Tumors arising in the nasal cavity and sinuses often present as large lesions involving one or more sinuses. This is due to the relatively large intranasal space allowing growth prior to the onset of symptoms. Early symptoms include nasal obstruction, headache, nasal discharge, epistaxis, and anosmia. Patients with large tumors present with exophthalmos, diplopia, chemosis, supraorbital swelling, and edema of the eyelid. The absence of pain with ophthalmologic symptoms does not rule out malignancy, though deep-seated facial pain and facial paresthesia raise the index of suspicion for malignant tumors. The presence of epiphora suggests obstruction or destruction of the nasolacrimal duct. Loose-fitting dentures or loss of teeth suggests invasion of the floor of the maxilla. As tumors progress and invade the anterior cranial fossa and frontal lobe, subtle changes such as reduced speech, reduced verbal fluency, and altered expressive language may occur. The patient may begin to show signs of impaired insight and judgment while maintaining cognitive ability and memory.

PHYSICAL EXAMINATION

The physical examination should include careful examination of the sinonasal region, orbit, cranial nerves, middle ear, and neck and should include bilateral nasal endoscopy. Examination begins with an otomicroscopic examination; fluid in the middle ear suggests compression, invasion, or blockade of the eustachian tube in the nasopharynx, posterior to the pterygopalatine fossa, or the infratemporal fossa. Eye findings will suggest compression and/or invasion of orbital contents. Examination using a nasal speculum may reveal the physical nature of the tumor and suggest the vascularity of the neoplasm. Evaluation of the oral cavity, particularly of the upper alveolar ridge and teeth, will suggest the effect of the neoplasm on the floor of the maxillary sinus and nasal cavity. Evaluation of the neck is vital since lymphadenopathy would suggest a malignant process. Finally, a complete evaluation of the cranial nerves is performed looking for focal deficits.

INDICATIONS

Tumors involving the orbit that do not involve the anterior wall of the maxillary sinus or anterior table of the frontal sinus, the optic nerve, and ophthalmic artery, with little involvement of the superior orbital bone may be accessed through an endonasal approach. Tumors located between the medial and inferior rectus and medial to the ophthalmic artery and optic nerve are readily resectable. In more experienced hands, tumors extending into the medial orbital apex and medial temporal lobe may be resected.

CONTRAINDICATIONS

Although there are a few solid contraindications for the transorbital approach, some contraindications may be relative based upon the experience and skill of the surgeon. Removal of the anterior table of the frontal sinus involved by tumor is not achievable by a totally endoscopic approach to ensure negative margins. Involvement of the most lateral extent of the frontal sinus cannot be obtained by a purely endoscopic, endonasal approach. Excision of malignant tumors invading the globe through an endonasal approach is also contraindicated and requires an open orbitotomy. Endonasal excision of benign tumors lateral to the optic nerve and carotid artery is also contraindicated if the patient’;s vision is intact. Posterior invasion of the carotid artery or cavernous sinus by malignant tumors greatly reduces the possibility for surgical resection with negative margins. In this situation, subtotal surgical resection followed by chemotherapy and radiation is recommended.

PREOPERATIVE PLANNING

Imaging Studies

Tumors involving the sinonasal tract require imaging using both computed tomography (CT) and magnetic resonance (MR) imaging with contrast. Contrast allows for an estimate of tumor vascularity. Image-guidance protocols should be performed if endoscopic approaches are entertained. CT imaging provides valuable information as to the integrity of the skull base, orbit, and sinonasal bony skeleton. MR allows for evaluation of soft tissue invasion, neural invasion, and entrapment of mucus in the sinuses versus tumor. If malignancy is confirmed, a positron emission tomography–CT scan should be performed for staging.

Nasal Endoscopy with Biopsy

I do not recommend in-office biopsy of sinonasal tumors, especially vascular tumors when the control of epistaxis can be very difficult to handle in the office setting. Patients are taken to the operating room for bilateral nasal endoscopy with biopsy. Definitive treatment is delayed until permanent pathologic diagnosis is confirmed.

Ophthalmology Evaluation

Patients with tumors of the sinonasal tract with ophthalmologic findings on physical examination or imaging undergo a complete eye examination by a neuro-ophthalmologist. Subtle findings such as ophthalmoplegia, visual field deficits, and optic nerve involvement may not be found on routine physical examination and help guide surgical planning. Furthermore, ophthalmologic assistance in tumor removal may be desirable in selected cases.

Neurosurgical Evaluation

At our institution, tumors abutting or eroding the skull base or involving or invading the brain undergo a full neurosurgical evaluation. It is my opinion that these tumors should be removed using a team approach.

Tumor Board

Once all of the preoperative evaluations, imaging, and pathology are complete, the case is presented at a multidisciplinary skull base tumor board for treatment planning. The tumor board consists of individuals from neurosurgery, otolaryngology, ophthalmology, medical oncology, radiation oncology, radiology, and nurse practitioners. Treatment planning is then finalized and presented to the patient.

SURGICAL TECHNIQUE

Transconjunctival Approach

Although not a requirement, some institutions prefer to have an ophthalmologist perform a transconjunctival approach in concert with an endoscopic transorbital approach to improve orbital retraction and allow retraction on the middle and inferior rectus muscles. As this is not uniformly established, the details of this approach are not described in this chapter (see Suggested Readings).

Transnasal Approach

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