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Neoplasms of nose and paranasal sinuses

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Neoplasms of nose and paranasal sinuses

  1. 1. Neoplasms of Nose and Paranasal Sinuses DR GURCHAND SINGH Ent department 5/23/2020 1NEOPLASMS OF NASAL CAVITY & PNS
  2. 2. Neoplasms of Nose and PNS  Very rare 3%  Delay in diagnosis due to similarity to benign conditions  Nasal cavity  ½ benign  ½ malignant  Paranasal Sinuses  Malignant 2 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  3. 3. Classification Benign Simple papilloma Osteoma Fibrous dysplasia Neurogenic tumors Haemangioma Chondroma Angiofibroma Meningoencephalocele Gliomas Intermediate Inverted papilloma Malignant  Squamous cell carcinoma  Adenocarcinoma  Haemangiopericytoma  Adenoid cystic carcinoma  Malignant melanoma  Esthesioneuroblastoma  Lymphoma  Rhabdomyosarcoma 5/23/2020 3NEOPLASMS OF NASAL CAVITY & PNS
  4. 4. Oeteoma  Osteomas are common incidental finding in frontal sinus x-ray  Majority are asymptomatic & do not grow  Surgery is done for symptomatic osteomas or those that rapidly increase in size  Complete removal of tumor with its base attachment is done by bicoronal osteoplastic flap technique5/23/2020 4NEOPLASMS OF NASAL CAVITY & PNS
  5. 5. Frontal sinus osteoma 5/23/2020 5NEOPLASMS OF NASAL CAVITY & PNS
  6. 6. Bicoronal osteoplastic flap 5/23/2020 6NEOPLASMS OF NASAL CAVITY & PNS
  7. 7. Osteoma exposed 5/23/2020 7NEOPLASMS OF NASAL CAVITY & PNS
  8. 8. Tumor removal + closing of bone flap 5/23/2020 8NEOPLASMS OF NASAL CAVITY & PNS
  9. 9. Fibrous dysplasia  Normal medullary bone is replaced by abnormal proliferation of fibrous tissue, resulting in distortion & expansion of bone  C.T. scan: ground - glass appearance with regions of osteolysis & calcification  Treatment: complete surgical excision5/23/2020 9NEOPLASMS OF NASAL CAVITY & PNS
  10. 10. Mccune Albright Sternberg Syndrome POLYOSTOTIC FIBROUS DYSPLASIA CUTANEOUS PIGMENTATION HORMONAL HYPERFUNCTION MOST COMMON SITE MAXILLA FRONTAL ETHMOSPHENOID AGE YOUNG AGE GROUP CF ASYMPTOMATIC MASS PATHOLOGICAL FRACTURES FACIAL DEFORMITY EYE DISPLACEMENT 5/23/2020 10NEOPLASMS OF NASAL CAVITY & PNS
  11. 11. 5/23/2020 11NEOPLASMS OF NASAL CAVITY & PNS
  12. 12. 5/23/2020 12NEOPLASMS OF NASAL CAVITY & PNS
  13. 13. 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). 13 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  14. 14. Chondroma  Arise from ethmoid,nasal cavity,septum.  Pure are Smooth,firm,lobulated  Others may be mixed type [fibro,osteo,angio]  Treatment –surgical excision 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS 14
  15. 15. Meningoencephalocele  Brain tissue & meninges –foramen caecum or cribriform plate  Smooth polyp ,upper part of nose  Mass increases in size on crying  If avulsed,CSF rhinorrhoea  CT SCAN  T/t—frontal craniotomy,repair of bony defect 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS 15
  16. 16. Gliomas  Rare congential lesion  60% extranasal,30%intranasal,10% both  Infants & children  Firm polyp,incompressible  sometimes protuding outside  T/t ..surgery alone. 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS 16
  17. 17. Papilloma  Vestibular papilloma- verrucous lesions like skin warts. Single/ multiple, pedunculated/ sessile. Tt- local excision with base cauterization.  Schneiderian papillomas derived from schneiderian mucosa (squamous)  Fungiform: 50%, nasal septum  Cylindrical: 3%, lateral wall/sinuses  Inverted: 47%, lateral wall 17 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  18. 18. Inverted papilloma  Locally aggressive sino-nasal tumour  Synonyms: Ringertz //Transitional cell papilloma // Schneiderian papilloma  Common in males between 50-70 years  It arises from the lateral wall of nose  Presents as unilateral, friable, pale, pink mass arising from middle meatus  Diagnosis made by punch biopsy5/23/2020 18NEOPLASMS OF NASAL CAVITY & PNS
  19. 19. Anterior rhinoscopy 5/23/2020 19NEOPLASMS OF NASAL CAVITY & PNS
  20. 20. Contrast C.T. scan P.N.S.  Left intra-nasal mass with opacification of maxillary and ethmoid sinuses (African continent sign).  Bone destruction of lateral nasal wall. 5/23/2020 20NEOPLASMS OF NASAL CAVITY & PNS
  21. 21. Punch Biopsy & H.P.E. Inward invasion of hyperplastic epithelium into underlying stroma. No evidence of malignancy. 5/23/2020 21NEOPLASMS OF NASAL CAVITY & PNS
  22. 22. Inverted Papilloma Resection  Initially via transnasal resection:  50-80% recurrence  Medial Maxillectomy via lateral rhinotomy:  Gold Standard  10-20% recurrence  Endoscopic medial maxillectomy:  Key concepts:  Identify the origin of the papilloma  Bony removal of this region  Midfacial Degloving. 22 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  23. 23.  Inverted papilloma has a marked tendency to recur after surgical removal.  Squamous cell ca is present in 1015% cases.  Radiotherapy is avoided,chances of conversion into malgnancy. 5/23/2020 23NEOPLASMS OF NASAL CAVITY & PNS
  24. 24. Moure’s lateral rhinotomy 5/23/2020 24NEOPLASMS OF NASAL CAVITY & PNS
  25. 25. Osteotomy cuts 5/23/2020 25NEOPLASMS OF NASAL CAVITY & PNS
  26. 26. MEDIAL MAXILLECTOMY REMOVE MEDIAL WALLOF MAXILLAFROM THE FLOOR OF ORBIT TO FLOOR OF NOSE CAN BE EXTENDED TO INCLUDE LOWER ETHMOID SINUSES & LAMINA PAPYRACEA 26 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  27. 27. Bone removed & tumor exposed 5/23/2020 27NEOPLASMS OF NASAL CAVITY & PNS
  28. 28. Tumour removed & inicision closed 5/23/2020 28NEOPLASMS OF NASAL CAVITY & PNS
  29. 29. Sino-nasal Malignancy 5/23/2020 29NEOPLASMS OF NASAL CAVITY & PNS
  30. 30. Epidemiology  O.5% of all body cancers  15% of all upper respiratory neoplasm  Maxillary sinus is most common  80-85% are squamous cell carcinoma  Male : female = 2:1  Commonly seen in 45-60 years 5/23/2020 30NEOPLASMS OF NASAL CAVITY & PNS
  31. 31. Risk factors  Hardwood dust (adenocarcinoma)  Softwood dust (squamous carcinoma)  Nickel refining; chromium workers  Boot, shoe and textile workers  Mustard gas exposure  Human papilloma virus 5/23/2020 31NEOPLASMS OF NASAL CAVITY & PNS
  32. 32. Maxillary sinus malignancy 5/23/2020 32NEOPLASMS OF NASAL CAVITY & PNS
  33. 33. Early Clinical features Mimic maxillary sinusitis  Nasal stuffiness  Blood-stained nasal discharge  Facial paraesthesias or pain  Epiphora 5/23/2020 33NEOPLASMS OF NASAL CAVITY & PNS
  34. 34. Spread 5/23/2020 34NEOPLASMS OF NASAL CAVITY & PNS
  35. 35. Medial spread:  Unilateral nasal obstruction  Unilateral purulent nasal discharge  Epistaxis  Unilateral, friable, nasal mass Anterior spread:  Cheek swelling  Invasion of facial skin Late Clinical features 5/23/2020 35NEOPLASMS OF NASAL CAVITY & PNS
  36. 36. . Late Clinical features Inferior spread:  Expansion of alveolus with dental pain  Loosening of teeth, poor fitting of dentures  Swelling in hard palate or alveolus Superior spread:  Proptosis  Diplopia  Ocular pain 5/23/2020 36NEOPLASMS OF NASAL CAVITY & PNS
  37. 37. Late Clinical features Posterior spread:  Pterygoid muscle involvement  trismus Intracranial spread via:  Ethmoids, cribriform plate or foramen lacerum Lymphatic spread:  Neck node metastases in late stages Systemic spread: Lungs, bone5/23/2020 37NEOPLASMS OF NASAL CAVITY & PNS
  38. 38. Cheek swelling 5/23/2020 38NEOPLASMS OF NASAL CAVITY & PNS
  39. 39. Cheek skin involvement 5/23/2020 39NEOPLASMS OF NASAL CAVITY & PNS
  40. 40. Alveolar & Palatal swelling 5/23/2020 40NEOPLASMS OF NASAL CAVITY & PNS
  41. 41. Nasal mass 5/23/2020 41NEOPLASMS OF NASAL CAVITY & PNS
  42. 42.  Diagnostic nasal endoscopy  X-ray paranasal sinus: expansion & destruction of bony wall  C.T. Scan: axial & coronal cuts with contrast  Biopsy Diagnosis 5/23/2020 42NEOPLASMS OF NASAL CAVITY & PNS
  43. 43. X-ray paranasal sinus 5/23/2020 43NEOPLASMS OF NASAL CAVITY & PNS
  44. 44. C.T. Scan 5/23/2020 44NEOPLASMS OF NASAL CAVITY & PNS
  45. 45. Ohngren’s Classification 5/23/2020 45NEOPLASMS OF NASAL CAVITY & PNS
  46. 46. Ohngren's Classification  Ohngren's line: An imaginary plane extending between medial canthus of eye & angle of mandible  Supra structural growths situated above this plane have a poorer prognosis  Intra structural growths situated below this plane have better prognosis 5/23/2020 46NEOPLASMS OF NASAL CAVITY & PNS
  47. 47. Lederman’s Classification 5/23/2020 47NEOPLASMS OF NASAL CAVITY & PNS
  48. 48. Lederman’s Classification 2 horizontal lines of Sebileau pass through floors of orbits & maxillary sinus, producing:  Suprastructure: ethmoid, sphenoid & frontal sinuses; olfactory area of nose  Mesostructure: maxillary sinus & respiratory part of nose  Infrastructure: alveolar process5/23/2020 48NEOPLASMS OF NASAL CAVITY & PNS
  49. 49. T.N.M. Staging T1 = tumor confined to antral mucosa T2 = bone destruction of hard palate / middle meatus T3 = involvement of skin of cheek, floor or medial wall of orbit, ethmoid sinus, posterior antral wall, pterygoid plates, infratemporal fossa T4 = involvement of orbital contents, cribriform plate, frontal or sphenoid sinus, skull base, nasopharynx5/23/2020 49NEOPLASMS OF NASAL CAVITY & PNS
  50. 50. Treatment  T1 & T2 = Surgery or Radiotherapy  T3 = Surgery + Radiotherapy  T4 = Surgery + Radiotherapy + Chemotherapy  Europeans: pre-operative Radiotherapy (5000- 6500 cGy (centiGray)  surgery after 4-6 weeks  Americans: Surgery  post-operative Radiotherapy after 4-6 weeks5/23/2020 50NEOPLASMS OF NASAL CAVITY & PNS
  51. 51. Surgical Options 1. Total maxillectomy (Weber Fergusson incision) = malignancy limited to maxilla 2. Radical maxillectomy with orbital exenteration (Weber Fergusson Diffenbach incision) = involvement of orbital fat 3. Anterior Cranio Facial Resection (extended lateral rhinotomy incision) = involvement of cribriform plate, frontal sinus5/23/2020 51NEOPLASMS OF NASAL CAVITY & PNS
  52. 52. Ethmoid sinus malignancy 5/23/2020 52NEOPLASMS OF NASAL CAVITY & PNS
  53. 53. Ethmoid sinus Primary tumor (T):  T1: Tumor confined to the ethmoid with or without bone erosion T2: Tumor extends into the nasal cavity T3: Tumor extends to the anterior orbit, and/or maxillary sinus T4: Tumor with intracranial extension, orbital extension including apex, involving sphenoid, and/or frontal sinus and/or skin of external nose 53 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  54. 54. Regional lymph nodes (N) NX: Regional lymph nodes cannot be assesse N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimension 54 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  55. 55.  Distant metastasis (M)  MX: Distant metastasis cannot be assessed M0:No distant metastasis M1:Distant metastasis 55 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  56. 56. AJCC stage groupings  Stage 0------Tis, N0, M0  Stage I------T1, N0, M0  Stage II------T2, N0, M0  Stage III------T3, N0, M0 T1, N1, M0 T2, N1, M0 T3, N1, M0  Stage IVA-------T4, N0, M0 T4, N1, M0  Stage IVB-----Any T, N2, M0 AnyT, N3, M0  Stage IVC------AnyT, Any N, M1 56 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  57. 57. Adenoid Cystic Carcinoma  3rd most common site is the nose/paranasal sinuses  Perineural spread  Anterograde and retrograde  Despite aggressive surgical resection and radiotherapy, most grow insidiously.  Neck metastasis is rare and usually a sign of local failure  Postoperative RT is very important 57 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  58. 58. Mucoepidermoid Carcinoma  Extremely rare  Widespread local invasion makes resection difficult, therefore radiation is often indicated 58 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  59. 59. Adenocarcinoma  2nd most common malignant tumor in the maxillary and ethmoid sinuses  Present most often in the superior portions  Strong association with occupational exposures (hard wood workers)  High grade: solid growth pattern with poorly defined margins. 30% present with metastasis  Low grade: uniform and glandular with less incidence of perineural invasion/metastasis. 59 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  60. 60. Haemangiopericytoma  Age 60—70 presents with epistaxis  Pericytes of Zimmerman surrounding the capillaries  Present as rubbery, pale/gray, well circumscribed lesions resembling nasal polyps with nasal bleed in elderly  Treatment is surgical resection with postoperative RT for positive margins 60 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  61. 61. 30 Melanoma  0.5- 1.5% of melanoma originates from the nasal  Nasal cavity and paranasal sinus.  Anterior Septum: most common site, bluish- black polypoid mass  Tumor spreads by both lymphatics and blood stream.  Treatment is wide local excision with/without postoperative radiation therapy 5/23/2020 61NEOPLASMS OF NASAL CAVITY & PNS
  62. 62. Olfactory Neuroblastoma Esthesioneuroblastoma  Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells.  Cherry red polypoidal mass in the upper third of nasal cavity.  Kadish Classification  A:confined to nasal cavity  B:involving the paranasal cavity  C: extending beyond these limits 62 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  63. 63. Olfactory Neuroblastoma Esthesioneuroblastoma  Aggressive behavior  Bimodal incidence at 10-20 & 50-60 years  Unilateral nasal obst with epistaxix  Biopsy only after imaging  Local failure: 50-75%  Metastatic disease develops in 20-30%  Treatment:  En bloc surgical resection with postoperative RT 63 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  64. 64. Sarcomas  Osteogenic Sarcoma  Most common primary malignancy of bone.  Mandible > Maxilla  Sunray radiographic appearance  Fibrosarcoma  Chondrosarcoma  Rare tumor of nose 64 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  65. 65. Rhabdomyosarcoma  Most common paranasal sinus malignancy in children  Non-orbital, parameningeal  Triple therapy is often necessary  Aggressive chemo/RT has improved survival from 51% to 81% in patients with cranial nerve deficits/skull/intracranial involvement.  Adults, Surgical resection with postoperative RT for positive margins. 65 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  66. 66. Lymphoma  Non-Hodgkins type on septum  Treatment is by radiation, with or without chemotherapy  Survival drops to 10% for recurrent lesions 66 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  67. 67. 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 67 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  68. 68. Surgery  Surgical approaches:  Endoscopic  Lateral rhinotomy  Transoral/transpalatal  Midfacial degloving  Weber-Fergusson  Combined craniofacial approach  Extent of resection  Medial maxillectomy  Inferior maxillectomy  Total maxillectomy 68 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  69. 69. ENDOSCOPIC SURGERY  ENDOSCOPIC MEDIAL MAXILLECTOMY INDICATIONS 1. SMALLINVERTED PAPILLOMA 2. SMALLBENIGN TUMORS 3. OSTEOMAS 69 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  70. 70. Lateral Rhinotomy 70 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  71. 71. Weber Fergusson incision 5/23/2020 71NEOPLASMS OF NASAL CAVITY & PNS
  72. 72. 72 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  73. 73. MIDFACIAL DEGLOVING  Described by Rouge.  Rediscovered by Casson et al.  Cosmetically better  Completely avoid facial incisions, allows bilateral exposure  Combines a b/l sublabial approach to the anterior wall of the maxilla with a midline mobilisation of the cartilaginous nose using rhinoplasty techniques.  Excellent exposure of nasal cavity, post nasal space, antra, pterygopalatine fossae, 73 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  74. 74. Midfacial degloving approach 5/23/2020 74NEOPLASMS OF NASAL CAVITY & PNS
  75. 75. LIMITATION POOR ACCESS TO ORBIT, LATERAL ASPECT OF MAXILLA, ETHMOID SINUS INDICATED FOR MEDIAL MAXILLECTOMY , UNCOMPLICATED CRANIOFACIAL RESECTION CONTRAINDICATION ORBITAL EXENTRATION SIGNIFICANT SKIN INVOLVEMENT 75 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  76. 76. STEPS 1) COMPLETE TRANSFIXION INCISION 2) NASAL STRUCTURE MOBILISATION 3) SUBLABIAL INCISION 4) ELEVATE PERIOSTEUM OF MAXILLAUPTO INFRAORBITAL NERVE 5) MAXILLECTOMY ,UNCOMPLICATED CRANIOFACIAL RESECTION IS PERFORMED  COMPLICATIONS HEMATOMA NASALVESTIBULAR STENOSIS INFECTIONS 76 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  77. 77. Orbital exenteration indications  Involvement of orbital apex  Involvement of extra-ocular muscles  Involvement of bulbar conjunctiva or sclera  Lid involvement beyond a reasonable hope for reconstruction  Non-resectable full thickness invasion through periorbital into retrobulbar fat5/23/2020 77NEOPLASMS OF NASAL CAVITY & PNS
  78. 78. Orbital exenteration 5/23/2020 78NEOPLASMS OF NASAL CAVITY & PNS
  79. 79. Tarsorrhaphy 5/23/2020 79NEOPLASMS OF NASAL CAVITY & PNS
  80. 80. MEDIAL MAXILLECTOMY REMOVE MEDIAL WALLOF MAXILLAFROM THE FLOOR OF ORBIT TO FLOOR OF NOSE CAN BE EXTENDED TO INCLUDE LOWER ETHMOID SINUSES & LAMINA PAPYRACEA 80 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  81. 81. INDICATIONS  INVERTED PAPILLOMA  ANY BENIGN / MALIGNANT TUMOR LIMITED TO MEDIAL WALLOF MAXILLA OR LOWER PART OF ETHMOID COMPLICATIONS-  ORBIT INJURY  NASALVESTIBULAR STENOSIS  NASAL CRUSTING 81 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  82. 82. TOTAL MAXILLECTOMY  COMPLETE REMOVAL OF ALLELEMENTS OF MAXILLA  INDICATIONS TUMORS CONFINED TO MAXILLARY SINUS MUCORMYCOSIS  CONTRAINDICATONS- INVOLVEMENT OF OPTIC CANAL ORBITAL FISSURES NASOPHARYNX SPHENOID SINUS CAVERNOUS SINUS MIDDLE CRANIAL FOSSA 82 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  83. 83. STEPS 1 INCISION& EXPOSURE 2 ELEVATE MUCOSAL FLAP TO EXPOSE BONE OF HARD PALATE 3 DISSECT PERIORBITAL FROM FLOOR OF ORBIT 4 OSTEOTOMIES PALATAL OSTEOTOMY THROUGH THE FRONTAL PROCESS OF MAXILLA THROUGH THE BODY OF ZYGOMA THROUGH THE PTERYGOID PLATES 83 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  84. 84. Osteotomy cuts 5/23/2020 84NEOPLASMS OF NASAL CAVITY & PNS
  85. 85. TOTAL MAXILLECTOMY WITH ORBITAL EXENTRATION  INDICATION MAXILLARYSINUS CANCER EXTENDING INTO SOFT TISSUE OF ORBIT (INVOLVEMENT OF PERIOSTEUM ITSELF IS NOT AN INDICATION) MUCORMYCOSIS 85 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  86. 86. STEPS 1Extended weber fergusson incision 2 Orbital content dissected from orbital walls preserving the attachment to floor 3Ant & post ethmoidal arteries ligated 4Lacrimal sac & gland elevated 5Optic canal reached 6Optic nerve clamped,transfixed,cut 7 Contents of superior orbital fissure removed 8Maxillectomy performed 86 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  87. 87. Total maxillectomy done & incision closed 5/23/2020 87NEOPLASMS OF NASAL CAVITY & PNS
  88. 88. Palatal defect & prosthesis 5/23/2020 88NEOPLASMS OF NASAL CAVITY & PNS
  89. 89. 89 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  90. 90. 90 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  91. 91. MAXILLARY SWING APPROACH  INDICATIONS Tumors of nasopharynx & middle cranial base & infratemporal fossa  Displace the maxilla by rotating lat on greater palatine vessels or completely removing maxilla asa free graft  CONTRAINDICATIONS Tumors Extending Post To Carotid, AntCranial Fossa, Contralateral Skull Base 91 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  92. 92. CRANIOFACIAL RESECTION  DESCRIBED BYDANDY IN 1941  DEVELOPED BYKetcham et al,Clifford  PRESENT 3APPROACHES DESCRIBED BYCheesman & Reddy  3 TYPES  1 CRANIOFACIAL (TRANSORBITAL) RESECTION An extended medial maxillectomy using lateral rhinotomy incision and allows wide exposure of ethmoid roof and orbital periosteum. 92 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  93. 93. Type 2 CRANIOFACIAL (WINDOW CRANIOTOMY) RESECTION Alateral rhinotomy for anterior access and extended superiorly in a frown line to the frontal bone. Asmall midline ‘window’ craniotomy made to access floor of ant. Cranial fossa. This gives exposure of both ant &post ethmoids, dura , adjacent brain &also into sphenoid , the orbit, the pterygopalatine fossae and the skull base centrally. 93 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  94. 94. Type 3 CRANIOFACIAL RESECTION  PERFORMED IN CONJUNCTION WITH NEUROSURGERY TEAM  COMBINES TRANSFACIALAPPROACH & CRANIOTOMY LIKE FRONTOLATERAL CRANIOTOMY LATERAL CRANIOFACIAL RESECTION suitable to clear infratemporal fossa 94 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  95. 95. Cranio-facial resection 5/23/2020 95NEOPLASMS OF NASAL CAVITY & PNS
  96. 96. Surgical Options - CFR Craniofacial resection 96 • Introduced by Smith et al., 1953 Frontoethmoidectomy 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  97. 97. INDICATIONS  RESECTION OF TUMORS INVOLVING CRIBRIFORM PLATE, ETHMOID SINUS, INTRACRANIAL EXTENSION  ESTHESIONEUROBLASTOMA  ADENOCARCINOMA & SCC  SARCOMAS  SINONASAL UNDIFFERENTIATED CARCINOMA  ADENOID CYSTIC CARCINOMA  MELANOMA  BENIGN TUMORS WITH LOCAL SPREAD  DESTRUCTIVE GRANULOMA  SKULL BASE OSTEOMYELITIS  INVASIVE FUNGAL INECTION 97 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  98. 98. STEPS DONE BYCOMBINED BICORONAL &TRANSFACIAL INCISION 1 PERICRANIAL FLAP ELEVATED (IN ADDITION A TEMPORAL GALEAL FLAP CAN BE EMPLOYED) 2 FRONTAL CRANIOTOMY 3 DURA ELEVATED 4 INTRACRANIAL BONE CUTS EXTENDED ASPER REQUIREMENTS 5 TANSFACIAL SURGERY PERFORMED 6 TOTAL ETHMOIDECTOMY &REMOVAL OF DISEASE DONE 98 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  99. 99. COMPLICATIONS  PERIOPERATIVE MORTALITY 1.3-7.7%  COMPLICATIONS INTRACRANIALrisk of CSF leak, meningitis, brain abscess, brain injury-mental status changes, stroke, coma EXTRACRANIAL  Loss of sense of smell (lifelong) ,  Blood loss (transfusion)  Damage to adjacent structures leading to Nasal crusting, nasal distortion, nasal obstruction, facial pain, facial numbness, epiphora, septal perforation, anosmia, blindness, diplopia 99 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS
  100. 100. 100 5/23/2020 NEOPLASMS OF NASAL CAVITY & PNS

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