Differential Dx of nasal obstruction

&
Neoplasms of Nose and paranasal sinuses

Dr. Ramesh Parajuli

Nasal obstruction

Sense of blockage
within the nose or
difficulty breathing
out of one or both
nostrils.

Sites of blockage
1. Nose
2. Paranasal sinuses
3. Nasopharynx

Differential diagnosis of nasal obstruction

Causes of unilateral nasal obstruction
1.Structural: DNS, inf.turbinate
hypertrophy,concha bullosa

Causes of Bilateral Nasal obstruction

1.Infection:
-Acute rhinitis
-CRS, Atrophic rhinitis

2.Infection: Unilateral sinusitis

2.Allergy:Allergic rhinitis

3.Polyp: Antrochoanal polyp

3.Non allergic,non infective:

4.Foreign body

Vasomotor rhinitis

5.Neoplasm

4.Adenoid hypertrophy

6.Congenital:choanal atresia

5.Structural: DNS

7.Trauma

6.Trauma:Septal hematoma

8.Granulomatous Dx:Rhinoscleroma 7. Ethmoidal polyposis

8.Neoplasms
9.Rhinitis medicamentosa

Neoplasms of Nose and PNS

Benign

Classification

1. Papilloma
2. Ossifying
Fibroma
3. Osteoma
4. Haemangioma
5. Neurofibroma
Intermediate
Inverted
papilloma

Malignant
1. Squamous cell
carcinoma
2. Adenocarcinoma
3. Anaplastic
carcinoma
4. Transitional cell
carcinoma
5. Malignant
melanoma

Frontal sinus osteoma

Fibrous dysplasia
Normal medullary bone is replaced by abnormal proliferation
of fibrous tissue, resulting in distortion & expansion of bone

C.T. scan: ground - glass appearance

Treatment: complete surgical excision

Inverted papilloma
Locally aggressive sino-nasal tumour
Synonyms: Ringertz or Schneiderian papilloma
Common in males between 50-70 years
It arises from the lateral wall of nose
Presents as unilateral, friable, pink mass
Diagnosis made by punch biopsy

Treatment:
Medial maxillectomy (& ethmoidectomy)
-endoscopic approach
-external approach by lateral rhinotomy incision
Tendency to recur after surgical removal
Squamous cell ca is present in 1015% cases
Radiotherapy is avoided

Lateral rhinotomy

Sinonasal malignancy
Epidemiology
Maxillary sinus>ethmoid>frontal>sphenoid
>80% are squamous cell carcinoma
Male : female = 2:1
Commonly seen in 45-60 years

Risk factors
1. Hardwood dust (adenocarcinoma)
2. Softwood dust (squamous carcinoma)
3. Nickel refining; chromium workers
4. Boot, shoe and textile workers
5. Mustard gas exposure
6. Human papilloma virus

Carcinoma Maxillary Sinus(Maxilla)

Early symptoms
Mimic maxillary sinusitis
Nasal blockage
Blood-stained nasal discharge
Facial paresthesia or pain
Epiphora

Spread

Late Clinical features

Medial spread:
Unilateral nasal obstruction
Unilateral purulent nasal
discharge
Epistaxis
Unilateral, friable, nasal mass
Anterior spread:
Cheek swelling
Invasion of facial skin

Inferior spread:
Expansion of alveolus with dental
pain
Loosening of teeth, poor fitting of
dentures
Swelling in hard palate or alveolus
Superior spread:
Proptosis
Diplopia
Ocular pain

Posterior spread:
Pterygoid muscle involvement trismus
Intracranial spread via:
Ethmoids, cribriform plate or foramen lacerum
Lymphatic spread:
Neck node metastases in late stages
Systemic spread: Lungs, bone

Initial presentation

7 months

11 months

Diagnosis

Diagnostic nasal endoscopy

C.T. Scan Nose & Paranasal sinus: expansion & destruction of bony wall
Biopsy

C.T. Scan

Ohngrens Classification

Ledermans Classification

TNM Staging
T1 = Tumor confined to antral mucosa
T2 = Bone destruction of hard palate / middle meatus
T3 = Involvement of skin of cheek, floor or medial
wall of orbit, ethmoid sinus, posterior antral wall,
pterygoid plates, infratemporal fossa
T4 = Involvement of orbital contents, cribriform plate,
frontal or sphenoid sinus, skull base, nasopharynx

Treatment
T1 & T2 = Surgery or Radiotherapy
T3 = Surgery + Radiotherapy
T4 = Surgery + Radiotherapy + Chemotherapy

Surgery post-operative Radiotherapy after 4-6 weeks

Surgical Options
1.Total maxillectomy:
Weber Fergusson incision
Malignancy limited to maxilla
2.Radical maxillectomy (with orbital exenteration):
Involvement of orbital fat

3. Anterior Cranio-Facial Resection:

Involvement of cribriform plate, frontal sinus

Weber Fergusson incision

Osteotomy cuts

Total maxillectomy done & incision

closed

Palatal defect & prosthesis

Orbital exenteration
indications

Involvement of orbital apex

Involvement of extra-ocular muscles

Involvement of bulbar conjunctiva or
sclera
Lid involvement beyond a reasonable
hope for reconstruction
Non-resectable full thickness invasion
through periorbita into retrobulbar fat

Orbital exenteration

Post-operative defect &

prosthesis

Cranio-facial resection