endonasal approaches for sinonasal and nasopharyngeal tumors

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ENDONASAL APPROACHES FOR SINONASAL AND

NASOPHARYNGEAL TUMORS

Dale H. Rice, MD

It is likely that many of the more senior endoscopic sinus surgeons in the United States have considerable experience with the endoscopic evaluation and management of sinonasal and nasopharyngeal neoplasms. Despite this, surpris- ingly little has been written about the subject. This article reviews the published literature and synthesizes that information with the author's personal experience into a rational approach to patients with the following disorders: inverted papilloma, adenocarcinoma, hemangioendothelioma, olfactory neuroblastoma, car- cinosarcoma, squamous cell carcinoma, melanoma, juvenile angiofibroma, chordoma, and chondrosarcoma. It might seem obvious that an open approach would allow better visualization and access to the perimeter of a sinonasal neoplasm; however, this may not be true. In the modern era with available instrumenta- tion, particularly the Hopkins telescope and its superior optics, combined with three-dimensional navigational systems, and modern imaging make the evaluation and management of these tumors through a transnasal approach feasible, though technically challenging.

One criticism might be that it is impossible to remove a tumor of any significant size en bloc using this approach. From a practical standpoint, it is rarely possible to remove these tumors en bloc through any open approach currently popular (e.g., a combined subcranial and midfacial degloving approach has been described for large inverted papillomas by Fliss et alh4 An experienced endoscopic sinus surgeon, however, would have no difficulty removing these same tumors through a transnasal approach with much lower hospital stays and associated morbidity rates.

In addition to the obvious cosmetic advantage of an endonasal approach, there are also practical advantages. The midface degloving approach and the lateral rhinotomy and medial maxillectomy approach for inverted papilloma have the potential for cosmetic deformity and an adverse functional impact on nasal airflow. (This finding has been reported by Lueg et al.)'' An endonasal approach avoids both problems.

From the Department of Otolaryngology, University of Southern California, Los Angeles, California

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

VOLUME 34 NUMBER 6 DECEMBER 2001 1087

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EVALUATION

Modern evaluation of sinonasal neoplasms requires the use of at least one imaging modality coupled with nasal endoscopy. CT scanning is excellent for showing bone detail, distortion, expansion or erosion, and soft tissue mass.

On the other hand, MR imaging is often necessary to separate neoplastic soft tissue from inflammatory soft tissue. CT scanning is very poor at discrimi- nating between these two soft tissue densities, whereas MR imaging is poor at showing bone detail. It is critical to have an accurate three-dimensional construct of the neoplastic process, separate from the often-associated inflammatory process. These imaging techniques should be performed in both the coronal and axial planes with CT scanning and in three planes with MR imaging.

The imaging evaluation is supplemented with nasal endoscopy, particularly to evaluate the areas of attachment of the tumor as opposed to areas where the tumor merely rests against an intranasal surface. It is important to ascertain as accurately as possible the ability to obtain a three-dimensional resection before making a final determination on treatment.

Additional evaluation, depending on the nature of the tumor, may involve angiography, with or without embolization, for particularly vascular tumors, such as the angiofibroma.

This article focuses on the operative management of these tumors. Clearly, many of these tumors may require adjuvant therapy, such as chemotherapy, ra- diotherapy, or both, but this therapy is not covered in depth in this discussion.

BENIGN NEOPLASMS

For the following reasons, a moderate amount has been written in the literature on the endoscopic management of the inverted papilloma: (1) the relative fre- quency of the tumor, and (2) it is the most common benign neoplasm occurring in the sinonasal cavity. In this situation, an endoscopic sinus surgeon is more likely to attempt management of the tumor compared with cases of high-grade malignant tumors.

Inverted papillomas represent approximately 0.5% to 4.0% of all nasal tumors and are found predominately in the fifth and sixth decades of life (Fig. l).9

These tumors tend to recur a'nd have a definite association with squamous cell carcinoma. They,variously are reported at a rate of 5% to 50%, but probably realistically occur about 10% of the time. As mentioned, multimodality imaging is essential in the preoperative evaluation of these tumors. The tendency for CT scanning to significantly overestimate the size of these tumors was demonstrated graphically in the study by Sukenik and Ca~iano. '~ These authors also pointed out the tendency for endoscopic examination to overestimate the extent of disease.

It is well known that inverted papillomas are locally invasive and can spread readily throughout the paranasal sinuses from their usual origin on the lateral nasal wall.

As Chee and Sethi3 have pointed out, to justify a seemingly more conserva- tive management, it is necessary to understand the underlying pathophysiology of the disease. This has been well-documented by Hyams? who noted that essentially all the cases in his review of 315 patients arose from a single wide base. Multifocal disease was present in only 4.6% of the cases. Hyams concluded that all recurrences occurred at essentially the same anatomic site, suggesting that recurrence is a function of extent and inadequate resection rather than other

ENDONASAL APPROACHES FOR SINONASAL AND NASOPHARYNGEAL TUMORS 1089

Figure 1. Axial CT scan of inverted papilloma involving right ethmoid sinus.

factors. These and many other studies have shown that the vast majority of recurrences arise from the area of the ostiomeatal complex and the lateral nasal wall composed of the medial wall of the maxillary sinus. The clinician should consider all unilateral polyps inverted papillomas, unless proved otherwise. MR imaging is particularly useful in differentiating a tumor from secondary sinusitis. The de- crease in free water content that occurs in chronically infected sinus contents re- sult in diminution of T2-weighted signal intensity.

McCary et a1 reported on a smaller number of primary and recurrent cases treated endoscopically with no recurrences with a maximum of 19 months of follow-up.'2 Chee and Sethi3 cautioned about tumors arising in the frontal recess area and suggested that more aggressive surgery may be necessary in these cases. On the other hand, Stankiewicz and Girgis found no difficulty in that area in their series.I4 Waitz and Wigand reported on a series of 51 patients comparing endoscopic treatment with open treatment and found the recurrence rates essentially identical and in conformance with reports in the general literature.I6 Califano et a1 have looked for and failed to demonstrate the usual key genetic alterations in inverted papilloma that would be expected to be associated with malignant transformation.2

A variety of other benign neoplasms can occur. A common neoplasm, osteoma, often occurs at the fronto-ethmoid suture and may be too superior to be resected endoscopically. It also may be too large; however, many osteomas can be resected easily. Figures 2A, ZB, 3A, and 3B represent a pleomorphic adenoma of the nasolacrimal duct.

MALIGNANT NEOPLASMS

Though a relatively large amount of material has been written about the management of inverted papillomas, a considerably lesser amount has been written about other tumors. A moderate amount of literature has been published con- cerning management of the olfactory neuroblastoma, which is a relatively rare neuroectodermal tumor ori inating from the olfactory epithelium first described by Berger and Luc in 1924. Since that time, more than 300 cases have been reported, and many more cases have gone unreported. Though generally found

?

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Figure 2. A, Coronal CT scan demonstrating osteoma of the left ethrnoid sinus. B, Axial CT scan demonstrating osteoma of the right ethmoid sinus.

in the upper nasal cavity, they are reported to arise in the ethmoid and maxillary sinuses and other sites. They are locally aggressive and have significant metastatic potential, both lymphatically and hematogenously. In general, multimodality treatment offers the best survival rate, particularly with more advanced disease. In one report, cervical metastasis was a particularly unfavorable prognos- tic indicator with zero survival at 2 years8

This tumor accounts for between 1.0% and 5.0% of malignant neoplasms of the nasal cavity and should be suspected whenever there is a mass lesion in the nasal vault in close proximity to the cribriform plate. It particularly should be considered when CT scanning or MR imaging show both expansion and destruc- tion of adjacent ~tructures.'~ The current Kadish classification grades them as:

Figure 3. Coronal (A) and axial (s) CT scans of pleomorphic adenoma of the nasolacrimal duct.


Grade A, tumor confined to the nasal cavity; Grade B, tumor confined to the nasal cavity and one or more paranasal sinuses; and Grade C, tumor extending beyond the nasal cavity or paranasal sinuses, including involvement of the orbit, skull base, intracranial cavity, cervical lymph nodes, or distant metastatic sites6

Pickuth et a1 compared the CT scanning and MR imaging characteristics of 22 biopsy-proven olfactory neurobla~tomas.'~ They found contrast enhancement with CT scanning to be moderate and homogenous. Direct coronal scans were of more value than axial scans in evaluating extension into the orbit and through the cribriform plate. With MR imaging, the tumors proved to be hy- pointense to gray matter on T1-weighted MR images and iso- or hyperintense on T2-weighted MR images. Gadolinium enhancement was observed to at least some degree. A small series described a minimally invasive approach combining endoscopic sinus surgical removal followed by stereotactic radiati~n. '~ This series is limited by the fact that only three patients were reported, although the follow-ups were 71, 50, and 39 months, respectively. The tumors were chosen carefully and showed no infiltration of the dura, no intracranial extension, no deep infiltration of the orbit, and no significant extension to the pterygopalatine fossa. With carefully selected tumors, however, they were able to obtain excellent responses.

There is a paucity of literature on the management of other types of non- inflammatory disorders. The author's experience includes managing the following disorders: inverted papillomas and olfactory neuroblastomas, carcinosar- coma, melanoma, squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, angiofibroma, chondrosarcoma, osteosarcoma, and chordoma. Of this group, there were no cases of recurrence with the exception of a patient with carci- nosarcoma, which recurred about 2 years after the initial resection. A second endoscopic resection was performed, and this patient has had no recurrence in 5 years. (Fig. 4)

Lund published her experience on the endoscopic management of mucocele." As she points out, a true mucocele is an epithelial-lined mucous- containing sac that completely fills a paranasal sinus and is capable of bone expansion. The most frequent location is in the fronto-ethmoid region. Lund

Figure 4. Endoscopic view of olfactory neuroblastoma.

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recommends an intranasal marsupialization of the mucocele that is as wide as possible, and in her series there were no recurrences at the 34-month follow-up. Her experience parallels that of Kennedy et a1 who also had no recurrences but with only an 18-month follow-~p.~ The author agrees with Lund that the widest possible marsupialization should be accomplished, but attempts to remove the remaining lining add nothing to the procedure and increase the risk of complication. It is the author's experience that an external approach is rarely necessary.

MANAGEMENT

It is obvious that a wide variety of neoplasms can be managed by the endonasal endoscopic route. There are several keys to the successful execution of the procedure.

The most important aspect is complete three-dimensional delineation of the tumor extent, which is best done with a combination of CT scanning and MR imaging. The CT scan is used to delineate any important changes in bone, whereas MR imaging is excellent in determining neoplasm from adjacent and surrounding inflammatory disease. Once accurate delineation of the extent of the tumor is accomplished, the surgeon should have a clear idea of whether a . three-dimensional resection can be accomplished through a transnasal endoscopic route.

This is key to beginning the procedure, and the surgeon always should be prepared to revert to an open approach should it become necessary. Most of the time, the trickiest part of the procedure is getting superior and lateral to the tumor. Often the smartest initial step is near total resection of the middle turbinate. The next steps depend on the type and extent of the tumor, but the author prefers, if possible, to make the next step a complete transection superior to the tumor to separate it from the skull base. The lateral resection extent depends on the extent and type of tumor and may involve removal of the lamina papyracea and medial floor of the orbit through an endoscopic approach. Once the superior and lateral margins have been attained successfully, the inferior and posterior cuts generally are accomplished easily, and the tumor can be removed.

Rarely can a tumor be removed en bloc, in one piece, unless it is quite small. This inability, however, does not seem to have any impact on prognosis. The author compare this with the transoral COn supraglottic laryngectomy in which cut- ting through the tumor also seems to have no impact on survival.

At the end of the procedure, margins are checked, and the procedure is termi- nated when the margins are clear.

As stated earlier, the author has used this procedure in a wide variety of neoplasms with, to date, excellent success and only a single recurrence of the carcinosafcoma.

It should be stated that these procedures should not be attempted without considerable experience in endoscopic sinus surgery and skull base surgery. In particular, the ability to repair on-the-spot cerebrospinal fluid leaks, should they occur, and manage other potential complications should be in the surgeon's ar- mamentarium. In the author's experience, there have been no complications from these procedures, but patient selection should be performed very carefully.

References

1. Berger L, Luc R Esthesioneuroepithelioma olfactif [in French]. Bulletin de L'Association Francaise pour I'Etude du Cancer. 13:410-421,1924


2. Califano J, Koch W, Sidransky D, et al: Inverted sinonasal papilloma. Am J Pathol

3. Chee LWJ, Sethi DS The endoscopic management of sinonasal inverted papillomas. Clin Otolaryngol24:61-66,1999

4. Fliss DM, Zucher G, Amir A, et al: The combined subcranial and midfacial degloving technique for tumor resection: Report of three cases. J Oral Maxillofac Surg 58:106-110, 2000

5. Hyams V Papillomas of the nasal cavity and paranasal sinuses: A clinicopathological study of 315 cases. Ann Otol Rhino1 Laryngol80:192-206,1971

6. Kadish S, Sordman M, Wang CC: Olfactory neuroblastoma: A clinical analysis of 17 cases. Cancer 371571-1576,1976

7. Kennedy DW, Josephson JS, Zinrecih SJ, et al: Endoscopic sinus surgery for mucoceles: A viable alternative. Laryngoscope 99:885-895,1989

8. Koka VN, Julieron M, Bourhis J, et al: Aesthesioneuroblastoma. J Laryngol Otol 112:628433,1998

9. Lawson W, H o BT, Shari CM, et al: Inverted papilloma: A report of 112 cases. Laryngo- scope 105282-288,1995

10. Lueg EA, Irish JC, Roth Y, et al: An objective analysis of the impact of lateral rhinotomy and medial maxillectomy on nasal airway function. Laryngoscope 108:1320-1324,1998

11. Lund UJ: Endoscopic management of paranasal sinus mucoceles. J Laryngol Otol 112:3640,1998

12. McCary WS, Dross CW, Raifel JF, et al: Preliminary report: Endoscopic versus external surgery in the management of inverted papilloma. Laryngoscope 104:415419,1994

13. Pickuth D, Heywang-Kobrunner SH, Spielmann RP: Computed tomography and mag- netic resonance imaging features of olfactory neuroblastoma: An analysis of 22 cases. Clin Otolaryngol24:457-461,1999

14. Stankiewicz JA, Girgis SJ: Endoscopic surgical treatment of nasal and paransal sinus inverted papillomas. Otolaryngol Head Neck Surg 109:988-995,1993

15. Sukenik MA, Casiano R Endoscopic medial maxillectomy for inverted papillomas of the paranasal sinuses: Value of the intraoperative endoscopic examination: Laryngo- scope 110:3942,2000

16. Waitz G, Wigand ME: Results of endoscopic sinus surgery for the treatment of inverted papillomas. Laryngoscope 102917-922,1992

17. Walch C, Stannberger H, Anderhuber W, et al: The minimally invasive approach to olfactory neuroblastoma: Combined endoscopic and stereotactic treatment. Laryngoscope 110:635- 640,2000

156~333-337,2000

Address reprint requests to Dale H. Rice, MD

Box 795 1200 North State Street Los Angeles, CA 90033

endonasal approaches for sinonasal and nasopharyngeal tumors

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