Sinonasal Carcinoma With Rhinotomy Lateral Approach
SINONASAL CARCINOMA WITH RHINOTOMY LATERAL APPROACH
Ashri Yudhistira, Farhat, Rizalina A Asnir, Siska Indriany Otorhinolaryngology Head and Neck Department Medical Faculty, University of Sumatera Utara
Introduction
Sinonasal malignancies are relatively rare comprising about 0.2 – 0.8% of all malignancies and 3% of head and neck malignancies. 77% of sinonasal tumors involve the maxillary sinus, 22 % Ethmoid sinus and 1 % sphenoid sinus and frontal sinus. 70 – 90% display invasion through at least one wall of the presenting sinus. 1
Cancer of nose and paranasal sinuses constitutes 0,44% of all body cancer in India (0,57% in males and 0,44% in females). Its incidence during the same period (year 2000) was 0,3% per 100,000 persons and second place is in China and Japan. 2
Most common pathological of sinonasal malignancies is squamous cell carcinoma (SCC) and adenocarcinoma which are strongly associated with environmental factors, including tobacco, alcohol and occupational exposure (e.g. to heavy metal particles such as nickel and chromium) and with workers in the leather, textile, furniture and wood industries, a recent report demonstrates a higher incidence of nasal cancer in cigarette smokers. 3,4
Early diagnosis is difficult because symptoms and signs are non-specific and closely resemble those of chronic sinusitis, allergic reaction and nasal polyposis. Initial symptoms are related to the effects of the mass causing unilateral nasal obstruction. Secondary infection is common, giving rise to a mucoid or purulent discharge. Epistaxis develops when the mucosa is ulcerated or tumour extends into the sinus wall. Tumours involving the ethmoid, maxillary, or frontal sinuses may cause proptosis, restriction of eye motility, diplopia or loss of vision. 3,4, 5
Universitas Sumatera Utara
Case Report
A 30 years old man consulted by Ophthalmologic outpatient clinic General Hospital of H. Adam Malik Medan to the ENT outpatient clinic on May 10th 2014 with chief complaint was swelling on the left cheek. It was experienced since the last eight months ago, the swelling begun at marble with size 2x1x1 cm, and became enlargement, with flat surface, immobile and tenderness was found. Swelling extends to the left orbita, vision on the left orbita became more decreased since for months ago and it was difficult to open. There were nasal obstruction, a history of blood and yellowish liquid out of nasal. Headaches was encountered intermittent. The complaint of the ear and throath was not found.
From the anterior rinoscopy examination, we found a narrow on the left nasal cavity, the left inferior turbinate was difficult to assess. The right one was narrow too and there was septum nasal deviation to the right and the right inferior turbinate was eutrofi. From the endoscopy examination on the left nasal cavity we found that furtherance to the right of the medial wall of the left maxillary sinus, the inferior turbinate was eutrofi and nasopharynx difficult to assess. The ear and oropharynx examination within normal limit. Left eye was swollen and there was edema in the letf medial cantus. There was no enlarged lymph nodes in the neck. (pic. 1)
Picture 1
After that we did the CT-Scan of the Nose and Paranasal Sinus examination with the result on May 22th 2014 : mass full fill the nasal cavity, maxillary sinus, anterior ethmoidalis
Universitas Sumatera Utara
and frontalis also left orbita which pull out the left bulbus oculi to left antero-supero-laterally which irregularitas of the infero-medial wall of orbita, medial wall of maxillary sinus and left ethmoidalis, suspect sinonasal carcinoma. Rhinosinusitis, right medial bulous concha and septal deviation. (pic 2)
Picture 2
We diagnosed this patient with suspect sinonasal carcinoma and we planned to do the operation with lateral rhinotomy approach. Previously, we did chest x-ray examination, ECG and laboratory examination with normal result and we consult to the anesthesia department. We did the operation on 10th June 2014 and we preapared three packed red cell. The following report of the operation :
1. The patient was lied on the surgical table with intravenous, chateter and endotracheal tube were attached, under general anesthesia
2. The surgical area and its surrounding were disinfected with betadhine and alcohol 96%. (pic. 3a)
3. And then we infiltrated the surgery area with pehakain.. (pic. 3b) 4. We made Weber Ferguson incision that are rhinotomy lateral incision (begins 4-5 mm
anterior to the medial canthus and over the nasal bone along the deepest portion of the nasomaxillary groove and following the alar crease) with horizontal incision below infraorbital rim and made the undermining until the mass was seen and its was attached on the anterior left maxillary wall and there was no destruction but the medial one was destruction. (pic. 3c,3d,3e)
Universitas Sumatera Utara
5. We took out the mass on it while bleeding controlled (pic. 3f) 6. To get in to the left maxillary cavity we made a hole by boor on the anterior left
maxillary wall and with endoscopy we looked polipoid mass on the left maxillary cavity and took it out. (pic. 3g-3j) 7. After that we put tamponade to the left maxillary cavity and infront anterior left maxillary cavity. (pic. 3k) 8. Then we made incision to the tissue inflammation on the left orbita canthus. (pic. 3k) 9. Surgical wound were sutured layer by layer and covered it with the steril gauze swabs. (pic. 3l) 10. Mass from the front of anterior left maxillary sinus wall (the left side) and mass from the left maxillary sinus (the right side). (pic. 4) Post operatively, we gave the patient with IVFD Ringer lactate 20gtt/I macro drip, ceftriaxon injection 1gr/12 hours, tranexamic acid 500 mg/12 hours, ranitidine injection 50mg/12 hours and dexamethason injection 5mg/8 hours (only one day). In the 4th day after the operation we taken out the tamponade (pic. 5) and the day after, the patient returned and the 9th day after the operation, sutured have opened all. (pic 5b). The histophatology result from the both mass were non keratinizing squamous cell carcinoma. We planned to give chemotherapy of Cisplatin 100mg/m2 + 5 FU with 3 cycles.
Universitas Sumatera Utara
AB DE
C F
GH
I
JK
L
Picture 3 Universitas Sumatera Utara
Picture 4
Picture 5a
Picture 5b
Discussion
Malignant tumors of the sinonasal tract constitute about 3% of tumors arising in the upper respiratory tract. They occur most commonly in white, and the incidence in males is twice the incidence in females. Exposure to industrial fumes, wood dust, nickel refining, and leather tanning has been implicated in the carcinogenesis of certain types of sinonasal malignant tumors. 2,4
Early feature of paranasal sinus malignancy are nasal stuffiness, blood stained nasal discharge, facial pain and may be facial paraesthesias and epiphora. Late features will depend on the direction of spread and extend of growth. Because many of the early symptoms simulate benign sinus disease, patients often delay seeking treatment and ultimately present with advanced-stage disease. Medial spread from maxilla sinus to nasal cavity gives rise to nasal obstruction, discharge and epistaxis. Anterior spread causes swelling of the cheeck. Superior spread of maxillary sinus invades the orbita causing proptosis, diplopia, ocular pain, ephipora, decreased visual acuity at the time of presentation. 1,2, 6 This is in accordance to the patient who has some complaint from nasal obstruction, epistaxis and/or nasal discharge,
Universitas Sumatera Utara
swelling of the cheek, propotosis, ocular pain, and loss of visual. Histologically, a malignant epithelial neoplasm originating from the mucosal epithelium of the nasal cavity or paranasal sinus that includes a keratinizing squamous cell carcinoma and non keratinizing carcinoma type. Sinonasal squamous cell carcinomas occur most frequently in the maxillary sinus (about 60-70%), followed by the nasal cavity (about 12-25%), ethmoid sinus (about 10-15%) and the sphenoid and frontal sinus (about 1%). 7 In this case, based on the results of anatomic pathology after surgery we found that was non keratinizing squamous cell carcinoma.
Regional and distant metastase are infrequent despite the advanced stage of the primary tumor. The incidence of cervical metastase on initial presentation varies from 1% to 26% with most series reporting less than 10%. In one large series, the 5 year incidence of neck metastase is 4,3% for primary ethmoid malignancies and 12,5% for primary maxillary malignancies. This number decreases in patients treated with radiation to the neck. 3 In this case, we did not found of nodal metastasis.
The choice of diagnostic studies should be guided by the results of a through head and neck examination. Assuming a working diagnosis of neoplasm on the basis of history and physical examination, the subsequent studies are directed toward estbalishing the extend of the lesion and its histologic findings. We have to do a biopsy to determine the type of cells contained in the mass and Imaging for sinonasal carsinoma like computed tomography scan and magnetic resonance imaging. 7,8 In this case we did CT Scan and did not do the biopsy at pre operatif because the mass cannot see from nasal cavity or other place in nasal with nasoendoscopy.
A staging system provide a guide to define the extent and prognosis of a tumor and also serves a communication tool, allowing different institutions to compare their experience with the use of different theraupetic modalities. The American Joint Committee on Cancer (AJCC) TNM staging system of the nose and paranasal sinuses is provide. 4 According to AJCC, we diagnosed this patient with Sinonasal Carsinoma stage III.
Surgical resection is usually recommended with curative intent. Palliative excision may be considered to alleviate intractable pain. To provide rapid decompression of vital structures or the bulk a massive lesion, thus freeing the patient from social embarrassment.4 In our case we did lateral rhinotomy approach to resection the mass of sinonasal carcinoma.
Radiation therapy is primary treatment for lymphoreticular tumors, for patient who are poor surgical candidates and for those patients who refuse surgery. 4
Universitas Sumatera Utara
The role of chemoterapy for sinonasal carsinoma is usually palliative, using its cytoreductive effect to relieve pain, obstruction, or to debulk a massive external lesion. Nevertheless, the failure of combination therapy, including surgery and radiation, to achieve local control, the need for deformating procedure or the shifting of cause of failure to distant metastases spearheaded the use of systemic and even topical chemotherapy in multimodal therapy protocols.4
Conclusion
We have reported a case of carsinoma sinonasal stage III and we did by rhinotomy lateral approach and horizontal inferior orbita incision. And we planed to gave the chemotheraphy after surgery.
References
1. Mohammed AW, Bakshi J, Nada R. Sinonasal undifferentiated carcinoma with contralateral cavernous sinus involvement. A rare case presentation. Current Research in Microbiology and Biotechnology. 2013:1(2):56-61
2. Dhingra PL. Disease of Ear, Nose and Throat : Neoplasma of Paranasal Sinuses. 12th ed. Australia : Reed Elsevier India Private; 2010:219-24
3. Thompson LDR. Sinonasal Carsinomas. Current Diagnostic Pathology. Mini Symposium Head and Neck Pathology.Elsevier.2006:12:40-53
4. Zimmer LA, Carrau RL. Neoplasma of the Nose and Paranasal Sinuses. In : Bailey BJ ,Johnson JT, Newelands SD, eds. Head & Neck Surgery Otolaryngology. Philadhelpia : Lippincott Williams & Walkins; 2014:2044-62
5. Vasan NR. Cancer Of The Larynx, Paranasal Sinuses, And Temporal Bone. In : Essential Otolaryngology Head & Neck Surgery, 9th Ed. Lee KJ. The McGraw-Hill 2008. p: 695701
6. Bruno CJ, Mesquita RA, Aquiar MCF. A Case of maxillary sinus carcinoma. Oral Oncology Extra. Elsevier.2005:42(4):157-59
7. Pilch BZ, Bouquot J, Thompson LDR. Tumours of the nasal cavity and paranasal sinuses. Available in : www.iarc.fr/en/publication/pdfs-online/pat-gen/
8. Weymuller J, Gal T. Neoplasm : In Head and Neck Surgery, 4th ed Vol 2. Cummings Otolaryngology, Chapter 51, 2009, P: 1197-1213
Universitas Sumatera Utara
Universitas Sumatera Utara
Ashri Yudhistira, Farhat, Rizalina A Asnir, Siska Indriany Otorhinolaryngology Head and Neck Department Medical Faculty, University of Sumatera Utara
Introduction
Sinonasal malignancies are relatively rare comprising about 0.2 – 0.8% of all malignancies and 3% of head and neck malignancies. 77% of sinonasal tumors involve the maxillary sinus, 22 % Ethmoid sinus and 1 % sphenoid sinus and frontal sinus. 70 – 90% display invasion through at least one wall of the presenting sinus. 1
Cancer of nose and paranasal sinuses constitutes 0,44% of all body cancer in India (0,57% in males and 0,44% in females). Its incidence during the same period (year 2000) was 0,3% per 100,000 persons and second place is in China and Japan. 2
Most common pathological of sinonasal malignancies is squamous cell carcinoma (SCC) and adenocarcinoma which are strongly associated with environmental factors, including tobacco, alcohol and occupational exposure (e.g. to heavy metal particles such as nickel and chromium) and with workers in the leather, textile, furniture and wood industries, a recent report demonstrates a higher incidence of nasal cancer in cigarette smokers. 3,4
Early diagnosis is difficult because symptoms and signs are non-specific and closely resemble those of chronic sinusitis, allergic reaction and nasal polyposis. Initial symptoms are related to the effects of the mass causing unilateral nasal obstruction. Secondary infection is common, giving rise to a mucoid or purulent discharge. Epistaxis develops when the mucosa is ulcerated or tumour extends into the sinus wall. Tumours involving the ethmoid, maxillary, or frontal sinuses may cause proptosis, restriction of eye motility, diplopia or loss of vision. 3,4, 5
Universitas Sumatera Utara
Case Report
A 30 years old man consulted by Ophthalmologic outpatient clinic General Hospital of H. Adam Malik Medan to the ENT outpatient clinic on May 10th 2014 with chief complaint was swelling on the left cheek. It was experienced since the last eight months ago, the swelling begun at marble with size 2x1x1 cm, and became enlargement, with flat surface, immobile and tenderness was found. Swelling extends to the left orbita, vision on the left orbita became more decreased since for months ago and it was difficult to open. There were nasal obstruction, a history of blood and yellowish liquid out of nasal. Headaches was encountered intermittent. The complaint of the ear and throath was not found.
From the anterior rinoscopy examination, we found a narrow on the left nasal cavity, the left inferior turbinate was difficult to assess. The right one was narrow too and there was septum nasal deviation to the right and the right inferior turbinate was eutrofi. From the endoscopy examination on the left nasal cavity we found that furtherance to the right of the medial wall of the left maxillary sinus, the inferior turbinate was eutrofi and nasopharynx difficult to assess. The ear and oropharynx examination within normal limit. Left eye was swollen and there was edema in the letf medial cantus. There was no enlarged lymph nodes in the neck. (pic. 1)
Picture 1
After that we did the CT-Scan of the Nose and Paranasal Sinus examination with the result on May 22th 2014 : mass full fill the nasal cavity, maxillary sinus, anterior ethmoidalis
Universitas Sumatera Utara
and frontalis also left orbita which pull out the left bulbus oculi to left antero-supero-laterally which irregularitas of the infero-medial wall of orbita, medial wall of maxillary sinus and left ethmoidalis, suspect sinonasal carcinoma. Rhinosinusitis, right medial bulous concha and septal deviation. (pic 2)
Picture 2
We diagnosed this patient with suspect sinonasal carcinoma and we planned to do the operation with lateral rhinotomy approach. Previously, we did chest x-ray examination, ECG and laboratory examination with normal result and we consult to the anesthesia department. We did the operation on 10th June 2014 and we preapared three packed red cell. The following report of the operation :
1. The patient was lied on the surgical table with intravenous, chateter and endotracheal tube were attached, under general anesthesia
2. The surgical area and its surrounding were disinfected with betadhine and alcohol 96%. (pic. 3a)
3. And then we infiltrated the surgery area with pehakain.. (pic. 3b) 4. We made Weber Ferguson incision that are rhinotomy lateral incision (begins 4-5 mm
anterior to the medial canthus and over the nasal bone along the deepest portion of the nasomaxillary groove and following the alar crease) with horizontal incision below infraorbital rim and made the undermining until the mass was seen and its was attached on the anterior left maxillary wall and there was no destruction but the medial one was destruction. (pic. 3c,3d,3e)
Universitas Sumatera Utara
5. We took out the mass on it while bleeding controlled (pic. 3f) 6. To get in to the left maxillary cavity we made a hole by boor on the anterior left
maxillary wall and with endoscopy we looked polipoid mass on the left maxillary cavity and took it out. (pic. 3g-3j) 7. After that we put tamponade to the left maxillary cavity and infront anterior left maxillary cavity. (pic. 3k) 8. Then we made incision to the tissue inflammation on the left orbita canthus. (pic. 3k) 9. Surgical wound were sutured layer by layer and covered it with the steril gauze swabs. (pic. 3l) 10. Mass from the front of anterior left maxillary sinus wall (the left side) and mass from the left maxillary sinus (the right side). (pic. 4) Post operatively, we gave the patient with IVFD Ringer lactate 20gtt/I macro drip, ceftriaxon injection 1gr/12 hours, tranexamic acid 500 mg/12 hours, ranitidine injection 50mg/12 hours and dexamethason injection 5mg/8 hours (only one day). In the 4th day after the operation we taken out the tamponade (pic. 5) and the day after, the patient returned and the 9th day after the operation, sutured have opened all. (pic 5b). The histophatology result from the both mass were non keratinizing squamous cell carcinoma. We planned to give chemotherapy of Cisplatin 100mg/m2 + 5 FU with 3 cycles.
Universitas Sumatera Utara
AB DE
C F
GH
I
JK
L
Picture 3 Universitas Sumatera Utara
Picture 4
Picture 5a
Picture 5b
Discussion
Malignant tumors of the sinonasal tract constitute about 3% of tumors arising in the upper respiratory tract. They occur most commonly in white, and the incidence in males is twice the incidence in females. Exposure to industrial fumes, wood dust, nickel refining, and leather tanning has been implicated in the carcinogenesis of certain types of sinonasal malignant tumors. 2,4
Early feature of paranasal sinus malignancy are nasal stuffiness, blood stained nasal discharge, facial pain and may be facial paraesthesias and epiphora. Late features will depend on the direction of spread and extend of growth. Because many of the early symptoms simulate benign sinus disease, patients often delay seeking treatment and ultimately present with advanced-stage disease. Medial spread from maxilla sinus to nasal cavity gives rise to nasal obstruction, discharge and epistaxis. Anterior spread causes swelling of the cheeck. Superior spread of maxillary sinus invades the orbita causing proptosis, diplopia, ocular pain, ephipora, decreased visual acuity at the time of presentation. 1,2, 6 This is in accordance to the patient who has some complaint from nasal obstruction, epistaxis and/or nasal discharge,
Universitas Sumatera Utara
swelling of the cheek, propotosis, ocular pain, and loss of visual. Histologically, a malignant epithelial neoplasm originating from the mucosal epithelium of the nasal cavity or paranasal sinus that includes a keratinizing squamous cell carcinoma and non keratinizing carcinoma type. Sinonasal squamous cell carcinomas occur most frequently in the maxillary sinus (about 60-70%), followed by the nasal cavity (about 12-25%), ethmoid sinus (about 10-15%) and the sphenoid and frontal sinus (about 1%). 7 In this case, based on the results of anatomic pathology after surgery we found that was non keratinizing squamous cell carcinoma.
Regional and distant metastase are infrequent despite the advanced stage of the primary tumor. The incidence of cervical metastase on initial presentation varies from 1% to 26% with most series reporting less than 10%. In one large series, the 5 year incidence of neck metastase is 4,3% for primary ethmoid malignancies and 12,5% for primary maxillary malignancies. This number decreases in patients treated with radiation to the neck. 3 In this case, we did not found of nodal metastasis.
The choice of diagnostic studies should be guided by the results of a through head and neck examination. Assuming a working diagnosis of neoplasm on the basis of history and physical examination, the subsequent studies are directed toward estbalishing the extend of the lesion and its histologic findings. We have to do a biopsy to determine the type of cells contained in the mass and Imaging for sinonasal carsinoma like computed tomography scan and magnetic resonance imaging. 7,8 In this case we did CT Scan and did not do the biopsy at pre operatif because the mass cannot see from nasal cavity or other place in nasal with nasoendoscopy.
A staging system provide a guide to define the extent and prognosis of a tumor and also serves a communication tool, allowing different institutions to compare their experience with the use of different theraupetic modalities. The American Joint Committee on Cancer (AJCC) TNM staging system of the nose and paranasal sinuses is provide. 4 According to AJCC, we diagnosed this patient with Sinonasal Carsinoma stage III.
Surgical resection is usually recommended with curative intent. Palliative excision may be considered to alleviate intractable pain. To provide rapid decompression of vital structures or the bulk a massive lesion, thus freeing the patient from social embarrassment.4 In our case we did lateral rhinotomy approach to resection the mass of sinonasal carcinoma.
Radiation therapy is primary treatment for lymphoreticular tumors, for patient who are poor surgical candidates and for those patients who refuse surgery. 4
Universitas Sumatera Utara
The role of chemoterapy for sinonasal carsinoma is usually palliative, using its cytoreductive effect to relieve pain, obstruction, or to debulk a massive external lesion. Nevertheless, the failure of combination therapy, including surgery and radiation, to achieve local control, the need for deformating procedure or the shifting of cause of failure to distant metastases spearheaded the use of systemic and even topical chemotherapy in multimodal therapy protocols.4
Conclusion
We have reported a case of carsinoma sinonasal stage III and we did by rhinotomy lateral approach and horizontal inferior orbita incision. And we planed to gave the chemotheraphy after surgery.
References
1. Mohammed AW, Bakshi J, Nada R. Sinonasal undifferentiated carcinoma with contralateral cavernous sinus involvement. A rare case presentation. Current Research in Microbiology and Biotechnology. 2013:1(2):56-61
2. Dhingra PL. Disease of Ear, Nose and Throat : Neoplasma of Paranasal Sinuses. 12th ed. Australia : Reed Elsevier India Private; 2010:219-24
3. Thompson LDR. Sinonasal Carsinomas. Current Diagnostic Pathology. Mini Symposium Head and Neck Pathology.Elsevier.2006:12:40-53
4. Zimmer LA, Carrau RL. Neoplasma of the Nose and Paranasal Sinuses. In : Bailey BJ ,Johnson JT, Newelands SD, eds. Head & Neck Surgery Otolaryngology. Philadhelpia : Lippincott Williams & Walkins; 2014:2044-62
5. Vasan NR. Cancer Of The Larynx, Paranasal Sinuses, And Temporal Bone. In : Essential Otolaryngology Head & Neck Surgery, 9th Ed. Lee KJ. The McGraw-Hill 2008. p: 695701
6. Bruno CJ, Mesquita RA, Aquiar MCF. A Case of maxillary sinus carcinoma. Oral Oncology Extra. Elsevier.2005:42(4):157-59
7. Pilch BZ, Bouquot J, Thompson LDR. Tumours of the nasal cavity and paranasal sinuses. Available in : www.iarc.fr/en/publication/pdfs-online/pat-gen/
8. Weymuller J, Gal T. Neoplasm : In Head and Neck Surgery, 4th ed Vol 2. Cummings Otolaryngology, Chapter 51, 2009, P: 1197-1213
Universitas Sumatera Utara
Universitas Sumatera Utara