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Sinonasal
Tract
SAYED MOSTAFA HASHEMI MD
World Health Organization classification
common policy to obtain imaging studies, which can help to define the
vascularization of the mass and its relationships with adjacent structures and
to rule out a diagnosis of encephalomeningocele.
In general, our preference is MRI because it can clearly differentiate tumor
from retained secretions, allows higher contrast resolution, and may even
suggest the nature of a soft tissue lesion.
CT with contrast medium enhancement can be considered as a reasonable
alternative
Diagnostic biopsy
Even though most benign tumors of the sinonasal tract can now be managed
through an endoscopic approach, certain situations still require an external or
a combined procedure.
Need for an external or combined procedure may be clearly suggested by
imaging studies, but there are cases in which a definitive decision can be
made only during surgery.
Consequently, the possibility of switching from an endoscopic to an external
procedure must be discussed with the patient preoperatively
INVERTED PAPILLOMA
Inverted papilloma included in the group of sinonasal papillomas,
it is the second most common benign tumor of the sinonasal tract after osteoma, even though it
represents the most common surgical indication for a benign sinonasal tumor.
Incidence that ranges from 0.6 to 1.5 cases per 100,000 population annually.
Men are more commonly affected than women, and the lesion is typically seen in the fifth and sixth
decades of life.
site of origin
Inverted papilloma most frequently arises from the lateral nasal wall in the
fontanelle area.
The maxillary sinus is the second most commonly affected site, and frontal
and sphenoid sinuses are rarely involved primarily.
Often the lesion extensively involves more than one sinus, making it
impossible to assess the exact site of origin.
Diagnosis
The association of inverted papilloma with squamous cell carcinoma has been
overemphasized, with reported frequencies as high as 56%.
Recent data clearly show that the prevalence varies between 3.4% and 9.7%
and that a synchronous occurrence is more common than a metachronous
one.
The presence of human papillomavirus
(HPV)
Serotypes 16 and 18 have been specifically found to be associated with
inverted papillomas that show histologic signs of malignant transformation.
Imaging studies
Imaging studies are required to assess the extent and three dimensional
configuration of the lesion and to disclose its relationship with surrounding
structures (i.e., orbit, skull base, optic nerve, internal carotid artery)
These goals are best achieved by MRI with gadolinium enhancement,.which
also has the advantage over CT of better differentiating tumor from
inflammatory mucosal changes.
CTS
Numerous studies indicate that focal hyperostosis and osteitic changes seen
on CT may be considered reliable predictors of tumor origin. These findings
may also be identified by MRI
Surgical treatment
Endoscopic surgery is a reliable alternative to traditional external techniques for the vast majority of
lesions.
However, an exclusively endoscopic approach may be contraindicated in the event of
1) massive involvement of the mucosa of the frontal sinus and/or of a supraorbital cell;
2) transorbital extension, a very uncommon situation usually found in patients who have already undergone
one or more surgical procedures;
3) concomitant presence of a malignancy that involves critical areas;
4)presence of significant scarring and anatomic distortion from previous surgery.
key point of endoscopic surgery
To dissect the involved mucosa along the subperiosteal plane and to drill the
underlying bone whenever required by imaging and/or intraoperative
findings.
The extent of the operation is dictated by the site of the lesion and the area
of mucosa involved by the lesion.
Three basic types of endoscopic resections
are
1) The area of origin invariably located at the level of the pterygopalatine fossa,
2) its hypervascular appearance after contrast enhancement,
3) its pattern of growth.39 On MRI, the presence on both
T1- and T2-weighted sequences of several signal voids within the lesion,
indicating major intralesional vessels,
Differential Diagnosis
The frontal sinus is the most frequently involved anatomic site (~80% of
cases), followed by the ethmoid, the maxillary sinus, and, more rarely,
the sphenoid sinus.
Osteomas can be observed in conjunction with Gardner syndrome,
a genetic disorder characterized by multiple polyps of the colon
in association with osteomas of the skull and multiple soft tissue
tumors.
main theories have been proposed
Cavitation is a surgical trick that helps resect even large osteomas through
the nose; the core of the lesion is drilled with a cutting or diamond bur,
leaving a very thin shell of bone that can be easily fractured and dissected
from the adjacent tissues
The possibility of using a device that induces ultrasound bone emulsification
or performing piezosurgery has also been proposed. Cerebrospinal fluid leak
can be expected during these maneuvers if the lesion is in contact with dura
postoperative surveillance
The relevance of trauma such as habitual nose picking and nasal packing is
supported by the fact that most lesions are located in the anterior half of the
nasal cavity at the level of the Little area or on the head of the inferior and
middle turbinates.
clinical presentation
The objective of surgical treatment is different for the two lesions. Ossifying
fibroma requires radical resection, in view of both the high rate of relapses—
which accounts for 44% of lesions localized in the ethmoids81—and the
aggressive behavior of recurring tumors, with local destruction and potential
invasion of adjacent vital structures.
Successful removal of ossifying fibroma via an endoscopic approach has been
reported in the literature.
surgery For fibrous dysplasia
Schwannoma is a neurogenic tumor that arises from the Schwann cells of the
sheath of myelinated nerves.
This is a rare neoplasm that can be found in any part of the body; in 25% to
45% of cases, it is localized at the level of the head and neck. Only 4% of the
lesions involve the sinonasal tract, where the ethmoid, maxillary sinus, nasal
fossa, and sphenoid are involved (listed in order of decreasing frequency).
Sinonasal schwannomas