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SURGICAL CONSIDERATIONS IN MALIGNANT NEOPLASIA OF NOSE AND PARANASAL SINUSES A. Gairola q D. A. Tandon q S. Bahadur

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alignant neoplasia of nose and paranasal sinuses are rare, constituting 0.2-0.8% of all cancers and 3°Io of all carcinomas of the upper aerodigestive tract (Batsakis 1979). Most such tumours arise in the maxillo-ethmoid complex.Total maxillectomy, the standard surgical procedure for large maxillary tumours does not provide adequate tumour clearance in a large proportion of patients due to spread of disease to subjacent areas. In 90% of the patients the cause of failure is local recurrence or residual tumour. Distant metastasis is the sole cause of death in only 10% of patients. Thus local control of disease is still a major concern (Terz et al 1980). A high proportion of cases is still diagnosed late in India (Bahadur et al 1984) The present paper is a re-appraisal of data on common operative modifications utilised for obtaining wider surgical clearance for such tumours. A. Gairola, Senior Resident, D. A. Tandon, Assisstant professor, S. Bahadur, Additional professor, Department of Otolaryngology, All India Institute of Medical Sciences, New Delhi-110029.

Address for Reprints Dr. D. A. Tandon, Assistant Professor, Department of ENT A.I.I.M.S. Ansari Nagar, New Delhi- 110029 127

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Fig. 1. Diagram showing bone cuts to include body of zygoma in the specimen. Fig. 2. Axial CT Section showing invasion of the orbit by erosion of lamina papyracea.

Materials and Methods We reviewed records of 78 patients with malignancies of the nose and paranasal sinuses undergoing surgery at the All India Institute of Medical Sciences, New Delhi, between 1982 and 1989. Besides a thorough physical examination each patient had undergone radiological assessment by CT scans to map the extent of tumour preoperatively. Details of the operative procedure and extensions were also noted. Observation There were 53 males and 25 females with a mean age of 44.2 years. In the majority

of patients the disease arose from the maxillary sinus (Table I). Maxillary sinus carcinomas were staged according to the AJC 1978 TNM classification. Eighty-two percent of patients with maxillary disease presented in an advanced stage (stage III or IV Table I). Among the epithelial tumours (Table II) chondrosarcoma was the commonest mesenchymal malignancy (4 cases). Tumour extensions (Table III) : Based on clinical and radiological assessment, it was found that the tumour frequently transgressed the antrum to extend into

and Neck Surrerv. Volume 2, No. 3, September 1993

Surgical Considerations in Malignant Neoplasia of Nose and Paranasal Sinuses— Gairola et al.

PALATAL CUTS

Showing Site and Stage of Disease Site and stage of disease Maxillary sinus (Stage I 2 Stage 11 10 Stage III 31 Stage IV –24 Ethmoids Nose Frontal sinus Total

No of cases 67

–

–

–

–

7 3 1 78

–

–

–

–

'.

Tb1efl

Showing the Lesion and Number of Cases 1

Lesion No. of Cases Squamous cell Ca Adenoid cystic Ca Adenocarcinoma Chondrosarcoma Olfactory neuroblastoma Malignant Melanoma Anaplastic carcinoma Spindle cell carcinoma Transitional cell Ca ...............................:................................... —

—

—

—

—

—

—

—

—

43 10 6 4 '3 2 1 1

Lesion Verrucous Ca Osteosarcoma Rhabdomyosarcoma Leiomyosarcoma Angiosarcoma Ewings Sarcoma Malig. Fibrous— Histiocytoma

No. of Cases 1 1 1 1 1 1 1

—

—

—

—

—

—

—

1

Showing Extensions of Tumour at Surgery Site Cheek Nose Orbit Ethmoids Pterygopalatine fossa Pterygoid plates Septum Infratemporal Fossa Zygoma Opposite Palate

I

No. of Cases 37 35 31 23 20 9 6 6 5 4

only, a medial or inferior maxillectomy was adjacent regions. The anterior wall of the maxilla was most frequently eroded with performed. In 2 of these the orbit was also tumour infiltrating into the overlying soft exenterated. Thetumour was limited to the tissues (37 cases). Immediately adjacent infrastructure in the remaining 7 patients, sites like the nasal cavity and orbit were all of whom underwent a palatal fenestration. also commonly involved (35 and 27 cases A total maxillectomy or some modification respectively). In 6 cases the infratemporal thereof was performed on 65 patients (table fossa was also involved. IV). In five patients in whom there was Operative observations : Adequate safety radiological evidence of zygomatic margins could be obtained in 13 patients involvement, the standard maxillectomy by a partial maxillectomy. In 6 of these, in whom the tumour involved the medial wall bone cut was modified : one cut passed

Fig. 3. Diagram showing modification of palatal cut.

through the frontal process of the zygoma to the inferior orbital fissure and the other transected the zygomatic arch, thus including the entire body of zygoma in the specimen(fig. 1). This also entailed severing the origin of the masseter. Orbit: orbital involvement was evidenced clinically as blunting of the inferior orbital margin (10 cases), proptosis (17 cases) and diminution of vision (7 cases). The decision to exenterate the orbit was made preoperatively in 20 cases. In another 7, the decision to exenterate was taken during the operation. Radiological assessment suggested orbital invasion in these 27 cases and revealed orbital involvement in another 3. Axial CT cuts (fig. 2 ) were more useful than plain x-rays for this purpose. The commonest site of orbital invasion was the anterior half of orbital floor. Infiltration of the orbital periosteum was taken as a definitive indication for exenteration. In cases where the decision to exenterate the orbit was made preoperatively the Weber-Fergusson incision was modified. The horizontal limb transected the medial canthus and passed laterally along the upper and lower fornices. In 2 cases orbital invasion ocurred by erosion through the lamina papyracea (fig. 2). In both these cases a craniofacial

Indian Journal of Otolaryngology and Head and Neck Surgery, Volume 2, No. 3, September 1993 - 133

constaerattons in malignant reoptasta 01 ivose aria raranasai aatuses— valrota et at.

Showing the Modifications Performed at Surgery

Modification –Total maxillectomy alone –Total maxillectomy With orbital exenteration –Total maxillectomy With inclusion of zygoma –Total maxillectomy With extended palatal cuts –Total maxillectomy With removal of pterygoid plates –Total maxillectomy with excision of overlying tissues –Septum included in maxillectomy specimen –Craniofacial resection –Simultaneous radical neck dissection –Medial maxillectomy –Palatal fenestration * In 32 patients some modification of a standard resection was performed, along with an orbital exenteration due to infiltration of superior ethmoidal cells. In all cases, substantial soft tissues were retained on the anterior maxillary wall when elevating the cheek flap. In 5 cases where the skin itself was indurated it was sacrificed and repair performed using a forehead or a deltopectoral flap. Palate : Lesions reaching or crossing the midline necessitated modification of the median palatal cut (fig. 3). A submucosal bony infiltration of the hard palate was discovered in 2 patients after removal of the specimen (fig. 4). Though, violating oncological principles, additional cuts were necessary. In 2 cases the hard palate was completely removed (one of which was a simultaneous bilateral total maxillectomy). Such patients were rehabilitated using a total palatal prosthesis. Nose : Tumour was present in the nasal cavity in 35 cases. Atleast a stripping of ipsilateral septal mucoperichondrium was done in all such cases. Where cartilage was involved clinically, the septum was included in the specimen leaving a dorsal strut for support for the cartilaginous pyramid (6 cases). The palatal cut in such cases passed through the nasal floor of the opposite side. Pterygoid region : The pterygoid fossa was involved radiologically in 9 cases. Only 5 of them had trismus. Minor involvement of the fossa was managed by removing pterygoid plates for additional clearance. Nevertheless, gross tumour was still left in situ in 6 cases in all of whom surgery was palliative. The erosion of posterior wall of

No. of Cases 40 31 5 4 9 5

was

maxilla represented the most common sign of inoperability. Ethmoids : Extension of tumour into the superior ethmoidal region or upto cribriform plate on CT scan necessitated a craniofacial resection in 7 cases In all cases a bicoronal flap was utilized for a forntal craniotomy. 3 patients had neck node involvement at the time of presentation and were thus taken up for a simultaneous radical neck dissection. Complications The commonest complication was an'orocutaneous fistula (4 cases). significant secondary haemorrhage from cavity occurred in 2 patients one of whom required an external carotid ligation. One patient developed C.S.F. rhinorrhoea followed by meningitis, to which he succumbed later. In cases undergoing orbital exenteration, dehiscence of the transverse limb of the incision occurred in.4 cases. Discussion

The complex anatomy of the paranasal sinuses, advanced stage of the disease at presentation and the technical limitations of radiotherapy make local control of cancers of the paranasal sinuses difficult. The standard procedure described for maxillary carcinoma is total maxillectomy. Unfortunately in most cases the disease extends beyond the confines • of the sinus, thus rendering the• standard resection inadequate. Delineation of tumour extent pre-operatively is therefore essential. The role of CT for Wis purpose is well known (Ktmdo et al 1982, Jeans et *11982) and

134 – Indian Journal of Otolaryngology and Head and Neck Surgery,

should be performed in all patients 48 0 of our cases the tumour had already infiltrated the soft tissues of the cheek at the time of diagnosis. In such cases a thin facial flap is elevated, leaving behind substantial soft tissues over the maxilla for oncological clearance. Occasionally advanced disease may cause skin ulceration or fistula (Dodd et al 1959). Such cases are technically resectable (Bahadur et al 1984), though the defect needs reconstruction with a forehead or a deltopectoral flap. We prefer the former as it is within the operative field and offers a good colour match. The decision to exenterate the orbit is difficult to make, particularly when vision is normal. Ocular symptoms occur in approximately 25% of patients and are usually due to the upward extension of tumour through the floor of the orbit (Larsson and Martinson 1954). Though clinical and radiological assessment especially by CT provides an accurate idea 'about the orbital contents, the decision is finally made at surgery. Erosion of bone by tumour is an indication for exenteration. However, where a bony dihiscence is found in presence of an intact periosteum frozen section is useful. The decision however is highly individualized (Becker et al 1987). We prefer to preserve vision in a young patient with orbital periosteal integrity, albeit the presence of underlying bony dehiscence. In an elderly patient however, identical circumstances would be an indication for exenteration. In selected cases with slow growing tumours, the eye may be saved by excising the periosteum. Nevertheless, consent to exenterate the orbit must be taken in all cases. Review of literature has shown persistent disease in the ethmoids or the pterygopalatine fossa to be the, cause of local recurrence in 90% of the -patients (Terz et al 1980). Radical maxillectomy involves only partial piecemeal removal of the ethmoid labyrinth. Tumour extension to the ethmoids with involvement of the fovea ethmoidalis is best dealt with by a combined anterior craniofacial resection (Ketcham et al 1973, Sillon et al 1976). Clinical evaluation and plain x-rays are inadequate in assessing superior and posterior spread of desease, which is often clinically silent. Axial CT c, is are ideal for this purpose. Tumour infiltration through the medial half of the posterior wall of the maxilla into the 1993

Surgical Considerations in Malignant Neoplasia of Nose and Paranasal Sinuses— Gairola et al.

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paranasal sinus in Comprehensive Management of Head and Neck Turnouts. W.B. Saunders Company, Philadeliphig pp. 445 -458. Dodd GD, Collins LC, Egan RL, Herrera JR (1959) - The systematic use of tomography in the diagnosis of carcinoma of the paranas l sinuses. R ldiology 72 :. 379-393. Jens WD, Gilani S, Bultimore J (1982) : The effects of CT scanning on staging of turnouts of the paranasal sinuses. Clinical Radiology, 33 173-179. Ketcham A, Chretien PB , Van Buren JM, Hoye RC, Beazley RM, Herdt JR (1973).: The ethmoid sinuses : A re-evaluation of surgical resection. American Journal of Surgery, 126

Fig. 4. Submucosal bony infiltration of the bony (arrow) palate seen on removal of specimen. pterygopalatine fossa makes removal of pterygoid plates mandatory. However, once the posterior wall is eroded, tumour residium will inevitably be left in situ, despite scrupulous attempts at complete removal. Even though such an ocurrence precludes cure, surgery nevertheless offers effective palliation. To improve the prospects in such patients (Terz et al (1980) extended the limits of craniofacial resection to include the base of middle cranial fossa so that the pterygoid plates and their attachments to the sphenoid bone could be removed enbloc. They achieved a 50% 5year survival in such patients. In patients with involvement of the contralateral half of the hard palate, the standard middle palatal cut can be modified to include a part of the opposite palate.Though such - cuts are easily individualised, an attempt must be made to retain healthy teeth in the opposite side to facilitate fitting a prosthesis. Excision of the soft palate inevitably results in a variable regurgitation and hypemasality, which can be minimized by an appropriate prosthesis. The large postoperative cavities occasionally encrust excessively. Removal of septum aggravates the problem, which to some extent is decreased by split skin grafting of the cavity. This is done routinely in all our cases.

The palliative value of maxillectomy needs to be recognised. With results of radiotherapy being disappointing in advanced cases, surgical debulking can render effective palliation from pain and obstructive symptoms. In our view the criteria of inoperability include extensive infratemporal fossa involvement, transgression beyond the floor of the anterior cranial fossa involvement, nasopharyngeal extension, uncontrollable neck secondaries and distant metastases. It is thus concluded that the surgeon needs to plan bone cuts and tailor surgery to each patient rather than performing a standard operation in every case. Even though oncologically clear margins may not always be obtainable useful palliation is nevertheless achieved.

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