Nose & Sinuses

DISEASES OF THE NOSE AND PARANASAL SINUSES RYAN DUNCAN, MD PGY-4 RESIDENT

OTOLARYNGOLOGY-HEAD AND NECK SURGERY February 6, 2006

NASAL ANATOMY

NASAL ANATOMY

NASAL ANATOMY

Bony Structure Ethmoid Maxilla Palatine Lacrimal Pterygoid plate of Sphenoid Nasal Inferior Turbinate

Sinus Anatomy Overview 7 bones 4 paired sinuses 4 turbinates 3 meati Drainage system Nervous supply Vascular supply Related structures

Arterial Supply

External Carotid Maxillary A. Sphenopalatine Internal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear

Innervation

VIRAL RHINITIS 

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Inflammation and swelling of the mucous membranes of the nose usually caused by rhinovirus (common cold) Symptoms consist of runny nose, congestion, post-nasal drip, cough, and a low-grade fever Diagnosis made by history; adjunct tests usually not necessary

VIRAL RHINITIS   

Complications may prolong illness often triggers asthma attacks Secondary infections: congestion in nose/ear blocks normal drainage allowing bacteria to grow  sinusitis, otitis media

VIRAL RHINITIS-TREATMENT  

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No vaccines available Echinacea, Vit C, Zinc effectiveness not confirmed Currently available antiviral drugs not effective Symptomatic treatment with antihistamines, decongestants, cough preparations

Function of Paranasal Sinuses        

Humidifying and warming inspired air Regulation of intranasal pressure Increasing surface area for olfaction Lightening the skull Resonance Absorbing shock Contribute to facial growth generate 1 L mucus/day

Rhinosinusitis Introduction  37 million Americans suffer from “sinusitis”  25 million office visits in 1994-incidence increasing  Over $200 million spent on prescriptions for cold products; over half is for products containing antihistamines  97 % of patients who see a physician with “cold symptoms” receive a prescription

Rhinosinusitis Defining “Sinusitis”  Acute rhinosinusitis (ARS)  Subacute rhinosinusitis (SARS)  Chronic rhinosinusitis (CRS)  Recurrent acute rhinosinusitis (RARS)  Acute superimposed upon chronic rhinosinusitis (ARS/CRS)

Rhinosinusitis Major Symptoms  Facial pain/pressure  Facial congestion  Nasal obstruction  Purulent PND  Altered sense of smell  Fever (ARS)

Minor Symptoms  Headache  Fever (all nonacute)  Halitosis  Fatigue  Dental pain  Cough  Ear pain/pressure

Rhinosinusitis Acute Rhinosinusitis  Duration < 4 weeks  > 2 major or 1 major and 2 minor factors or purulence seen on examination Subacute Rhinosinusitis  Duration-4-12 weeks

Middle turbinate Septum

MSO

Rhinosinusitis Chronic Rhinosinusitis  Duration-> 12 weeks Recurrent Acute Rhinosinusitis  > 4 episodes/yr. of ARS with symptoms lasting > 7 days with no intervening signs and symptoms of CRS Acute Exacerbation of Chronic Rhinosinusitis

CRS-”Empty nose”-Pseudomonas, Staph. aureus

MT remnant

Septum

MSO

Rhinosinusitis Diagnosis  Physical examination-anterior rhinoscopy vs. nasal endoscopy    

Edema Hyperemia Purulence Polyps

Rhinosinusitis Diagnosis  Plain radiography of the paranasal sinuses  Magnetic resonance imaging  Computerized tomography (noncontrast)   

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Screening CT Standard CT Timing of CT

Other tests

Rhinosinusitis Management  Goals  

Elimination of infection Restoration of ventilation and drainage

Rhinosinusitis Surgical Management  Prior to 1985, most surgery via external approach with emphasis on maximum tissue removal  With introduction of functional endoscopic sinus surgery (FESS) in 1985, emphasis is on maximum tissue preservation

Rhinosinusitis Surgical Management  ARS-no role for surgery except for management of complications  CRS-indicated for medically refractory disease; 80-98 % improvement, revision rate < 10 %, major complications <0.3 %  RARS-focused surgery often helpful

Techniques of Functional Endoscopic Sinus Surgery

MT MT LNW

LNW

Uncinectomy

Techniques of Functional Endoscopic Sinus Surgery Maxillary Antrostomy

Accessory ostium

0 degree telescope

MSO

45 degree telescope

Rhinosinusitis Surgical Management  Computer assisted surgery (CAS) of the anterior skull base and paranasal sinuses has been commercially available since 1996  CAS has allowed us to safely expand minimally invasive endoscopic transnasal techniques

Rhinosinusitis Conclusion  “Sinusitis” is a complicated disease  Defining categories is beneficial  Management options are varied  Surgical therapy plays a role for a well-defined, small population of patients

EPISTAXIS (nosebleeds)

Why bleeding from the nose ?

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Vascular organ secondary to incredible heating/humidification requirements Vasculature runs just under mucosa (not squamous) Arterial to venous anastamoses ICA and ECA blood flow

EPISTAXIS         

External Carotid Artery -Sphenopalatine artery -Greater palatine artery -Ascending pharyngeal artery -Posterior nasal artery -Superior Labial artery Internal Carotid Artery -Anterior Ethmoid artery -Posterior Ethmoid artery

Kesselbach’s Plexus/Little’s Area: -Anterior Ethmoid (Opth) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX)

Woodruff’s Plexus: -Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)

Anterior vs. Posterior  

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Maxillary sinus ostium Anterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severe Posterior: older population, usually from Woodruff’s plexus, more serious.

Etiology 

Local factors       

Vascular Infectious/Inflammatory Trauma (most common) Iatrogenic Neoplasm Dessication Foreign Bodies/other

Etiology 

Systemic factors   

Vascular Infection/Inflammation Coagulopathy

Local Factors -- Vascular 

ICA Aneurysms  

extradural cavernous sinus

Local Factors Infection/Inflammation 

Rhinitis/Sinusitis    

Allergic Bacterial Fungal Viral

Local Factors - Trauma     

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Nose picking Nose blowing/sneezing Nasal fracture Nasogastric/nasotracheal intubation Trauma to sinuses, orbits, middle ear, base of skull Barotrauma

Nasal Fracture with Septal Hematoma

Local Factors - Iatrogenic nasal injury   

Functional endoscopic sinus surgery Rhinoplasty Nasal reconstruction

Local Factors - Neoplasm 

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Juvenile nasopharyngeal angiofibroma Inverted papilloma SCCA Adenocarcinoma Melanoma Esthesioneuroblastoma Lymphoma

Local Factors – Dessication 

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Cold, dry air—more common in wintertime Dry heat—Phoenix and Death valley Nasal oxygen Anatomic abnormalities Atrophic rhinitis

Local Factors - Other

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Self-inflicted (pedi) vs. traumatic foreign bodies Intranasal parasites Septal perforation Chemical (cocaine, nasal sprays, ammonia, etc.)

Systemic Factors -- Vascular  

Hypertension/Arteriosclerosis Hereditary Hemorrhagic Telangectasias (OWR)

Epistaxis

R

L

Osler-Weber- Rendu (HHT)

Systemic Factors – Infection/Inflammation     

Tuberculosis Syphillis Wegener’s Granulomatosis Periarteritis nodosa SLE

Systemic Factors – Coagulopathies 

Thrombocytopenia Platelet dysfunction  

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Clotting Factor Deficiencies   

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Systemic disease (Uremia) drug-induced (Coumadin/NSAIDs/Herbal supplements) Hemophilia VonWillebrand’s disease Hepatic failure

Hematologic malignancies

Etiology and Age 

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Children—foreign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o) Adults—trauma, idiopathic Middle age—tumors Old age--hypertension

Initial Management    

ABC’s Medical history/Medications Vital signs—need IV? Physical exam  

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Anterior rhinoscopy Endoscopic rhinoscopy

Laboratory exam Radiologic studies

bayonet forcepts

vaseline gauze

suction T.C.A. bacitracin

gelfoam good light

anesthetic epistat

Afrin endoscopes silver nitrate

suction bovie/bipolar

merocels surgicel

Non-surgical treatments  

Control of hypertension Correction of coagulopathies/thrombocytopenia 

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FFP or whole blood/reversal of anticoagulant/platelets

Pressure/Expulsion of clots Topical decongestants/vasocontrictors Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie) Nasal packing (effective 80-90% of

Non-surgical treatments – on d/c      

Humidity/emolients Discontinue offending meds Nasal saline sprays Avoidance of nose picking/blowing Sneeze with mouth open Avoid straining/bedrest

Nasal packs 

Anterior nasal packs  

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Posterior nasal packs  

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Traditional Recent modifications Traditional Recent modifications

Ant/Post nasal packing

TSS—Nugauze vs. Merocel Electron microscopy

Posterior Packs – Admission 

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Elderly and those with other chronic diseases may need to be admitted to the ICU Continuous cardiopulmonary monitoring Antibiotics Oxygen supplementation may be needed Mild sedation/analgesia

Indications for surgery/embolization 

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Continued bleeding despite nasal packing Pt requires transfusion/admit hct of <38% (barlow) Nasal anomaly precluding packing Patient refusal/intolerance of packing Posterior bleed vs. failed medical mgmt after >72hrs (wang vs. schaitkin)

Selective Angiography/embolization

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Helps identify location of bleeding Embolization most effective in patients who   

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Still bleeding after surgical arterial ligation Bleeding site difficult to reach surgically Comorbidities prohibit general anesthetic

Effective only when bleeding is >.5 ml/min 90+% success rate, complication rate of 0.1% Only able to embolize external carotid & branches Complications: minor (18-45%)/major (0-

Surgical treatment     

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Transmaxillary IMA ligation Intraoral IMA ligation Anterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligation External carotid artery ligation Septodermoplasty/Laser ablation

Transmaxillary IMA ligation   

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Waters view Caldwell-Luc Electrocautery of posterior wall before removal Microscopic dissection and ligation of IMA --descending palatine & sphenopalantine most important Recurrence rate (failure rate) of 1015% Complication rate of 25-30% (oa

Intraoral IMA ligation 

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Posterior gingivobuccal incision beginning at second molar Temporalis mm split and partially dissected IMAX visualized, clipped and divided Advantages: children/facial fractures Disadvantages: more proximal ligation Complications: trismus, damage to

Ant./Post. Ethmoidal ligation 

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Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclear Lynch incision Fronto-ethmoid suture line 12-24-6 (14-18, 8-10, 4-6)

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Transnasal Endoscopic Sphenopalatine Artery ligation

Follow Middle Turbinate to posteriormost aspect Vertical mucoperiosteal incision 78mm anterior to post middle turb (between mid. and inf. turbs) Elevation of flap—ID neurovascular bundle at foramen Ligation with titanium clip Reapproximate flap Complications –few, Failures—0-13%

Transnasal Sphenopalatine Artery ligation

ECA ligation    

Effectiveness Anterior border of SCM ID ECA/ICA Ligation after clear that surrounding structures are safe.

Septodermoplasty/Laser 

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Remove mucosa from anterior ½ septum, floor of nose, lateral wall STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autografts Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod disease Still bleed, but not as bad Definitive treatment (severe disease) —closure of nose

Statistically speaking,…. 

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Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs. Others compared all medical treatment to surgery and showed cost cut using medical management. Complication rates: posterior packs-2540%, embolization 27%, IMAX ligation 28% Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equal

Neoplasms of Nose and Paranasal Sinuses  

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Very rare 3% Delay in diagnosis due to similarity to benign conditions Nasal cavity  

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½ benign ½ malignant

Paranasal Sinuses 

Malignant

Neoplasm 

Benign 

Schneiderian papilloma Squamous  Inverted-13 % incidence of malignant degeneration  Cylindrical 

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Malignant   

Squamous cell carcinoma Salivary gland tumors Neuroepithelial tumors

MRI demonstrating right nasal mass with no intracranial involvement

Nasal mass

Nasal mass

Septum

Angiofibroma

Neoplasms of Nose and Paranasal Sinuses   

Multimodality treatment Orbital Preservation Minimally invasive surgical techniques

Epidemiology  

Predominately of older males Exposure:  

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Wood, nickel-refining processes Industrial fumes, leather tanning

Cigarette and Alcohol consumption 

No significant association has been shown

Location 

Maxillary sinus 

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Ethmoid sinus 

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20%

Sphenoid 

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70%

3%

Frontal 

1%

Presentation 

Oral symptoms: 25-35% 

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Nasal findings: 50% 

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Obstruction, epistaxis, rhinorrhea

Ocular findings: 25% 

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Pain, trismus, alveolar ridge fullness, erosion

Epiphora, diplopia, proptosis

Facial signs 

Paresthesias, asymmetry

Radiography 

CT  

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Bony erosion Limitations with periorbita involvement

MRI 

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94 -98% correlation with surgical findings Inflammation/retained secretions: low T1, high T2 Hypercellular malignancy:

Benign Lesions     

Polyps Papillomas Osteomas Fibrous Dysplasia Neurogenic tumors

NASAL POLYPS 

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Benign, semitransparent lesions Arise from nasal mucosa Caused by chronic inflammation a/w asthma, CF, aspirin intolerance, CRS, Allergic Rhinitis

NASAL POLYPS   

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Nasal Endoscopy CT/MRI Medical Tx: topical/systemic steroids Surgical Tx: FESS with polypectomy

Papilloma  

Vestibular papillomas Schneiderian papillomas derived from schneiderian mucosa (squamous)   

Fungiform: 50%, nasal septum Cylindrical: 3%, lateral wall/sinuses Inverted: 47%, lateral wall

Inverted Papilloma    

4% of sinonasal tumors Site of Origin: lateral nasal wall Unilateral Malignant degeneration in 2-13% (avg 10%)

Inverted Papilloma Resection 

Initially via transnasal resection: 

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Medial Maxillectomy via lateral rhinotomy:  

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50-80% recurrence Gold Standard 10-20%

Endoscopic medial maxillectomy: 

Key concepts:  

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Identify the origin of the papilloma Bony removal of this region

Recurrent lesions:  

Via medial maxillectomy vs. Endoscopic resection 22%

INVERTED PAPILLOMA

Osteomas 

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Benign slow growing tumors of mature bone Location: 

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Frontal, ethmoids, maxillary sinuses

When obstructing mucosal flow can lead to mucocele formation Treatment is local excision

Fibrous dysplasia 

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Dysplastic transformation of normal bone with collagen, fibroblasts, and osteoid material Monostotic vs Polyostotic Surgical excision for obstructing lesions Malignant transformation to rhabdomyosarcoma has been seen with radiation

Neurogenic tumors 

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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

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

Squamous cell carcinoma  

Most common tumor (80%) Location:  

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Maxillary sinus (70%) Nasal cavity (20%)

90% have local invasion by presentation Lymphatic drainage:  

First echelon: retropharyngeal nodes Second echelon: subdigastric nodes

Treatment 

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88% present in advanced stages (T3/T4) Surgical resection with postoperative radiation 

Complex 3-D anatomy makes margins difficult

Adenoid Cystic Carcinoma 

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3rd most common site is the nose/paranasal sinuses Perineural spread 

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Anterograde and retrograde

Despite aggressive surgical resection and radiotherapy, most grow insidiously. Neck metastasis is rare and usually a sign of local failure Postoperative XRT is very important

Mucoepidermoid Carcinoma  

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

Adenocarcinoma

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2nd most common malignant tumor in the maxillary and ethmoid sinuses Present most often in the superior portions 

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Strong association with occupational exposures

High grade: solid growth pattern with poorly defined margins. 30% present with metastasis Low grade: uniform and glandular

Hemangiopericytoma  

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Pericytes of Zimmerman Present as rubbery, pale/gray, well circumscribed lesions resembling nasal polyps Treatment is surgical resection with postoperative XRT for positive margins

Melanoma 

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0.5- 1.5% of melanoma originates from the nasal cavity and paranasal sinus. Anterior Septum: most common site Treatment is wide local excision with/without postoperative radiation therapy END not recommended AFIP: Poor prognosis 

5yr: 11%

Olfactory Neuroblastoma Esthesioneuroblastoma 

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Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells. Kadish Classification   

A: confined to nasal cavity B: involving the paranasal cavity C: extending beyond these limits

Olfactory Neuroblastoma Esthesioneuroblastoma 

UCLA Staging system 

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T1: Tumor involving nasal cavity and/or paranasal sinus, excluding the sphenoid and superior most ethmoids T2: Tumor involving the nasal cavity and/or paranasal sinus including sphenoid/cribriform plate T3: Tumor extending into the orbit or anterior cranial fossa T4: Tumor involving the brain

Olfactory Neuroblastoma Esthesioneuroblastoma   

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Aggressive behavior Local failure: 50-75% Metastatic disease develops in 2030% Treatment: 

En bloc surgical resection with postoperative XRT

Sarcomas 

Osteogenic Sarcoma 

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Most common primary malignancy of bone. Mandible > Maxilla Sunray radiographic appearance

Fibrosarcoma Chondrosarcoma

Rhabdomyosarcoma 

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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

Lymphoma  

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

Sinonasal Undifferentiated Carcinoma (SNUC)  

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

Metastatic Tumors 

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Renal cell carcinoma is the most common Palliative treatment only

Staging of Maxillary Sinus Tumors

Staging of Maxillary Sinus Tumors 

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T1: limited to antral mucosa without bony erosion T2: erosion or destruction of the infrastructure, including the hard palate and/or middle meatus T3: Tumor invades: skin of cheek, posterior wall of sinus, inferior or medial wall of orbit, anterior ethmoid sinus T4: tumor invades orbital contents and/or: cribriform plate, post ethmoids or sphenoid, nasopharynx, soft palate, pterygopalatine or infratemporal fossa or

Surgery 

Unresectable tumors:    

Superior extension: frontal lobes Lateral extension: cavernous sinus Posterior extension: prevertebral fascia Bilateral optic nerve involvement

Surgery 

Surgical approaches:      

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Endoscopic Lateral rhinotomy Transoral/transpalatal Midfacial degloving Weber-Fergusson Combined craniofacial approach

Extent of resection   

Medial maxillectomy Inferior maxillectomy Total maxillectomy

MIDFACIAL DEGLOVING

LATERAL RHINOTOMY

CRANIOFACIAL APPROACH

Treatment of the Orbit 

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Before 1970’s orbital exenteration was included in the radical resection Preoperative radiation reduced tumor load and allowed for orbital preservation with clear surgical margins Currently, the debate is centered on what “degree” of orbital invasion is allowed.

Current indications for orbital exenteration  

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Involvement of the orbital apex Involvement of the extraocular muscles Involvement of the bulbar conjunctiva or sclera Lid involvement beyond a reasonable hope for reconstruction Non-resectable full thickness invasion through the periorbita into

Conclusions 

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Neoplasms of the nose and paranasal sinus are very rare and require a high index of suspicion for diagnosis Most lesions present in advanced states and require multimodality therapy

REFERENCES   

www.utmb.edu/oto http://www.emedicine.com/PED/topic155 http://www.merck.com/mmhe/sec19/ ch221/ch221g.html