2. A FEW CHARACTERISTICS OF NOSE & P.N.S TUMOUR
Wide variety of tumors.
Short clinical course of patients afflicted with these neoplasms.
Rarity with which the tumors occur.
Nasal tumours are difficult to separate from paranasal sinus tumour except in early stage.
Most of them are malignant in nature and therefore poor prognosis for patients with nasal and paranasal sinus malignancy.
This has led many investigators to focus their attention on it.
Recent developments in fibre-optics, radiographic imaging, and a growing consensus on staging and nomenclature.
A vast amount of clinical information is now coming into focus and becoming available.
5. THE DISTRIBUTION OF
VARIOUS SITES FOR
PRIMARY TUMORS OF THE
NASAL CAVITY AND
THE DISTRIBUTION OF
TUMORS OF THE NASAL
CAVITY AND PARANASAL
6. SQUAMOUS PAPILLOMA
This verrucous growth is similar to skin warts.
It can arise fromthe vestibule andlower part of nasal septum.
These papillomas may be single/multiple and pedunculated/sessile.
• They needlocal excision. The cauterization of the base prevents
• They can be managedeven with cryosurgery or laser.
8. INVERTED PAPILLOMA/ RINGERTZ TUMOR:
• These are histologicallya squamous or transitional cellepitheliumsurroundingfibrovascular stroma with
• The neoplastic epitheliumof this variety of papilloma grows towards the underlying stroma rather
thanon the surface and hencethey are called INVERTEDPAPILLOMA.
• It is thought to be causedby human papillomavirus(HPV).
• Theyarise from the lateral nasalwalland have beenreported to be associated withsquamous cell carcinomain 5 to
• These are the most common benign tumour of nose .
• The invertedpapillomas are very muchknown for recurrence.
• CLINICALFEATURES –
1. These are mostlyseenin males of 40 -70 yearsof age.
2. Unilateral nasal obstruction and nasal discharge .
3. Theyarise from the lateral nasalwallat or nearmiddle meatus.
4. Theypresent as gray or reddishpolypoidmass.
5. It can invade the paranasal sinuses andorbit.
May also present
lamina papyracea is
9. Coronal T1-
intensity in the
• CT and MRIare complementaryand bothare neededto plan the appropriate surgical approach.
• CT is usedto define the extent of the disease and to identifyareas of bonyerosion.
• Up to 75% of patients withIPs have evidence of variousdegrees of bone destruction, which mayappear
as corticalthinning, remodeling, erosion, or sclerotic changes.
• Areas of bonythickeningmay represent the site of attachment of the tumor.
• CT alone hasa sensitivityof 69%and a specificityof 20%.
• T2-weighted images and contrast-enhancedT1- weighted MRIs are usedin conjunction to further
evaluatethe surroundingsoft tissueand to define the extent of orbital or intracranial involvement.
• Tumors will be of intermediateintensityon T2-weightedimages, whereas the inflammatorycomponent
will be of highsignal intensity.
• Additionally, the tumor will have intermediateintensityon T1 images withIV gadolinium enhancement;
retainedsecretions will not enhance but will be rimmed by a bright signal fromthe inflamed mucosa.
13. • Medial maxillectomyis the treatment of choice. It can
be performedby lateral rhinotomyor sublabial
degloving approach. Although endoscopicapproach
is being more preferrednowadays.
• Up to 20%of invertedpapillomas may show surface keratinization, and anywhere
from5% to 10% may show varying degrees of dysplasia. Thesetwo latter features,
although not necessarily indicative of malignancy, shouldreinforce the need for
thorough histologicevaluation of the lesion.
• Recurrence does not correlatewiththe subsequent development of malignancy. When
malignancydoes occur, it most frequentlymanifests in the formof squamous cell
carcinoma; however, verrucous carcinoma, mucoepidermoid carcinoma, spindle cell
carcinoma, and clear cell carcinoma also may be seen.
Wide surgical resection is the mainstay of treatment for inverted
papillomas and can be performedendoscopically or by an open
approachbased on the extent and location of the tumor
INVERTED PAPILLOMA: TREATMENT:
15. EXOPHYTIC PAPILLOMA/
TRANSITIONAL CELL PAPILLOMA/
FUNGIFORM PAPILLOMA/ SEPTAL
These are the papillomas arising fromthe
Schneiderian membrane withrich papillary
fronds and fibrovascular cores covered by
These tumours are more commonly seen in
men (2–10 times) between 20–50 years of age.
In contrast to invertedpapilloma------
I. Thesevariants are localised more on the lower anterior nasal septumwith
no significant lateralisation.
II. They are infrequent on the lateral nasal wall.
III. Malignant change in exophytic papilloma is rare.
16. ONCOCYTIC/ CYLINDRICAL CELL PAPILLOMAS:
• Thesetumours also arise fromthelateral nasal wall and likeinvertedpapillomas.
• They are in associationwith malignant disease.
• Histological pictureshows that theepithelial lining contains multiplelayers of eosinophilic
cells, goblet cells, and microcysts full of mucin.
• The highcontent of cytochrome C oxidase and mitochondria establishes thisoncocytic
• In contrast to inverted papilloma, there is equal distributionamong the sexes and HPVhas
not been isolatedfromthesevariants.
17. INTRANASAL MENINGOENCEPHALOCELE:
• Meningoencephalocele is usuallyseenin infants and youngchildren. It is herniation of braintissues and
meninges throughforamencecumor cribriformplate.
• Clinical: A smoothpolyp like massin the upper part of nose betweenthe septumand middle turbinatecan
be seen, whichincreases in size on cryingor straining.
• D/D: It can be easilymisdiagnosedas a polyp, whichif avulsedresults in CSF rhinorrhea andmeningitis.
• Biopsy: It is contraindicated.
• CT scan: It demonstrates the defect in the base of skull.
• Treatment: Frontal craniotomywithsevering the stalkfrom the brain is done alongwiththe repair of
dural andbonydefect. Aftersealing the cranial defect, intranasal massis removed.
FURSTENBERG'S TEST- compression of
the ipsilateral internal jugular vein usually
causes an encephalocele to enlarge. So,
this test is positive in encephalocele.
• Herniation of brain tissue withmeninges occurs througha congenital
bonydefect, whichmay be intranasalor extranasal.
• Clinical features:
An extranasalmeningoencephalocele presents withpulsatile
swelling. This cystic swellingis reducible and showscoughimpulse.
Swellingmay be present in the following sites:
1. Root of nose (naso-frontal variety).
2. Side of nose (naso-ethmoidal variety).
3. Anteromedialaspect of the orbit (naso-orbitalvariety).
• Treatment: It needs neurosurgery, whichincludes severingthe stalk
fromthe brainand repairing the bonydefect.
• Most of the gliomas, whichare nipped off portionsof encephalocele (during embryonic
development), are extranasal (60%).
• Othertypesinclude intranasal (30%) and bothintra and extranasal (10%).
• EXTRANASAL GLIOMAS:
Clinical feature: Firmencapsulatedsubcutaneous swellings may be seenon nasal
bridge,side of nose or nearthe inner canthus.
Treatment: Gliomais removedby external nasal approach.
• INTRANASAL GLIOMAS:
Patients are infantsand children.
It presents as a firmpolyp and maybe seenprotruding at the anterior nares.
FURSTENBERG'S TEST- compression of the ipsilateral internal jugular vein
usually causes an encephalocele to enlarge, but not a glioma. So, this test is
negative in nasal glioma.
20. NASAL DERMOID:
• There occurs widening of upperpart of nasal septum withsplayingof nasal bones and
Simple dermoid: It presentsas a midline swelling over the nasal bones anddoes not have
Dermoid cyst withsinus:
External pit: Infantsand childrenpresent witha pit or a sinus overthe dorsum of
nose. Hair maybe protrudingout fromthe sinus.
Intracranial connection: The sinustrack communicate intracranially. Dermoidcyst
lies between nasal bones and upper part of septum.
• Treatment:Surgeryconsists of splittingof the nasal bones and removal of cyst along withits
extensionin the upper part of the nasal septum. Intracranial extension needs associated
lies superficial to
sinus tract has an
external pit in the
midline of dorsum
21. OSTEOMA vs CHONDROMA
€Osteoma is formed of mature lamellar bone.
€The most common site is frontal sinus followed by ethmoidandmaxillary.
€Theyusuallyremain asymptomaticand are seenincidentallyon X-rays.
€The obstructionto the sinusostiumcan lead to mucoceleand pressure symptomsin
the orbit, nose andcranium.
€Treatment: Symptomatic osteomaneeds surgical removal.
§The various types include mixed, and fibro, osteoand angio- chondromas.
§Histological differentiation between benign and malignant tumors is not completely
§The common sites of originare ethmoid, nasal cavityand nasal septum.
§Theypresent as smooth, firmand lobulated growth.
§Treatment is wide excision because of their tendencyto malignant transformation.
23. MONOSTOTIC FIBROUSDYSPLASIA
@Site: The most commonsite is maxillafollowed by ethmoidand frontal sinuses.
@Clinical features: Patient developsdisfigurement of the face, nasal obstruction and
displacement of the eye.
@Treatment: Wide removal (surgical resculpturing) providesgoodcosmeticand
• This benign non-odontogenicjaw neoplasm
is a hamartomatous lesion. Normal bone is
replacedby fibroustissue, whichcalcifiesin
• It involvesjaw bones, more commonlyin
mandible than maxillaoccasionallyarising
withinthe maxilla. Theymay be polyostotic
and monostotic forms, withmonostotic
being more common.
24. (A)The plainx-rayfrontal viewshowingthe CLASSICALGROUNDGLASSAPPEARANCE.
(B) The 3D CT scan showingthe increased densityof the left maxillaimpinging on the
nasal bone and the orbit.
Giant fibrousdysplasiaof the left maxilla
impinging up on the orbit, nose and
distortion of the facial features
The oblique right lateral viewshowingthe
completeobstruction of the left nostriland the
encroachment of the oral cavityby the swelling
It is a tumor arising fromSchwanncells.
Between 25%and 45%of suchtumors have
been observedin the headand neck region,
where the vestibular nerve is the most
frequent site of origin.
Only 4%of headand neck schwannomas
originate fromthe sinonasal tract.
Ethmoid > Maxillary Sinus > Nasal Fossa >
SphenoidSinus; Involvementof more thanone
sinus is a not uncommon finding.
Age: 6-78yrs (25-55yrs).
The lesion is almost alwayssolitary, but
instances of multiple schwannomas have been
documented, particularly in Von
Sympatheticnerves to the septal blood vessels,
parasympathetic nerves to septal mucous glands,
and sensorynerves to thenasal septum
(nasopalatine nerve and the anterior and
posterior ethmoidal nerves) have been suggested
as structures of origin for a schwannoma of this
◦ Unilateral nasal obstruction;
◦ Mucopurulent rhinorrhea;
◦ Facial swelling;
◦ Proptosis and painwhenthe maxillary sinus
◦ Extensioninto the sphenoidsinus can lead to
diplopia (secondary to deficits of III, IV and VI
cranial nerves), deepretro-orbital pain and
occipital, frontal and bitemporal headache.
26. • CT clearlydepicts the relationship of the lesionto the
surroundingbonystructures; erosionis more common
withlarge schwannomas. The lesions usuallyhave a
mottled central lucency withperipheral intensification on
contrast-enhancedCT scans. The heterogeneous
appearance is relatedto areas of increasedvascularity
withadjacent non-enhancing cystic or necrotic regions.
• MRI is superior to CT in differentiating a tumorfrom
inflammatory changesand normal tissues; furthermore,
intracranial extension can be better delineated.
• Schwannomas havean intermediatesignal intensityon
T1-weighted images, whereasa T2-weighted signal varies
fromintermediateintensity(highlycellular lesion) to
non-homogeneouslyhighintensity(cystic and stromal