Sinonasal malignancies

Introduction

The sinonasal cavities, which include the nasal cavity and paranasal sinuses (maxillary, sphenoid, frontal, and ethmoid), occupy a relatively small anatomic space, but can be afflicted by a variety of distinct benign and malignant tumors. Sinonasal tumors occur in 1 per 100,000 people per year, and the most common are squamous cell and adenocarcinoma, which account for 80% of these tumors. In terms of malignant tumors, the primary tumors that involve the sinonasal cavities include sinonasal squamous cell carcinoma (50%), intestinal type adenocarcinoma (13%), mucosal melanoma (7%), esthesioneuroblastoma (7%), adenoid cystic carcinoma (7%), and sinonasal undifferentiated carcinoma (SNUC) (3%). The region where these tumors occur is a complex anatomic area in close proximity to the eye and brain. Although this region is more pertinent to otolaryngologists, tumors in this region can invade the anterior skull base, and therefore can also be relevant to neurosurgeons. In this chapter, we present a case of a patient with a sinonasal malignancy that involves the anterior skull base.

Example case

Chief complaint: epistaxis

History of present illness

A 64-year-old, right-handed man with a history of sleep apnea on continuous positive airway pressure, hypertension, and hypercholesterolemia presented with persistent right naris epistaxis. He complained of unprovoked nosebleeds for several months, and saw an ear, nose, and throat doctor who did a biopsy of a sinonasal mass consistent with SNUC. This led to magnetic resonance imaging (MRI) ( Fig. 64.1 ), and he was referred for evaluation and management.

Medications : Lisinopril, atorvastatin.
Allergies : No known drug allergies.
Past medical and surgical history : None.
Family history : No history of intracranial malignancies.
Social history: Business owner, no smoking or alcohol.
Physical examination : Awake, alert, oriented to person, place, time; Cranial nerves II to XI; Moves all extremities with good strength.
Positron emission tomography scan: Hypermetabolic lesion in the right nasal cavity without any evidence of systemic disease.

	Luigi Maria Cavallo, MD, PhD, University of Naples Federico II, Naples, Italy	Kenji Ohata, MD, PhD, Osaka City University, Osaka, Japan	Gustavo Pradilla, MD, Emory University, Atlanta, GA, United States	Shaan M. Raza, MD, MD Anderson Cancer Center, Houston, TX, United States
Preoperative
Additional tests requested	High-resolution CT Neck ultrasound	High-resolution CT CTA Neuroophthalmology evaluation (OCT, visual fields)	Staging scans including PET CTA head and neck CT sinus ENT evaluation Neuroophthalmology evaluation	Pathology consultation Head and neck medical and radiation oncology evaluation Ophthalmology evaluation
Neoadjuvant therapy	Yes	No	Yes	YesInduction chemotherapy with platinum-based therapy
Surgical approach selected	Endoscopic nasoethmoidal	Endoscopic endonasal combined transcranial frontobasal	Endoscopic endonasal transcribriform, transplanum	Endoscopic endonasal approach with pericranial flap reconstruction
Other teams involved during surgery	ENT	ENT	ENT	ENT
Anatomic corridor	Transnasal trancribriform	Transnasal and transcranial	Transnasal transcribriform, transplanum	Transnasal transcribriform, transplanum
Goal of surgery	Radical resection after neoadjuvant radiation	Radical resection	Radical resection	Oncologic resection with negative margins, protection of critical neurovascular structures, optimal aesthetic outcome
Perioperative
Positioning	Supine neutral	Supine neutral	Supine neutral, no pins	Supine neutral with head of bed at 30 degrees and neck extension
Surgical equipment	Surgical navigation Endoscopes Ultrasonic aspirator	Surgical navigation Endoscopes	Surgical navigation IOM (SSEP) Endoscopes	Endoscopes Tissue implants
Medications	None	Mannitol	None	None
Anatomic considerations	Posterior wall of frontal sinus, ethmoidal arteries, medial orbital walls, lacrimal ducts	Crista galli, cribriform plate, planum sphenoidale, orbital roofs	Orbits, orbital nerve, medial rectus, frontal lobes, olfactory nerves, orbito-frontal / fronto-polar / anterior and posterior ethmoidal arteries	Nasal septum, nasal floor, posterior nasopharynx, lamina papyracea, frontal sinuses, sphenoid sinus, anterior skull base dura, orbital contents, frontal lobes
Complications feared with approach chosen	Ethmoidal artery injury, orbital hematoma, epistaxis, frontal lobe hematoma, CSF leak	Brain contusion, visual decline	Frontal lobe retraction, orbital hematoma, CSF leak	Positive margins, orbital injury, frontal lobe injury, reconstruction failure
Intraoperative
Anesthesia	General	General	General	General
Skin incision	None	Bicoronal	None	Bicoronal incision for pericranial graft harvest
Bone opening	Nasoethmoidal	Bifrontal	Posterior nasal septum, bilateral sphenoidotomies, sphenoid septum, sphenoid rostrum, posterior frontal sinuses, medial maxillectomy, medial orbital walls, cribriform and planum	Nasal septectomy, right maxillary antrostomy, right MT/IT, left anterior and posterior ethmoids, right lamina papyracea, Draf III, frontal sinusotomy, anterior skull base from posterior frontal sinus wall to planum sphenoidale
Brain exposure	Frontal	Bifrontal	Bifrontal	Anterior cranial fossa
Method of resection	Draf III procedure, identify anterior border of tumor, bilateral ethmoidectomy with lamina papyracea removal, identification of ethmoidal arteries and lateral border of tumors, nasal septectomy and identification of inferior tumor border, opening of cribriform plate and removal of intradural component, biopsy of dural borders, multilayer reconstruction	Transcranial approach first with bicoronal incision, harvesting pericranial flap, low bifrontal craniotomy, curetting of frontal sinuses, separate subfrontal dura from anterior skull base, remove tumor from orbit and anterior cranial fossa bone with negative margins, reconstruction with pericranium, endonasal resection by ENT.	Nares packed with epinephrine solution, ENT and neurosurgeon work together with four handed technique, mass debulked once encountered, posterior two-thirds of nasal septum, bilateral sphenoidotomies, removal of sphenoid septum and sphenoid rostrum, Draf III approach to frontal sinus, opening of the entire frontal sinus, define anterior and superior boundary of resection, identify lamina papyracea to define lateral extent of resection, identify posterior and ethmoid arteries identified and ligated, osteotomies made posterior to front sinus at lamina papyracea, expose frontal lobes, widen osteotomies to medial wall of orbit, medial maxillectomy on right to confirm negative margin, continue centripetal piecemeal resection with care to preserve normal anatomy, exposed frontal lobe dura exposed and incised, biopsy of olfactory bulbs and periorbital fat to confirm negative margins, closure of anterior skull base in layers with collagen inlay in subdural space and allograft in epidural space, dural sealant, nasal tampons, lumbar drain	Nasal approach first, septectomy from inferior to tumor to maxillary crest and posterior to sphenoid rostrum to clear inferior portion of tumor and allow binasal access, wide right maxillary antrostomy, removal of right IT and MT, open right anterior and posterior ethmoid sinus, mucosal margins of maxillary sinus taken, identification and ligation of SPA, opening of left maxillary sinus and margin taken, preservation of left IT if no tumor involvement, open sphenoid sinus and removal of septations with mucosa taken as margin, open left anterior and posterior ethmoids to identify fovea ethmoidalis with sacrifice of the left anterior and posterior ethmoidal arteries, resection of lamina papyracea on right side with periorbita taken as margin, identify right fovea ethmoidalis after sacrificing right anterior and posterior ethmoidal arteries, Draf III frontal sinusotomy to identify crista galli and posterior frontal sinus wall, anterior skull base removal from posterior frontal sinus wall to planum sphenoidale and extending from orbital roof to orbital roof, dura circumferentially incised along with falx with transection of the olfactory bulbs from the frontal lobes with margins along dura and olfactory bulbs, reconstruction with button graft (fascia lata) in subdural and epidural space, observe for CSF leak, harvest pericranial flap and rotate into nasal cavity via opening at nasofrontal suture
Complication avoidance	Identification of ethmoidal arteries, delineate tumor borders	Pericranial harvest and reconstruction, two stage approach, use of ENT for endonasal component	Wide bony exposure, centripetal resection, biopsy of margins to confirm tumor-free margins, lumbar drain	Wide bony exposure, circumferential and anatomic margins, removal of anterior skull base dura in one piece
Postoperative
Admission	ICU	ICU	ICU	Intermediate care
Postoperative complications feared	Orbital hematoma, epistaxis, frontal lobe hematoma, CSF leak	CSF leak	CSF leak	CSF leak, orbital dysfunction (diplopia secondary to medial rectus injury), epiphora
Follow-up testing	CT within 24 hours after surgery MRI 1 month after surgery	CT immediately after surgery MRI 1 week after surgery Neuroophthalmology evaluation	Lumbar drain for 3 days MRI within 24 hours after surgery Physical and occupational therapy	Confirmation of margins by pathology MRI within 48 hours after surgery
Follow-up visits	1 week after surgery	Follow-up with ENT	2 weeks after surgery with ENT	2 weeks after surgery
Adjuvant therapies recommended	PET/neck ultrasound, second attempt, palliative measures with diffuse disease	Radiation/chemotherapy	Radiation/chemotherapy	Radiation/chemotherapy