Benign Neoplasms of the Nose Ivan El Sayed, MD Disclosure - - PDF document

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Benign Neoplasms of the Nose Ivan El Sayed, MD Disclosure - - PDF document

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Department of Otolaryngology Head and Neck Surgery Pursuing Wellness Through Teaching, Learning and Healing Benign Neoplasms of the Nose Ivan El Sayed, MD Disclosure

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SLIDE 1

BenignNeoplasmsoftheNose

IvanElSayed,MD

DepartmentofOtolaryngology HeadandNeckSurgery PursuingWellnessThroughTeaching,LearningandHealing

Disclosure

  • PrincipalInvestigator:GrantSupportfor“Skull

BaseApproachSelection”.ResidentCourse StrykerCorporation.

– AcombinedNeurosurgeryandOtolaryngology lecture/anatomicdissectioncourseforseniorlevel residents.

  • PatentTechnologyrelatedtogoldnanorods

fortherapyanddiagnosisofcancer.

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SLIDE 2

ArrayofPathologies

  • Epithelial

– Nasalpolyposis – Invertedpapilloma

  • Vascular

– JuvenileNasopharyngealAngiofibroma – Hemangioma

Otherlesions

  • Osseocartilaginous

– Osteoma,chondroma, fibrousdysplasia,

  • Softtissue

– Myxoma,leiomyoma

  • Neurogeniclesions

– schwannoma – neurofibroma – meningioma

Rosai Dorfman Disease

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SLIDE 3
  • Unilateralnasalobstructionismostcommon

presentingsymtpom ofanytumorofthenasal tract.

  • Osteoma andIParethemostcommontumors

InvertedPapilloma

  • 2nd mostcommonlesion
  • 15%ofallsurgicallyremovednasallesions
  • Frequentlyarisefromlateralnasalwall
  • Maxillarysinussecondmostcommonsite
  • Rarelyinvolvedprimarily

– Frontal,sphenoid,sphenoid

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SLIDE 4

OriginofLesion

  • Oftenpedunculated
  • Canhavebroadbasemakingorigindifficultto

determine.

  • Hyperostosisandosteotic changesoften

identifiedatbaseoflesiononCTimaging.

AJNRAmJNeuroradiol.2007Apr;28(4):61821.FocalhyperostosisonCTof sinonasal invertedpapillomaasapredictoroftumororigin.LeeDK,Chung SK,Dhong HJ,KimHY,KimHJ,BokKH.

InvertedPapilloma

  • 310%riskofcancer(SCCA)
  • Mayhaveviraletiology
  • HPVDNAfound(6,11,16,18)

– HPV16,18maybeassociatedwithSCCA transformation

  • PhysicalExam

– Polypoid lesion Papillaryappearance

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SLIDE 5

InvertedPapilloma

  • Keytoremovalisresectionalongthe

subperiosteal plane,drilloutdiseasedmucosa frombone

  • Mostaccessiblenowtoendoscopicapproach

EndoscopicApproachtoIP

  • Acceptableapproach
  • Reccurence rate

– pre1970’s 4080% – 1980’sLateralrhinotomy withmedialmaxillectomy: 2030% – Endoscopic1520%(OHNS2006Mar;134(3):47682.)

  • Contraindications(relative)

– Extensivefrontalsinus – Supraorbitalcell – Intradural extension?

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SLIDE 6

VascularTumors

  • Hemangioma’s
  • JNA

JNA

  • JNASecondmostcommonsinonasal lesion

– TeenageMales – Vascularendotheliumlinedbyfibrousstroma – Atumororpostulatedavascularmalformationof abranchial arteryarisingduringembrogenesis. – Hypervascular lesiononphysicalexam – DoNotbiopsyinclinic

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SLIDE 7

JNA

  • Epicenterisatthe

pterygopalatine fossa

  • Growththroughtypical

patternsalongskullbase

  • EarlyPhase

– ExtendsthroughSPA forameninto nasopharynx – Alongvidian nerveinto sphenoidsinusfloor – Extendslaterallyintothe ITF – Anteriorlybowsthe posteriormaxillarywall

  • LatePhase

– Canextendintracranially viainferiorandsuperior

  • rbitfissure

– ThroughITFtoCheek – AlongMaxillaryV3nerve intoparasellar region

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SLIDE 8

SymptomsJNA

  • Nasalobstruction
  • Epistaxis
  • CheekSwelling
  • Proptosis canoccur

JNAEndoscopicapproach?

  • Achievablewhenlimitedto:

– Maxillarysinus – Ethmoid – Sphenoid – Pterygoid fossaandITF – Orbit – Paracavernous area

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SLIDE 9

JNA

  • Openapproachusuallyneeded:

– Involvemiddlefossafloor – Encaseinternalcarotid – Recurrenceincriticalarea

PreoperativeEmbolization

  • Perform48hoursorless

priortosurgery

  • Superselectiveembolization

possile

  • Mapourremainingfeeder

fromIACandVertebral arteries.

  • Ifcarotidencased:aballoon
  • cclusiontestisperformed

preoperatively

– Optionsofsacrificeor stentingcarotid

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SLIDE 10

EmbolizationControversy

  • Devascularized tumoratperipherymaybe

unrecognizedintraop andleftbehind?

KeytoJNASurgery

  • VascularControl
  • Subperiosteal Dissection
  • Drilloutbasisphenoid wheretumorembeds

inboneforcompleteresection

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SLIDE 11

Unresectable orResidualTumor?

  • LowDoseradiotherapy 35Gycancontrol

lesion.

  • Monitoring?

– Mostrecurrencesarediagnosedwithin1yearof surgery – EndoscopicSurgeryreportsrecurrencerateof5 15%

JNA

  • Continuepostoperativesurveellance for

recurrence

– Physicalexam – MRI

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SLIDE 12

Osteoma

  • Oftenincidentalfinding
  • 3%ofpopulationhaving

sinusCT

  • 2050yearolds
  • Frontalsinusmost

frequentsite

  • Associatedwith

headache

  • Slowgrowingtumor

Osteoma

  • Frequentlyinvolvethefrontalsinus
  • Endosocopic resection

– Amenableforlesionsmedialtomedialorbitwall – OntheposteriorwallofFS – FrontalsinusAPopeningis>1cm – Lesionsremovedbycentraldebulking andshelling

  • utercore

– Consistencyrangesfromhardtosoft

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SLIDE 13

Osseouslesions:whentointervene?

Surgery

  • Growthnearopticnerve

cuasing lossofvision?

  • Proptosis
  • Cosmeticdeformity
  • Pain(osteomas?)

Observation

  • Nonobstructivemass
  • Notthreateningcritical

structures

  • Risk>Benefit?

Presentation

  • Incidentalfinding
  • Unilateralnasalobstruction/rhinorhea
  • Epistaxis
  • Facialdistortion
  • Epiphoria
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SLIDE 14

WorkUp

  • History

– Cranialnerve dysfunction? – Clearrhinorhea? – Headaches

  • Exam:KeyPoints

– OcularExam – CN5pinprick – Trismus?

  • Rhinoscopy

– AppearanceLesionmay suggestthediagnosis – Hypervascular,large bloodvessels – Polypoid appearance IP

WorkUp?

  • Imagingfirst
  • ImagingshouldruleoutJNAorvascularlesion
  • Needdiagnostictissue?

– Nonvascularlesion canbiopsyinclinic – Vascularlesions

  • Donotbiopsyinclinic
  • FNAcanbeperformed(notcoreneedle).
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SLIDE 15

Imaging

  • CTScan

– JNAwideningthePTF – Hyperosteotic spiculeatbaseofIP

  • MRI

Extrinsic/Otherlesions

  • Encephalocele
  • Pseudotumor/Fibroinflammatory lesions
  • Rosaidorfman
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SLIDE 16

Management

  • Pathology?

– IP riskofmaligancy,locallyinvasive

  • Expecteddiseasecourse
  • Symptomatology

– Fibrousdysplasia treatcosmesis andmasseffect – JNA bleeding,expectedgrowth

SurgicalTherapy

  • Stepladderapproach

Transnasal Transeptal/MedialMaxillectomy EndoscopicAnteriormaxillotomy Sublabial Transfacial

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SLIDE 17

AClearUnderstandingofParanasal SinusAnatomy

MidlineLesions

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SLIDE 18

Case:Osteoma

Transnasal Approach:Hemangioperiocytoma of NasalSeptum

  • LimitedLesions

– Needaccessaround tumor – Uncinectomy – Ethmoidectomy – ?Skullbaseinvovled?

Hemaniopericytoma

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SLIDE 19

MidlineLesions FibrousDysplasiawithVisionLoss

  • Transnasal Approachwith

widecorridor

– FibrousDysplasiaharmsvia masseffect – Goalisdecompression

  • Createsurgicalcorridor

– Ethmoidectomy – MidTurbinateresection – Widesphenoidotomy

37

FrontalSinusExtension?

  • Draf IIBorDraf

IIIProcedure

  • Addlynchincision

ifnecesarry

  • Iftoolateral–

requiresfrontal

  • steoplasticflap
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SLIDE 20

FrontalSinusInvolvement

  • Lynchwithfronto

ethmoidectomy forlimitedlesions

  • Osteoplasticflap

forextensive lesions

LateralLesions

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SLIDE 21

MedialMaxillectomy

  • Iflaterallesion,remove

medialmaxillarywall

Robinsonetal.TheLaryngoscope Volume115,Issue10,pages1818–1822,October2005

UnderstandthePtergyoid Wedge

  • Vidian arteryisguideto

CarotidArteryandmost thingsbad

  • Lateraliscavernoussinus
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SLIDE 22

Schwannoma: EAMandTransptergyoid appraoch

ComparisonofThreeApproaches

  • Transnasal
  • Transeptal
  • EAM

Pletcher,ElSayed.Surgeryof theInfratemporal Fossa

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SLIDE 23

AnteriorMaxillotomy

ElSayedI,PletcherS,etal.Laryngoscope.2011Apr;121(4):6948.

TumorDissection

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SLIDE 24

47

EAMProvideAnterior/LateralAccessJNA

ReachAnteriorRamus DissecttoGreaterSphenoid Wing

MorbidityisLittleafterEAM

  • MinimalDeformity
  • ~2mmretractionala
  • Perialar andincisor

numbness

4yearsafter JNARsxn

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SLIDE 25

Sublabial Incision

  • CaldwellLucApproach
  • Midfacial Degloving

50

Sublabial Incision CanAugmentwithEndoscope

SuperiorAccesstoGSphWing PosteriorInferiortoCarotid

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SLIDE 26

Transfacial Incision

  • Ifyouneedit.
  • LesionExtendsbeyondsafelimits
  • Notalesionthatcanbe“debulked”

JNA

  • LateralExtensioninto

cheek

  • Skullbaseinvasionin

sphenoid

  • FacialDislocation
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SLIDE 27

Whatiflesionextendsinferiorlyinthe ITF?

  • ForSelectlesions

– Transptergyoid – EAM – Transcervical

Summary

  • Themanagementofbenignlesionsofthe

sinonasal tractisoftenobservationorsurgical intervention.

  • Endoscopicapproachesplayasignficant role

inthemanagementoftheselesionwithlow morbidityandacceptablecomplicationrates.