactory NeuroblastomaEsthesioneuroblastoma Aggressive behavior Local failure: 50-75% Metastatic disease develops in 20-30% Treatment: En bloc surgical resection with postoperative XRT 35

Sarcomas : 

Sarcomas Osteogenic Sarcoma Most common primary malignancy of bone. Mandible > Maxilla Sunray radiographic appearance Fibrosarcoma Chondrosarcoma 36

Rhabdomyosarcoma : 

Rhabdomyosarcoma Most common paranasal sinus malignancy in children Non-orbital, parameningeal Triple therapy is often necessary Aggressive chemo/XRT has improved survival from 51% to 81% in patients with cranial nerve deficits/skull/intracranial involvement. Adults, Surgical resection with postoperative XRT for positive margins. 37

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Groups Localised disease,completely resected regional resection with microscopic residents incomplete resection with gross residents destant metastasis 38

Lymphoma : 

Lymphoma Non-Hodgkins type Treatment is by radiation, with or without chemotherapy Survival drops to 10% for recurrent lesions 39

Sinonasal Undifferentiated Carcinoma : 

Sinonasal Undifferentiated Carcinoma Aggressive locally destructive lesion Dependent on pathological differentiation from melanoma, lymphoma, and olfactory neuroblastoma Preoperative chemotherapy and radiation may offer improved survival 40

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