Original Paper

Received: October 19, 2000

ORL 2001;63:366–371
Accepted after revision: February 8, 2001

Endonasal Approach for Nasal and

Paranasal Sinus Tumor Removal
Uta M. Kühn a Wolf J. Mann a Ronald G. Amedee b
a Department of ORL, Head and Neck Surgery, University of Mainz Medical School, Mainz, Germany;
b Department of ORL, Head and Neck Surgery, Tulane University School of Medicine, New Orleans, La., USA

Key Words Introduction

Nose W Paranasal sinuses W Endonasal surgical
approach W Microscopic W Endoscopic W Benign W
Malignant
Abstract
Patients with benign (53) and malignant (22) tumors of
the nose and paranasal sinuses were treated for tumor
removal via an endonasal approach. Patient selection
was based on tumor location (centrally) rather than his-
tology. Tumors attainable by the endonasal approach
were located in the nasal cavity, the ethmoid sinus, the
sphenoid sinus and the medial wall of the maxillary si-
nus. Endonasal microscopic techniques including endo-
nasal orbital decompression and endonasal closure of
CSF-leaks were combined with surgical navigation tools
in selected cases. Surgical trauma and morbidity could
be minimized without compromising radicality of tumor
removal. Postoperative hospitalization was comparable
to the period needed after chronic inflammatory disease.
Growing experience with endonasal techniques is lead-
ing towards a safe and effective treatment option for cen-
trally located, selected tumors of the nose and paranasal
sinuses.
Copyright © 2001 S. Karger AG, Basel
Tumors of the nose and the paranasal sinuses have
nonspecific symptoms and progression is indolent. The
tumor may reach high volume and invade contiguous
structures before becoming clinically evident.
In most patients surgery is a major part of definitive
treatment. It can be performed either by external ap-
proaches (like lateral rhinotomy, maxillectomy or trans-
basal approaches depending on location) or an endonasal
approach using the natural orifice of the nose. The endo-
nasal approach avoids external scars, preserves the bony
structure of the facial skeleton, and produces excellent
functional results. It is a viable alternative in selected
cases for management of tumors of the paranasal sinuses.
Over the last two decades the endonasal approach has
been increasingly adopted in the treatment of chronic
inflammatory disease, muco- and pyoceles, decompres-
sion of the optic nerve and decompression of the orbit in
endocrine orbitopathy. The endonasal approach is also
applied for resection of benign tumors like osteomas and
is accepted in the therapy of inverting papilloma [1].
The major problems endonasal surgery has to deal with
are (1) limited view of the infiltrated area and thereby
uncertainty about tumor extension and (2) insecure mar-
gins because the endonasal approach resects the tumor by

© 2001 S. Karger AG, Basel Prof. Dr. W. Mann

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Table 1.

Tumor type Number Localization Recurrences Follow-up

Benign tumors
Inverting papilloma 28 nasal cavity (11), ethmoid (10), maxillary-ethmoidal 2 22 months
complex (4), maxillary sinus (1), frontal sinus (1),
nasal cavity-ethmoid-sphenoid-orbital invasion (1)
Osteoma 6 confined to one of the paranasal sinuses each 1 12 months
Juvenile angiofibroma 7 Fisch classification: 1 or 2 0 22 months
Hemangiopericytoma 4 nasal cavity, ethmoid sinus 0 21 months
Adenoma of the pituitary 2 sphenoid, pterygoid fossa, cavernous sinus 1 24 months
post. nasal cavity, ethmoid, sphenoid, sella turcica 0 5 months
Meningioma 2 ethmoid, sphenoid, orbit 0 7 months
nasal cavity ethmoid, sphenoid 0 38 months
Hemangioma 1 nasal cavity 0 23 months
Chondroma 1 sphenoid, clivus, anterior skull base 0 14 months
Glioma 1 nasal cavity 0 9 months
Fibrous dysplasia 1 maxillary sinus 0 24 months
Total 53

Malignant tumors
Carcinoma in inverting papilloma
Lymphoepithelial carcinoma
Mucoepidermoid carcinoma
Adenocarcinoma
Esthesioneuroblastoma
Chondrosarcoma
Myxosarcoma
Malignant melanoma
Non-Hodgkin lymphoma
Total
2 nasal cavity 0 20 months
2 epipharynx, ethmoid 11 months
nasal cavity, epipharynx, cervical lymph nodes, no local
liver metastasis recurrence
1 epipharynx, nasal cavity 0 10 years
3 nasal cavity, ethmoid, maxillary sinus (3), 0 17 months
Fossa pterygopalatina (1), cervical lymph nodes (1)
2 ethmoid, nasal cavity 0 20 months
3 sphenoid, ethmoid, nasal cavity, ant. skull base 0 6–24 months
2 ethmoid, sphenoid, maxillary sinus, epipharynx, 2 deceased after
cervical lymph nodes, liver metastasis 3–4 years
3 nasal cavity (2), ethmoid (1) 0 9–16 months
4 confined to centrally located paranasal sinuses 1 8–16 months
22

piecemeal instead of en-bloc. The accusation of imperfect Patients and Methods

radicality connected with higher recurrence rates has lim-
ited its use [2]. It is important to emphasize that dimin-
ished surgical trauma by using endonasal approaches
must not be compromised by incomplete tumor removal
and result in higher rates of local recurrences.
In this retrospective study we present our experiences
with benign (53) and malignant (22) tumor removal using
the endonasal, microscopic-endoscopic approach for cen-
trally located tumors. Patient selection was based on
tumor location rather than histology. This article details
tumor location, intraoperative requirements and recur-
rence rates after the endonasal approach.
During 1994–1999 a total of 74 patients with 75 tumors of the
nose and the paranasal sinuses were treated (46 male and 28 female,
ages range from 1 to 88 years).
These patients were divided into groups according to their histo-
pathological diagnosis (table 1). The infiltrated areas are listed in
table 2.
In all cases preoperative diagnosis consisted of endoscopic evalu-
ation and CT scans. Whenever tumor location permitted so, endo-
scopic biopsies were taken. MRI was used in selected cases for fur-
ther differentiation. Preoperative angiographic embolization was
performed 24 h prior to resection in seven juvenile angiofibromas.
Computer Aided Surgery (CAS) was applied in revision cases with
distorted anatomy and lacking landmarks for better intraoperative
orientation: (1) recurrence of an inverting papilloma, (2) recurrence
of an osteoma, and (3) recurrence of an adenocarcinoma. No compli-
cations occurred connected with the CAS system. Preoperative plan-

Endonasal Approach for Nasal and ORL 2001;63:366–371 367

Paranasal Sinus Tumor Removal
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 1 2

Fig. 1. Chondrosarcoma in a 56-year-old

male before endonasal surgery.
Fig. 2. Chondrosarcoma in a 56-year-old
male before endonasal surgery.

Table 2. Nose and paranasal sinus involvement of 75 tumors

Nasal Ethmoid Frontal Sphenoid Medial Epi- Other

cavity sinus sinus sinus maxillary pharynx (orbit, pterygoid fossa,
sinus cavernous sinus)

Benign tumors 16 17 2 5 7 5 5
Malignant tumors 12 16 2 3 4 3 2

ning included software-based CT imaging. Localisation accuracy was
estimated to be 2 mm or better. In one patient with inverting papillo-
ma a microdebrider system was used as part of the surgical procedure
for rapid debulking.
Endonasal microscopic surgery was performed under general
anaesthesia in all cases. Precise visual evaluation was maintained at
any stage of the operation and frozen sections defined tumor mar-
gins. Intranasal resection was performed piecemeal depending on
tumor spread: anterior ethmoidectomy to total ethmoido-sphenoid-
ectomy, with or without resection of the turbinates. Resection of the
periorbit was performed if indicated. This became necessary in three
patients: one with a non-secreting adenoma of the pituitary, one with
a meningioma and one with an adenocarcinoma invading the orbit.
Cerebrospinal fluid leak (CSF) was sealed endonasally twice during
resections of an inverting papilloma and an esthesioneuroblastoma.
No patient in the series required blood transfusions because of exces-
sive bleeding.
Additional Procedures Besides Endonasal Surgery
Neck dissections were performed in four patients with malignan-
cies because of ultrasonographically enlarged lymph nodes (1 1 cm).
Primary tumors included an adenocarcinoma, a lymphoepithelial
carcinoma, and two myxosarcomas.
Following the idea of regional chemotherapy first introduced by
Sato et al. [3], topical intranasal chemotherapy with 5-fluorouracil
plugs completed therapy in two patients with adenocarcinoma. Sys-
temic chemotherapy was needed for systemic metastasis of a lym-
phoepithelial carcinoma and two myxosarcoma. Postoperative ra-
diotherapy was applied in seven patients: a lymphoepithelial carcino-
ma, a mucoepidermoid carcinoma, a myxosarcoma, two esthesio-
neuroblastomas and two chondrosarcomas.
Different to the other groups where tumor removal was done
under curative intention, surgery to the lymphoma group was per-
formed to remove local tumor mass. The aim was to facilitate nasal
breathing and improve the quality of life. Systemic therapy was
planned by the Department of Hematology/Oncology including
radiotherapy and chemotherapy.
Post-treatment follow-ups consisted of endoscopic evaluation ev-
ery three months. CT scans were indicated whenever there was clini-
cal suspicion of tumor recurrence.
Results
Table 1 summarizes localization, recurrences, and fol-
low-up for all these tumors.
Benign Tumors
Inverting Papilloma. This group consisted of 28 pa-
tients. One patient had a recurrent tumor of the ethmoid,
which was operated using CAS. 2/28 patients showed
recurrences and were treated with a lateral rhinotomy.
Osteoma. Six osteomas included in the study were con-
fined to one of the paranasal sinuses each: the frontal si-
nus (3!), ethmoid sinus (2!), and the nasal cavity (1!).
One recurrence occurred in the frontal sinus and was
removed using CAS.

368 ORL 2001;63:366–371 Kühn/Mann/Amedee

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 3 4
Fig. 3. Chondrosarcoma in a 56-year-old
male after endonasal surgery.
Fig. 4. Chondrosarcoma in a 56-year-old
male after endonasal surgery.
Juvenile Angiofibroma. Four tumors were limited to
the nasopharynx without bone destruction, classified as
type 1 according to Fisch. Three tumors invaded the pter-
ygoid fossa and the paranasal sinuses with bone destruc-
tion, classified as type 2 according to Fisch [4].
Hemangiopericytoma. Four cases of hemangiopericy-
tomas were located in the ethmoidal sinus and the nasal
cavity.
Adenoma of the Pituitary. A prolactinoma extended
from the sella turcica to the posterior nasal cavity. A non-
secreting adenoma of the pituitary was located in the
sphenoid sinus and the pterygoid fossa with extension
into the cavernous sinus. Two years after the first proce-
dure the patient presented with a unilateral exophthalmus
and was treated with endonasal debulking and orbital
decompression.
Meningioma. A recurrent meningioma extending into
the ethmoidal and sphenoid sinuses and the orbit was
resected endonasally with decompression of the orbit.
Another recurrent meningioma was located in the eth-
moid, sphenoid sinuses and in the nasal cavity.
Other tumors that were resected endonasally were a
hemangioma of the nasal cavity, a chondroma of the cli-
vus and sphenoid sinus with involvement of the anterior
skull base, a glioma of the nasal cavity in a 1-year-old, and
fibrous dysplasia in the right maxillary sinus.
Malignant Tumors
Carcinoma in Inverting Papilloma. Carcinoma devel-
oped in two patients with inverting papilloma who had
been resected twice before at other institutions over a
four-year period.
Lymphoepithelial Carcinoma. One tumor invaded the
ethmoid and epipharynx; the other infiltrated the nasal
cavity, the ethmoid, and epipharynx. In one case trans-
nasal removal was followed by bilateral neck dissection
Endonasal Approach for Nasal and
Paranasal Sinus Tumor Removal
and radiotherapy. Because of coexisting liver metastasis
systemic chemotherapy followed. There has been no sign
of local recurrence; however, the liver metastasis are pro-
gressing.
Adenocarcinoma. Three patients with this tumor entity
were operated endonasally for local recurrences. All of
them have had external approaches for initial treatment
previously. In one case with tumor infiltration of the pter-
ygoid fossa CAS was used. Intranasal chemotherapy fol-
lowed in two patients.
Mucoepidermoid Carcinoma. This tumor was located
in the posterior nasal cavity and the epipharynx. Treat-
ment consisted of transnasal surgery and radiotherapy.
Esthesioneuroblastoma. The tumors were located in
the ethmoid and in the nasal cavity. Radiotherapy fol-
lowed in both patients.
Chondrosarcoma. Two of the tumors extended from
the nasal cavity into the ethmoid sinuses bilaterally. The
third one extended from the nasal cavity into the ethmoid
and sphenoid sinuses. Radiotherapy followed in all cases.
Myxosarcoma. Recurrent myxosarcomas grew bilater-
ally in the ethmoid and medial walls of the maxillary si-
nuses, and the epipharynx. Metastasis was found in the
neck. Radiotherapy and chemotherapy followed. The pa-
tients died after three and four years with liver metastasis
and systemic disease.
Malignant Melanoma. There were three patients with
malignant melanomas. Two of them were in the nasal cav-
ity and the third one in the ethmoid. All were resected
with clear margins.
Non-Hodgkin Lymphoma. In four patients the tumors
were removed endonasally to improve nasal airway ob-
struction. Surgery was part of a multimodality treatment
concept followed by chemotherapy and/or radiotherapy
according to the treatment protocol.
ORL 2001;63:366–371 369
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 Discussion
Growing experience has led to extending indications
for endonasal approaches of benign and malignant tu-
mors [1, 5–10]. The aim of our study was to detail our
experience with various tumors.
Although the inverting papilloma is benign in histolo-
gy, it might become aggressive. It is prone to recurrence
and might turn into carcinoma in 12% of patients [11].
Reviewing literature since 1970 recurrences vary between
24% for the external and 48% for the endonasal approach
[12]. Patients with papillomas of the maxillary sinus seem
to be unsuitable for endonasal removal because of high
likelihood for local recurrence [12]. Increasing surgical
experience and introduction of angled telescopes de-
creased the rate of recurrence for the endonasal approach
to 17–20% [1, 2, 13]. All this compares favourably with
7% observed in this study.
There is also evidence that osteomas, including the
frontal sinus, and fibrous dysplasia are accessible for
endonasal removal [14–16]. This was successfully accom-
plished in all seven of our patients.
Combining technical advances of instrumentation,
imaging, and interventional radiology, angiofibromas
stage 1 and 2 seem to be suitable for endonasal removal
[10, 17, 18]. This was also experienced in our study.
A review of literature reveals 9 cases of nasal and para-
nasal hemangiopericytoma that were removed endonasal-
ly [19]. Our four patients added in this report underline
the fact that endonasal removal may be adequate for these
lesions.
Treatment of paranasal sinus cancer must not be uni-
form, but depend on the individual patient, tumor exten-
sion and histopathology. Craniofacial procedures provide
for en-bloc resection of the ethmoid and cribriform plate
with acceptable morbidity [20, 21]. Free and myocuta-
neous flaps may close the defect. However, these flaps
lower the ability to detect possible recurrences. Alterna-
tively, a pericranial flap to reconstruct the anterior cranial
fossa can be applied [20].
The endonasal approach for removal of malignant
tumors has recently been reported for specific entities and
tumors of limited extensions. Shah et al. [22] reported an
endoscopic sphenoethmoidectomy for well-differentiated
adenocarcinoma. Anderhuber et al. [10] treated 28 malig-
nant tumors of various histologies successfully via the
endonasal route.
Reviewing our data, the endonasal microscopic-endo-
scopic approach was adequate in 22 patients with malig-
nant tumors. For patients with malignant tumors, not
370 ORL 2001;63:366–371
counting lymphoma (n = 4), surgery was the only thera-
peutic modality in 4/18 and combined with radiotherapy
(and/or chemotherapy) in 12/18 patients.
Endonasal approach was elected for several indica-
tions: (1) Sufficient exposure and radical tumor removal
by piecemeal technique was expected after careful pre-
operative evaluation (16/22). (2) Surgery was part of a
combined treatment protocol with radiotherapy and/or
chemotherapy, such as in lymphoma (4/22). (3) In pa-
tients with generalized disease endonasal tumor removal
provided for minimal trauma, fast recovery, and institu-
tion of other treatment modalities with minor morbidity
for the patient (2/22).
At present it is impossible to present long-term surviv-
al rates after endonasal removal of malignancies, because
experiences with the endonasal approach for tumor re-
moval are limited worldwide to the last few years. We
keep following our patients and hope to present long-time
survival rates in a few years. So far, few recurrences com-
bined with excellent functional results encourage us to
further explore the indications and limitations for endo-
nasal tumor removal. Reviewing the data presented in lit-
erature and our own personal experience, we see endona-
sal tumor removal as an alternative to open procedures
for centrally located tumors. Areas recommended for
endonasal treatment are the nasal cavity, the ethmoid and
sphenoid sinuses, and the medial wall of maxillary sinus.
However, lateral extensions into the maxillary sinus or
cranial extension into the frontal sinus limit its indica-
tion. The success of first-line treatment is a major factor
for the prognosis of disease [21]. Therefore, preoperative
diagnosis consisting of endoscopy, CT, MRI, and endo-
nasal biopsies, are highly important to determine the
proper surgical approach. Intraoperatively tumor margins
must be controlled using frozen sections taken from all
tumor margins. Frequent follow-up every three months is
highly recommended to detect recurrences early.
These results show how improved preoperative imag-
ing, introduction of new equipment and growing surgical
experience can encourage us to apply endonasal tech-
niques to benign and malignant tumor removal. All this
takes place in an attempt to minimize surgical trauma,
reduce morbidity and accelerate recovery without in-
creased risk to our patients.
Kühn/Mann/Amedee
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