NEOPLASM OF MAXILLARY

SINUS
Definitions
 Neoplasm(willis)- abnormal mass of tissue, the
growth of which exceeds & uncoordinated with
that of normal tissue & persists in same manner
after cessation of stimuli which evokes the
change.
 Tumour- a mass of tissue formed as a result of
abnormal, excessive, uncoordinated,
autonomous, purposeless proliferation of cells
TNM classification
 TNM classification 1,2
 TNM classification of carcinomas of the nasal cavity and sinuses
 T – Primary tumour
 TX Primary tumour cannot be assessed
 T0 No evidence of primary tumour
 Tis Carcinoma in situ

 Maxillary sinus
 T1- Tumour limited to the antral mucosa with no erosion or destruction of bone

 T2- Tumour causing bone erosion or destruction, including extension

into hard palate and/or middle nasal meatus, except extension to posterior antral
wall of maxillary sinus and pterygoid plates

 T3- Tumour invades any of the following: bone of posterior wall of

maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa,
ethmoid sinuses
T4a- Tumour invades any of the following:
anterior orbital contents, skin of cheek,
pterygoid plates, infratemporal fossa,
cribriform plate, sphenoid or frontal
sinuses
 T4b- Tumour invades any of the following:
orbital apex, dura, brain, middle cranial
fossa, cranial nerves other than maxillary
division of trigeminal nerve V2,
nasopharynx, clivus
 N – Regional lymph nodes 3
 NX: Regional lymph nodes cannot be
assessed
 N0: No regional lymph node metastasis
 N1: Metastasis in a single ipsilateral lymph
node, 3 cm or less in greatest dimension
 N2 Metastasis as specified in N2a, 2b, 2c below
 N2a: Metastasis in a single ipsilateral lymph
node, more than 3 cm but not more than 6 cm in
greatest dimension
 N2b: Metastasis in multiple ipsilateral lymph
nodes, none more than 6 cm in greatest
dimension
 N2c: Metastasis in bilateral or contralateral lymph
nodes, none more than 6 cm in greatest
dimension
 N3: Metastasis in a lymph node more than 6 cm
in greatest dimension
 M – Distant metastasis
 MX Distant metastasis cannot be assessed
 M0 No distant metastasis
 M1 Distant metastasis
 Stage grouping
 Stage 0 Tis N0 M0
 Stage I T1 N0 M0
 Stage II T2 N0 M0
 Stage III T1, T2 N1 M0
T3 N0, N1 M0
 Stage IVA T1, T2, T3 N2 M0
 T4a N0, N1, N2 M0
 Stage IVB T4b Any N M0
 Any T N3 M0
 Stage IVC Any T Any N M1
 TUMORS
 Intrinsic origin
 Squamous papilloma
 Inverted papilloma
 Juvenile angiofibroma
 Vascular lesions
 Myxoma
 Giant cell tumor

 Extrinsic origin
 Ameloblastoma
 OAT
 Odontoma
 Odontogenic myxoma

TUMOR-LIKE LESIONS:
Giant cell granuloma
Fibrous dysplasia
 MALIGNANT LESIONS

Squamous cell carcinoma

Adenoid cystic carcinoma

Adenocarcinoma

Sarcoma (Chondrosarcoma, Osteosarcoma, Fibrosarcoma)

Non-Hodgkin’s lymphoma
Ohngren lines
Polyp
 Nonneoplastic
epithelial & stroma
tumours
 Types:
 Inflammatory polyp
 Antrochoanal polyp
Papilloma
 Benign tumor of nasal
cavity composed of
vascular connective
tissue covered by
well-differentiated
stratified squamous
epithelium that tends
to grow under and
elevate mucosa.
Pathogenesis

— allergy, chronic inflammation

 — human papilloma virus (HPV)
Clinical Features
 Most common in males aged 40–70 years
 Nasal stuffiness or obstruction.
 Secondary bacterial sinusitis.
 Postoperative recurrence 35–40%.
 May be associated with malignancy (about
10%).
Types (Batsakis)
1) Keratotic papilloma
 simple cutaneous wart, exophytic with
broad base, in the nasal vestibule or
nasal septum.
2) Inverted papilloma-lateral nasal wall
3)Fungiform (50%) - septum
4)Cylindrical (3%) - lateral nasal wall
Inverted papilloma
 Arises from
respiratory mucosa of
sinonasal tract
 Involves lateral nasal
wall & extends to
adjacent maxillary
sinus
 Bulky, deep red, gray
colour
 Age>40ys ， high
morbidity: 50—60ys;
 M: F=3:1
 Site of occurance: junction of antrum &
ethmoid sinus
 Unilateral nasal obstruction, congestion,
epistaxis, abnormalities of smell.
Histopathology
Hyperplastic epithelia
with inverting pattern
of growth. Epithelial
inversion into
underlying stroma.
Basal membrane is
intact.
Fungiform papillomas
 an exophytic growth pattern and do not
grow down into the underlying normal
stroma. They are almost always
associated with human papillomavirus,
and unlike inverted papillomas, do not
have a tendency to recur.
Cylindrical cell papillomas
 They have a ragged, beefy appearance
and histologically they appear totally
different. They are composed of columnar
cells. They have a pink cytoplasm, their
nuclei are oval or round,
Axial CT
Juvenile angiofibroma
 Highly vascular lesion, locally invasive, non encapsulated
 Age-10-17 years
 Site: posterior nares & nasopharyx
 Etiology:Popular theories include abnormal growth of
embryonal chondrocartilage, testosterone acting on a
hamartomatous nidus of inferior turbinate tissue mislocated
in the nasopharynx, tumor growth from normal
nasopharyngeal fibrovascular stroma- may be due to
androgen receptors capable of binding dihydrotestosterone
& testosterone may indicate hormonal influence
 trauma, inflammation, infection, allergy, and heredity.
Clinical features
 Site: posterolateral wall of the nasal cavity at
posterior nares & nasopharynx
 From its origin, tumor spreads into the nasal
cavity and nasopharynx- displacing the soft
palate inferiorly, Anteriorly, it pushes forward the
posterior wall of the maxillary sinus, creating the
classic "antral bowing sign" visible by x-ray.
 Posteriorly, it disrupts the root of the pterygoid
plates. Superiorly, tumor expands into the orbit
via the inferior orbital fissure, continuing
eventually into the superior orbital fissure and
middle cranial fossa.
 With further lateral expansion, the tumor
will pass through the pterygomaxillary
fissure into the infratemporal fossa, often
creating a bulging of the cheek. If it
reaches the temporal fossa, the tumor can
create a bulge above the zygoma.
 lobulated, firm, non-encapsulated mass,
usually pink-gray or purple-red. The tumor
base may be sessile or pedunculated.
 The most common presenting symptoms
are nasal obstruction, epistaxis, diplopia,
blindness, hearing loss, otitis media,
rhinorrhea, nasal speech, noisy sleep,
mouth breathing, eye pain, and headache.
histopathology
 CT- cleft like vascular
vascular channels
 Cellular atypia
Ameloblastoma
 Secondary to direct extension from
maxillary alveolar ridge
 Misplaced dental analage from epithelial
lining of dentigerous cyst
 c/f:asymptomatic swelling of cheek and
mucobuccal fold
 On penetration it enlarges & fills the antral
space
 Proptosis, nasal obstruction due to
involvment of superior & lateral nasal wall.
R/F
odontoma
 End products of anomalous anomalous
completion or lack of completion of tooth
formation by odontogenic epithelium &
ectomesenchyme
 Complex
 Compound
 c/f- nasal obstruction, discharge, sinusitis
R/F
Odontogenic myxoma
 Site- maxillary bone, antral mucosa
 slow-growing, persistent and destructive,
may cross midline
 Gross feature: slimy, pale yellow mucoid
substance. Consistency is soft to moderate
firm. Poorly circumscribed & infiltrates to
surrounding tissues
 R/F

unilocular/multilocular radioluscency with honeycomb or

soap bubble appearance
H/F
 Loosely arranged
fibroblast and
myofibroblast.
 Cells are stellate with
long protoplasmic
process
Fibrous dysplasia
 Site: posterior maxilla
 C/F: rapid growth and enlargement of jaw
with facial deformity, Painless swelling
R/F
3D CT
Ossifying fibroma
 C/F: nasal obstruction, proptosis, malar
enlargement, vestibular swelling
 R/F: expansion, margination, demarcation,
cortication, displacement of teeth
Malignant tumors
Metaplastic type of epithelium- squamous
cell group
Glandular cell type epithelium-
adenocarcinoma group.
Squamous cell carcinoma
 A malignant epithelial neoplasm
originating from the mucosal epithelium of
the nasal cavities or paranasal sinuses
that includes a keratinizing and a non-
keratinizing type.
Etiology
 Reported risk factors have include
exposure to nickel, chlorophenols, and
textile dust, smoking, and a history or
concurrence of sinonasal papilloma.
Clinical features
 More than 60% originate in maxillary sinuses,
followed by nasal cavity, and ethmoid sinuses
 nasal fullness, stuffiness, or obstruction;
epistaxis; rhinorrhea;
pain; paraesthesia; fullness or swelling of the
nose or cheek or a palatal bulge; a persistent or
non-healing nasal sore or ulcer; nasal mass;
In advanced cases, proptosis, diplopia, or
lacrimation
Macroscopy
 exophytic, fungating,
or papillary; friable,
haemorrhagic,
partially necrotic, or
indurated;
demarcated or
infiltrative.
R/F
R/F

Intrasinus mass with irregular

Destruction of LT maxilla destruction
Coronal CT

Intrasinus mass with irregular destruction

of alveolus MRI- intrasinus & intraoral mass
H/F
extracellulr or intracellular
keratin (pink cytoplasm,
dyskeratotic cells) and/or
intercellular bridges. Tumour
cells are generally apposed to
one another in a “mosaic tile”
arrangement.
The tumour may be arranged in
nests, masses, or as small
groups of cells or individual
cells.
 Invasion occurs as blunt
projections or ragged,
irregular strands. carcinomas
may be well, moderately, or
poorly differentiated
Adenoid cystic carcinoma
 Adenoid cystic carcinoma is the most
frequent malignant salivary gland-type
tumour of the sinonasal tract.
 Age-11-92 years.
 C/F: nasal obstruction, epistaxis, pain,
paraesthesia, displacement of orbital
content, swelling of the palate or face,
loosening of the teeth.
 Evidence of perineural & intraneural
spread
R/F
 CT scan shows a nasal
sinus mass focally
extending into the
bone.
H/F
 An intact surface
mucosa overlying the
cribriform and cystic
patterns
Common route of distant
metastasis
 Lung, bone, liver, brain
adenocarcinoma
 glandular malignancies of the sinonasal tract.
 Etiology: wood dust and leather dust
 C/F: unilateral nasal obstruction, rhinorrhea and
epistaxis. Advanced tumours may cause
pain, neurologic disturbances exophthalmos
and visual disturbances.
R/F
H/F
 papillary growth
pattern and occasional
tubular glands
Non Hodgkin’s lymphoma
 Involve lymph nodes, lymphoid organs,
extranodal organs and tissues
 B lymphomas are found mostly in
maxillary sinus
 C/F: swelling which may ulcerate later,
pain.
Staging of Maxillary Sinus Tumors
 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 base of skull
 TREATMENT OF
NEOPLASM OF
MAXILLARY SINUS
Surgery
 Unresectable tumors:
 Superior extension: frontal lobes
 Lateral extension: cavernous sinus
 Posterior extension: prevertebral fascia
 Bilateral optic nerve involvement
Surgery
 Surgical approaches:
 Lateral rhinotomy
 Transoral/transpalatal
 Midfacial degloving
 Weber-Fergusson
 Combined craniofacial approach
 Extent of resection
 Medial maxillectomy
 Inferior maxillectomy
 Total maxillectomy
Culd wel luc procedure
 Indications:
 Mucoceles
 Antrochoanal polyp
 OKC
Transpalatal approach
 Indications:
 Small tumors of inferior and posterior
aspect
Lateral Rhinotomy & medial
maxillectomy
 Indications:
 Well differentiated or low grade tumour
 Ameloblastoma
 Inverted papilloma
Medial maxillectomy
 A. access ostectom
 B. Removal of septum
to gain contralateral
access
 C.More lateral
extension to gain
access to ethmoids
 D.Bone cuts to gain
access to antrum
Webwr fergusson approach
 OKC, myxoma, Ameloblastoma, CEOT
Midfacial degloving
Chemotherapy
 Palliation, unresectable disease
 (+) margins, perineural spread, surgical
refusal, ECS
 Robbins - 86% response of T4 lesions
 Lee - 91% satisfactory response
 Agents: 5FU(1000mg/m2),
Cisplatinum(150mg/m2/wk/4wk)
Radiation therapy
 Primary tx only for palliation
 10-15% improved 5 year survival
 XRT = 23% vs. Surgery + XRT = 44%
 68-72 Gy
Reconstruction
 Split thickness skin graft with obturator
 Soft tissue flaps and bone graft
MAXILLECTOMY
Surgical removal of maxilla
Classification of
maxillectomy
 According to Cordeiro and Sanatamaria

 Type 1 defects (limited maxillectomy)

 Type 2 defects (subtotal maxillectomy).
 Type 3 (total maxillectomy) which is
subdivided into type 3a (orbital content
preservation) and type 3b (orbital content
exenteration).
 Type 4 defects (orbitomaxillectomy)
Maxillectomy classification scheme
according to Okay et al.
 Class 1a includes defects of any
portion of the hard palate
excluding tooth bearing maxillary
alveolus.
 Class 1b includes defects of
premaxilla or any portion of
alveolus or dentition posterior to
canines.
 Class 2 defects include any
portion of hard palate, alveolus
and only one canine tooth. Also
includes transverse palatectomy
involving less than 50% of the
hard palate.
 Class 3 defects include resection
of any portion of hard palate,
alveolus and both canine teeth.
Also includes transverse
palatectomy involving greater
than 50% of the hard palate.
Subtotal maxillectomy
 Indications:
 Lesions of palate,
antrum, beyond the
confines of antrum
Medial maxillectomy
 Indications:well
differentiated/low
grade malignant
tumour, inverted
papilloma, or other
tumors of limited
extent to lateral wall
of nasal cavity or
medial wall of antrum
Total maxillectomy
 Indications:
 Primary tumour
arising from surface
lining of maxillary
antrum fills the entire
antrum.
Treatment of the Orbit
 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
 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 the retrobulbar
fat
Classification and Concepts in
Reconstruction
Flaps used in maxillary reconstruction
 Palatal mucoperiosteal island flap
 Buccal fat pad
 Submental island flap
 Temporalis flap system
 Radial forearm flap
 Fibula flap
 Scapular flap system
 Iliac crest flap
 Abdominal rectus flap
 A Class 1 defect can be simply treated with obturation or a
soft tissue flap often preferred at the junction of the hard
and soft palate.
 Pedicled flaps:iliac crest maintained in a titanium mesh
structure, the buccal fat pad, submental island flap
 Free tissue transfer: composite fibula flap, Radial forearm
flap
 Class 2b-c
 fibula flap
 iliac crest
 Class 3a-c
 iliac crest with internal oblique
 titanium mesh or free bone from the hip
 Class 4a
 iliac crest with internal oblique, Rectus,
Lattisimus dorsi
Radial Forearm Flap
 1978 (China) by Yang etal, 1985 (pharyngeal
recon)
 Oral cavity, base of tongue, pharynx, soft palate,
cutaneous defects, base of skull, small volume
bone and soft tissue defects of face
 Thin, pliable skin
 Reconstitution of contours, sulci, vestibules
 Fasciocutaneous flaps are highly tolerant of
radiation therapy
 Composite flap with bone, tendon, brachioradialis
muscle and vascularized nerve.
Neurovascular pedicle
 Up to 20 cm long
 Vessel caliber 2 – 2.5 mm
 Radial artery
 cephalic vein
 Lateral antebrachial
cutaneous nerve (sensory)
Technical considerations
 Tourniquet  External skin monitor can be
incorporated into the flap
(proximal segment)
 Flap designed with skin
paddle centered over the
radial artery
 Dissection in subfascial level
as the pedicle is approached.
 Pedicle identified b/w medial
head of the brachioradialis,
and the flexor carpi radialis
 Radial artery is dissected to
its origin
Radial Forearm Flap
Radial Forearm Flap
 Morbidity
 Hand ischemia
 Fistula rates - 42% to 67% in early series
 Radial nerve injury
 Variable anesthesia over dorsum of hand.

Advantage:
Thin pliable skin, often hairless,long pedicle(12-
15cm),
Disadvantage:
Donor site defect visible
Fibular free flap
 1975
 Hidalgo – mandibular recon
1989
 Longest possible segment of
revasularized bone (25 cm)
 Ideal for osseointegrated
implant placement
 Mandible reconstruction (near
total), maxillary reconstruction
Neurovascular pedicle
 Peroneal artery and vein
 Sensate restoration with lateral sural
cutaneous nerve
 Peroneal communicating branch
vascularized nerve graft for lower lip
sensation
 Skin perforators
 Posterior intermuscular septum
(septocutaneous or musculocutaneous
through flexor hallucis longus and
soleus)
 Should always include cuff of flexor
hallucis longus and soleus in flap
harvest
 5-10% of cases blood supply to skin
paddle is inadequate
Technical considerations
 Choose leg based on ease
of insetting
 Intraoral skin paddle
 Harvest flap from
contralateral side of
recipient vessels
 8 cm segment preserved
proximally and distally to
protect common peroneal
nerve and ensure ankle
stability
 Center flap over posterior
intermuscular septum
 Anterior to soleus and
posterior to peroneus
Fibular free flap
 Morbidity
 Donor site complications
 Edema
 Weakness in dorsiflexion of great toe
 Skin loss in 5 – 10% of flaps
Submental artery island flap
 Thin, supple skin
 Submental branch of
facial artery
 Primary closure of
donor site
 Poor reliability if:
 Facial artery sacrificed
 Irradiated neck
 Adv:
 Large flap size (7-15
cm)
 Superior skin color
match
disadvantage
 Not suitable if patient has previous level 1
nodal disease
Temperoparietal Fascia Flap
 Described by Golovine
 More commonly transferred as a pedicled flap but can be
used as a free flap when arc of rotation is inadequate
 Ultra thin – 2 to 4 mm thick
 Highly vascular, pliable and durable
 Fascial, fasciocutaneous
Neurovascular pedicle
 Superficial temporal artery and vein – travel in TPF
layer
 3 cm superior to root of helix
 Vessels branch into frontal and temporal divisions
 Most commonly based on parietal branch
 Ligation of frontal artery 3 – 4 cm distal to branching
point to avoid frontal nerve injury
 Venous pedicle may course with arteries or 2 to 3 cm
posteriorly
 Middle temporal artery – proximal superficial
temporal artery at zygomatic arch (supplies
temporalis muscular fascia)
 Including middle temporal artery enables a two-
layered fascial flap on a single pedicle.
Temperoparietal Fascia Flap
Technical considerations
 Vertical incision over
root of helix to
superior temporal line
 V-shaped extension at
superior limit of
incision
 Scalp elevation ant
and post
 Dissect deep to flap
 Loose areolar tissue
deep to flap
Temperoparietal Fascia Flap
 Morbidity
 Frontal branch weakness (travels in TPF)
 Secondary alopecia – damage to hair follicles
due to superficial dissection
Buccal fat pad
 A – branches of buccinator artery
 Rapid reepithelialization & only suitable for
medium sized defects up to 4cm
 Adv:
 Rapid reepithelialization
 Rich vascular supply
 No donor site skin scars
 Disadvantage:
 Only suitable for medium sized defects up
to 4cm
 Prone to dehiscence
 Iliac crest flaps
 Osteocutaneous, osteomusculocutaneous
 Up to 16 cm bone
 Oromandibular reconstruction
 Only vascularized bone used extensively with simultaneous or delayed
endosteal dental implant placement
 Skin paddle was not ideal for relining the oral cavity
 Too thick for accurate restoration of the 3D anatomy
Neurovascular pedicle

 Deep circumflex iliac artery from

lateral aspect of external iliac
artery
 1 – 2 cm cephalic to inguinal
ligament
 Ascending branch of deep
circumflex iliac artery supplies
internal oblique muscle
 Deep circumflex iliac vein –
 Can pass either superficial to deep
to artery
 Artery caliber – 2 to 3 mm
 Vein caliber – 3 to 5 mm
 Pedicle to internal oblique can
arise separately from deep
circumflex iliac artery
Iliac crest flaps
 Morbidity
 Hernia
 Need to approximate cut edge of iliacus muscle to
transversus abdominis
 Can be reinforced by drilling holes into cut edge of iliac
bone
 Approximate external obliques and aponeurosis to tensor
fascia lata and gluteus muscles
 Keep inferior oblique inferior and anterior to ASIS
 Skin loss from perforator sheer injury
 poor color match
Rectus abdominis
 Easy to harvest
 Long pedicle(10cm)
 Skin from abdomen and lower chest
 Myocutaneous flap or muscle only flap
 Not used for functional motor reconstruction
 Can include entire muscle or only small portion in
paraumbilical region
 Plentiful people – thinner flap created by skin grafting the
muscle
 Skinny people
 Flap used for moderately volume defects
 Poor color match
 Tends to become ptotic
 Able to fill large tissue deficits
Neurovascular pedicle
 Two dominant pedicles
 Deep superior epigastric artery/vein
 Deep inferior epigastric artery and
vein
 Based on inferior epigastrics when
used for h/n recon because of larger
pedicle size
 Inferior epigastric diameter – 3 to 4
mm
 Reinnervated with any of the lower
six intercostal nerves.
 Pedicle may travel along lateral
aspect of muscle before taking
intramuscular route
 Scapular flaps
 Fasciocutaneous, osteofasciocutaneous,
cutaneous flap, parascapular cutaneous
flap, latissimus dorsi myocutaneous flap,
and serratus anterior flap
 Thin, hairless skin
 Two cutaneous flaps may be harvested
 Horizontally oriented flap – transverse
cutaneous branch
 Vertically oriented flap parascapular flap –
descending cutaneous branch
 Long pedicle length
 Large surface area
 Complex composite midfacial or
oromandibular defects
 Up to 10 cm bone
 Osseointegrated implants possible
 Single team approach
 Neurovascular pedicle
 Subscapular artery and vein
 Circumflex scapular artery and vein emerge from
triangular space (teres major, teres minor and long
head of triceps)
 Paired venae comitantes
 Artery caliber – 4 mm at takeoff from subscapular
 Subscapular caliber – 6 mm at takeoff from axillary
artery
 Pedicle length – 7 to 10 cm, 11 to 14 cm (from
axillary artery)
 Largest amount of tissue available for transfer
Technical considerations
 Decubitis positioning
 15 degree angle
 Separate axillary incision
helpful in dissecting pedicle to
axillary artery and vein
 Bone harvest
 Teres major,

subscapularis and
latissimus dorsi need to be
reattached to scapula
 Flap harvest opposite side of
modified or radical neck
dissection
Scapular flaps
 Morbidity
 Brachial plexus injury 2/2 lateral decubitis
positioning
 Use axillary roll
 Stay 1 cm inferior to glenoid fossa
 Detach teres major and minor to harvest bone
 Can cause shoulder weakness and limit range of
motion.
Scapular flaps
 Preoperative  Postoperative
Considerations management
 Prior axillary node  Immobilize for 3 to 4
dissection – days
contraindication  Early ambulation
 5 days for bone harvest
 PT
 Zygomatic implants

 This long implant is

anchored in the upper
jawbone and in the very
dense zygoma bone. A
temporary prosthesis can
be fixed immediately after
placing the implant and
until the final restoration,
once the aesthetic criteria
have been met and your
expectations have been
fulfilled
obturator