The Role of Endoscopy in the Management of Benign and Malignant Sinonasal Tumors


The Role of Endoscopy in the Management of Benign and Malignant Sinonasal Tumors

Piero Nicolai, Paolo Castelnuovo, Andrea Bolzoni Villaret, and Davide Farina


Endoscopic sinus surgery (ESS) has a well-defined role in the management of benign and malignant neoplasms of the sinonasal tract not only in view of the rapidly evolving expertise in the field, but also because of the advances in surgical instrumentation and imaging techniques. The vast majority of the most frequently encountered benign lesions, such as osteoma, inverted papilloma, juvenile angiofibroma, and other vascular and fibroosseous tumors, can be adequately managed by an endoscopic approach. Based on the experience acquired with these lesions, the indications have been expanded to include selected malignant tumors with encouraging results. Over the past 10 years, the skill gained in the endoscopic management of cerebrospinal (CSF) leaks and the repair of large skull base defects fosters the endoscopic surgeons to confidently approach even tumors encroaching upon the anterior skull base.

Based on data collected over a 16-year period at two tertiary care academic centers, the authors provide a wide overview of the indications, surgical steps and tricks, complications, and results of endoscopic surgery in the management of sinonasal neoplasms. Moreover, special emphasis has been dedicated to anesthesiologic management and positioning of the patient during the procedure, perioperative management, and the criteria adopted to perform a “custom-made” postoperative surveillance strategy.

The endoscopic technique must be included in the surgical armamentarium for the management of sino-nasal and skull base tumors. Traditional external approaches still have a role, and they can be associated with endoscopic surgery as hybrid procedures. The surgical team should have the required expertise in all the surgical techniques to intraoperatively modify the surgical strategy according to the specific needs.


Over the past 2 decades, the progressive application of endoscopic surgery to the management of benign and malignant tumors of the sinonasal tract has led to a revolution in their treatment. This has been favored not only by the rapidly evolving expertise in the field, but also by advances in surgical technology and imaging techniques. The first reports date back to the 1980s, when experiences in the management of inverted papilloma and osteoma appeared in the literature.1,2 It took some years before the use of endoscopic surgery was extended to the treatment of juvenile angiofibroma3 and subsequently, in a logical progression of indications, to malignant tumors.4,5

At the beginning, these procedures were welcomed with a mixture of criticism and skepticism mainly in view of the fact that the frequently overemphasized concept of “en bloc” resection cannot be met with endoscopic re-sections, thus preventing the possibility of achieving a radical resection, at least in the mind of their opponents. There are now databases of large series that contradict this view. At the same time, limitations to the use of endoscopic techniques in accordance with the nature and extent of the single disease indeed exist. This clearly indicates that even today head and neck surgeons should have traditional external approaches in their surgical armamentarium in addition to endoscopic techniques.

Based on the analysis of the “European Position Paper on Endoscopic Management of Tumors of the Nose, Paranasal Sinuses, and Skull Base,”6 it is evident that virtually all of the results on endoscopic surgery are from retrospective studies and that the accrual of large cohorts of patients is rendered difficult by the rarity of these diseases. Therefore, most series can only be considered as providing evidence at levels III and IV and recommendations at levels C and D.

Selection criteria for endoscopic surgery, preoperative assessment, and surgical technique of resection are quite variable in relation to the nature of the lesion (benign vs malignant) and to the particular histology, so that in this chapter we will provide specific information based on a large experience (840 benign and 331 malignant tumors) gathered during a 16-year period at two tertiary care academic centers in endoscopic surgery.

A Quick Look at Epidemiology, Symptoms, Diagnosis, and Staging

Benign and malignant tumors of the sinonasal tract are rare, with a notable histologic heterogeneity ( Table 43.1 ).7 Although originating from the pterygopalatine fossa, juvenile angiofibroma (see Video 72, Juvenile Angiofibroma ) is habitually included among the benign tumors of the sinonasal tract in view of its common clinical presentation as a mass growing in the nasal cavity. Data on the incidence or prevalence of benign lesions are available only for inverted papilloma (see Video 73, Medial Maxillectomy for Inverted Papilloma, and Video 74, Residual Inverted Papilloma in Frontal, Ethmoid, and Maxillary Sinuses—Draf IIb, Ethmoidectomy, and Exploration of the Maxillary Sinus ) (0.68 to 1.5 cases9 per 100,000 inhabitants per year) and osteoma (3% in CT scans obtained in patients with sinonasal symptoms10). Malignant tumors account for 3 to 5% of all head and neck malignancies,11,12 with an annual incidence of 0.5 to 1 new case per 100,000 inhabitants in Italy.13 For osteoma and inverted papilloma, which are the most frequent benign lesions, no major differences in worldwide distribution is reported; slight variations in the distribution of the most frequent malignant histologies (i.e., squamous cell carcinoma [SCC], adenocarcinoma, adenoid cystic carcinoma, and olfactory neuroblastoma) in different geographic areas are well documented. In general, SCC (see Video 75, Endoscopic Excision of Sinonasal Squamous Cell Carcinoma ) is the most frequently observed histology, but in many countries in central and southern Europe, adenocarcinoma, which is strongly associated with exposure to wood dust particles, is at least as frequent as SCC, with the ethmoid being the most common site. Overall, malignant tumors more frequently affect the maxillary sinus, followed by the nasal cavity and ethmoid. Localizations in the frontal and sphenoid sinuses are extremely rare.


Squamous cell carcinoma is the most common malignant tumor of the paranasal sinuses, although in parts of central and southern Europe, adenocarcinoma appears at least as commonly.

Unilateral nasal obstruction associated with discharge is the most frequent presenting symptom of both benign and malignant tumors. Complaints as proptosis, chemosis, epiphora, deficit of the third, fourth and sixth cranial nerves (CN III, IV, and VI), and visual loss are commonly indicative of a malignant lesion involving the orbit, while a swelling in the maxillary area, loosening of teeth, trismus, and pain in the maxillary area suggest a malignancy of the antrum. Hypoesthesia or paresthesia in the territory of CN V2 is quite typical of tumors with a tendency to spread along the nerves, as adenoid cystic carcinoma. Not infrequently, these symptoms are underestimated for months or even years, and the diagnosis is made at a late stage when the tumor has already reached intracranial structures, such as the gasserian ganglion. Headache and neurologic deficits are often seen in lesions involving the anterior cranial fossa. Epistaxis is frequently associated with hypervascularized lesions, either benign or malignant, such as angiofibroma and olfactory neuroblastoma ( Table 43.2 ).


New presentation of unilateral nasal obstruction and discharge should raise the possibility of nasal tumor, especially if accompanied by hypo- or paresthesia in the region of CN V2, as well as eye and neurologic symptoms or signs.

The presence at level I and II of palpable neck nodes suggestive of metastasis is a rare event clearly indicating the malignant nature of a lesion. This manifestation is more commonly observed in tumors involving the infrastructure, and in some very aggressive lesions, as sinonasal undifferentiated carcinoma.

Any patient with one or more of these symptoms or signs should be inspected first by endoscopy, which can show a mass occupying the nasal cavity or protruding from the maxillary sinus. The endoscopic appearance can even suggest the nature of the lesion itself, as in the case of an inverted papilloma, which presents as a polypoid gelatinous mass with a papillary appearance, or juvenile angiofibroma, which is typically growing from the area of the sphenopalatine foramen and shows a smooth surface with well-evident capillaries and vessels. Malignant tumors frequently show necrotic-hemorrhagic areas, but the coexistence of inflammatory polyps may obscure the lesion ( Fig. 43.1 ).

World Health Organization histologic classification of tumors of the nasal cavity and paranasal sinuses

Malignant epithelial tumors

  • Squamous cell carcinoma

    • Verrucous carcinoma

    • Papillary squamous cell carcinoma

    • Basaloid squamous cell carcinoma

    • Spindle cell carcinoma

    • Adenosquamous carcinoma

    • Acantholytic squamous cell carcinoma

  • Lymphoepithelial carcinoma

  • Sinonasal undifferentiated carcinoma

  • Adenocarcinoma

    • Intestinal-type adenocarcinoma

    • Non-intestinal-type adenocarcinoma

  • Salivary gland-type carcinomas

    • Adenoid cystic carcinoma

    • Acinic cell carcinoma

    • Mucoepidermoid carcinoma

    • Epithelial-myoepithelial carcinoma

    • Clear cell carcinoma not otherwise specified

    • Myoepithelial carcinoma

    • Polymorphous low-grade adenocarcinoma

  • Neuroendocrine tumors

    • Typical carcinoid

    • Atypical carcinoid

  • Small cell carcinoma, neuroendocrine type

Benign epithelial tumors

  • Sinonasal papillomas

    • Inverted papilloma (Schneiderian papilloma, inverted type)

    • Oncocytic papilloma (Schneiderian papilloma, oncocytic type)

    • Exophytic papilloma (Schneiderian papilloma, exophytic type)

  • Salivary gland adenomas

    • Pleomorphic adenoma

    • Myoepithelioma

  • Oncocytoma

Soft tissue tumors

  • Malignant tumors

    • Fibrosarcoma

    • Malignant fibrous histiocytoma

    • Leiomyosarcoma

    • Angiosarcoma

    • Malignant peripheral nerve sheath tumors

  • Borderline and low malignant potential tumors

    • Desmoid-type fibromatosis

    • Inflammatory myofibroblastic tumor

    • Glomangiopericytoma (sinonasal-type hemangiopericytoma)

    • Extrapleural solitary fibrous tumor

  • Benign tumors

    • Myxoma

    • Leiomyoma

    • Hemangioma

    • Schwannoma

    • Neurofibroma

  • Meningioma

Tumors of bone and cartilage

  • Malignant tumors

    • Chondrosarcoma

    • Mesenchymal chondrosarcoma

    • Osteosarcoma

    • Chordoma

  • Benign tumors

    • Giant cell lesion

    • Giant cell tumor

    • Chondroma

    • Osteoma

    • Chondroblastoma

    • Chondromyxoid fibroma

    • Osteochondroma (exostosis)

    • Osteoid chondroma

    • Osteoblastoma

    • Ameloblastoma

  • Nasal chondromesenchymal hamartoma

Hematolymphoid tumors

  • Extranodal NK/T cell lymphoma

  • Diffuse large B-cell lymphoma

  • Extramedullary plasmacytoma

  • Extramedullary myeloid sarcoma

  • Histocytic sarcoma

  • Langerhans cell histiocytosis


  • Ewing sarcoma

  • Primitive neuroectodermal tumor

  • Olfactory neuroblastoma

  • Melanotic neuroectodermal tumor of infancy

  • Mucosal malignant melanoma

Germ cell tumors

  • Immature teratoma

  • Teratoma with malignant transformation

  • Sinonasal yolk sac tumor (endodermal sinus tumor)

  • Sinonasal teratocarcinosarcoma

  • Mature teratoma

  • Dermoid cyst

Secondary tumors

Adapted from Barnes L, Eveson JW, Reichart P, Sidransky D. Tumours of the nasal cavity and paranasal sinuses. In: Barnes L, Eveson JW, Reichart P, Sidransky D, eds. World Health Organization Classification of Tumours: Pathology and Genetics of Head and Neck Tumours. Lyon, France: IARC Press; 2005:10.


Be aware that a malignant lesion may coexist with a benign nasal polyposis, which may lead to false-negative biopsies.

At this point, it is common policy to obtain cross-sectional imaging studies, which are meant to give a three-dimensional map of the lesion; to differentiate it from inflammatory changes; to assess the relationships with the pterygopalatine and infratemporal fossae, orbit, skull base, dura, brain, internal carotid artery, and cavernous sinus; to look for bony involvement and its pattern (resorption vs infiltration); and to suggest the nature of the disease. In our experience, these goals are best achieved using magnetic resonance imaging (MRI) (performed before and after contrast administration) because of its unsurpassed contrast resolution. Adequate manipulation of acquisition parameters allows MRI to enhance the difference between lesions and surrounding structures, such as cortical and spongiotic bone, nerves, and vessels. Conversely, computed tomography (CT) should be preferred in the pretreatment work-up of osteoma and fibrous dysplasia: the excellent spatial resolution of modern multislice scanners (0.5–0.75 mm) is of great help in showing how sinus drainage pathways or skull base neurovascular foramina are affected by the lesion ( Table 43.3 ).

Common symptoms and signs of sinonasal tumors according to their location

Primary site


Nasal cavity

Inferiorly into palate

Nasal blockage, bleeding, discharge, hyposmia

Mass, ulceration, fistula

Posteriorly into nasopharynx and eustachian orifice, compression of eustachian tube

Middle ear effusion/deafness

Anterosuperiorly into the nasal bone

Glabellar mass

Externally into skin


Superiorly into anterior cranial fossa

Minimal, personality change, headache, neurologic deficit, CSF leak/meningitis (rarely)

Maxillary sinus

Medially into nasal cavity

As above

Anteriorly into cheek directly or via infraorbital canal

Mass, ulceration of skin, paresthesia

Posteriorly into pterygoid region and infratemporal fossae

Trismus and pain

Inferiorly into the palate or alveolar ridge

Mass, loosening of teeth, malignant oroanthral fistula, proptosis, diplopia

Ethmoid sinuses

Medially into nasal cavity

As above, can cross to contralateral side

Inferolaterally into maxilla

Mucus retention

Medially into orbit

Proptosis, chemosis, diplopia, visual loss, epiphora

Superiorly into the anterior cranial fossa

Minimal, personality change, neurologic deficit, CSF leak/meningitis (rarely)

Frontal sinus


Mass on forehead or glabella

Posteriorly into anterior cranial fossa

As above

Inferiorly into nasal cavity, orbit

As above

Medially to contralateral side

None of note until breaches confines of sinus

CSF, cerebrospinal fluid.

Adapted from Lund VJ, Stammberger H, Nicolai P, et al. European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base. Rhinol Suppl 2010;1(22):1–143.


The use of contrast-enhanced radiological imaging (CT and/or MRI) is mandatory in all patients with known or suspected malignancy.

A biopsy is required whenever a diagnosis cannot be established by imaging studies, but it should be avoided when angiofibroma is suspected.14

The use of additional imaging studies, such as positron emission tomography (PET)/CT scan, is indicated only in advanced stages and histologically aggressive (i.e., sinonasal undifferentiated carcinoma, neuroendocrine carcinoma, or high-grade sarcomas) malignant tumors. Ultrasound examination of the neck is included in the preoperative work-up when suspicious nodes are palpable.

Staging systems, which are routinely used for malignant tumors, have been proposed even for benign lesions. Whereas for malignant tumors a committee periodically updates the classification system that is used worldwide, numerous different staging systems have been presented for specific lesions, such as inverted papilloma and juvenile angiofibroma, with the result that none are officially accepted, and consequently comparison of treatment outcomes continues to be problematic. All five staging systems introduced for inverted papilloma1519 have some limitations, and only the one by Krouse15 ( Table 43.4 ) has gained some popularity. Among the many staging systems reported for juvenile angiofibroma, only those from Andrews et al20 and Radkowski et al21 ( Table 43.5 ) have been extensively used. Interestingly, the most recently introduced system by Snyderman et al22 (see Table 43.5 ) considers the extent of the lesion and also takes into account the absence/presence of vascularity after embolization in advanced tumors.

Endoscopic view of a squamous cell carcinoma, arising on a pre-existing inverted papilloma. (Courtesy of AMC.)
Endoscopic view of an olfactory neuroblastoma. (Courtesy of AMC.)
Initial debulking of the tumor, before the removal of the remaining attachment of the olfactory neuroblastoma en bloc. (Courtesy of AMC.)

Malignant tumors are staged according to the seventh edition of the International Union Against Cancer (UICC) classification ( Table 43.6 ), which is applicable to all epithelial and neuroendocrine tumors, but not to soft tissue, bone and cartilage, neuroectodermal, germ cell, and hematolymphoid tumors. For olfactory neuroblastoma, other specific staging systems have been introduced based on extent23,24 or histologic findings.25 The most widely used is the Kadish staging system, as modified by Morita et al26 ( Table 43.7 ).

Malignant sinonasal tumors: pretreatment imaging



Standard MR

Study planes

Additional MR sequences

To distinguish tumour from retained mucus

Adequate, though less sensitive than MR. (3 mm slice thickness better than 1 mm)

TSE T2 weighted sequences are indicated. (slice thickness 3 mm)

Axial and coronal planes

FLAIR sequence to differentiate CSF from the cystic/fluid content of tumours or mucoceles

To assess periorbita invasion

Bone erosion precisely shown by CT. The periorbita is not usually distinguished from tumour signal. (slice thickness 1 to 2 mm)

SE T1 and TSE T2-weighted sequences are indicated. Periorbita can be more easily separated from tumour signal. (slice thickness not > 3mm)

Axial and coronal planes

STIR (orbital fat signal suppressed) may be used to increase detection of orbital fat infiltration.

To assess dura mater invasion

Though skull base erosion is precisely shown by CT, only large dura breakage is detected. Contrast enhancement is required. (slice thickness 1 to 2 mm)

TSE T2 and post-contrast SE T1-weighted sequences are indicated. (slice thickness not > 3mm)

Axial, coronal and sagittal planes

To assess perineural spread

Limited to indirect signs (fat effacement or enlargement of foramina, muscular atrophy)

Direct demonstration of the abnormal nerve by enhanced fat saturated SE T1 weighted sequences (slice thickness not > 3mm)

Axial and coronal planes

GE sequences with sub-millimetric isotropic slices (FIESTA; VIBE) to image the intraforaminal segment of cranial nerves

To assess relationships of tumour with cisternal cranial nerve segments

Not indicated

TSE T2 weigheted sequence (slice thickness < 3 mm)

Axial, coronal (and sagittal planes)

MR cisternography with sub-millimetric isotropic slices (3DFT-CISS; DRIVE)

To analyse the intracranial/upper neck internal carotid artery course

CT angiography (requires contrast agent injection, high spatial resolution acquisition). MIP reconstructions

Axial, coronal (and sagittal planes)

MR angiography (requires contrast agent injection). MIP reconstructions

SE, spin echo sequence; TSE, turbo spin echo sequence; STIR, short tau inversion recovery sequence; GE, gradient echo sequence; FIESTA, fast imaging emploting steady state sequence; VIBE, volume interpolated breath-hold examination sequence; 3DFT-CISS, three-dimensional constructive interference in a steady state sequence; DRIVE, driven equilibrium radio frequency reset pulse sequence; MIP, maximum intensity projection Adapted from Lund VJ, Stammberger H, Nicolai P, et al. European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base. Rhinol Suppl 2010;1(22):1–143.

Staging system for inverted papilloma according to Krouse et al.15


Totally confined to the nasal cavity, without extension into the sinuses. The papilloma can be localized to one wall or region of the nasal cavity or can be bulky and extensive within the nasal cavity but must not extend into the sinuses or into any extranasal compartment. There must be no concurrent malignancy.


Involving the ostiomeatal complex and ethmoid sinuses and/or the medial portion of the maxillary sinus, with or without involvement of the nasal cavity. There must be no concurrent malignancy.


Involving the lateral, inferior, superior, anterior, or posterior walls of the maxillary sinus, the sphenoid sinus, and/or the frontal sinus, with or without involvement of the medial portion of the maxillary sinus, the ethmoid sinuses, or the nasal cavity. There must be no concurrent malignancy.


All types with any extranasal/extrasinus extension to involve adjacent, contiguous structures, such as the orbit, the intracranial compartment, or the pterygomaxillary space. All types associated with malignancy.

Staging systems for juvenile angiofibroma

Andrews et al20


Limited to the nasopharynx and nasal cavity; bone destruction negligible or limited to the sphenopalatine foramen


Invading the pterygopalatine fossa or the maxillary, ethmoid, or sphenoid sinus with bone destruction




Invading the infratemporal fossa or orbital region without intracranial involvement

Invading the infratemporal fossa or orbit with intracranial extradural (parasellar) involvement




Intracranial intradural without infiltration of the cavernous sinus, pituitary fossa, or optic chiasm

Intracranial intradural with infiltration of the cavernous sinus, pituitary fossa, or optic chiasm

Radkowsky et al21




Limited to posterior nares and/or nasopharyngeal vault

Involving the posterior nares and/or nasopharyngeal vault with involvement of at least one paranasal sinus





Minimal lateral extension into the pterygopalatine fossa

Full occupation of pterygopalatine fossa with or without superior erosion of orbital bones

Extension into the infratemporal fossa or extension posterior to the pterygoid plates




Erosion of the skull base (middle cranial fossa/base of pterygoids), minimal intracranial extension

Extensive intracranial extension with or without extension into the cavernous sinus

Snydermann et al22


No significant extension beyond the site of origin and remaining medial to the midpoint of the pterygopalatine space


Extension to the paranasal sinuses and lateral to the midpoint of the pterygopalatine space


Locally advanced with skull base erosion or extension to additional extracranial spaces, including orbit and infratemporal fossa; no residual vascularity following embolization


Skull base erosion, orbit, infratemporal fossa; residual vascularity


Intracranial extension, residual vascularity

M: medial extension

L: lateral extension


The UICC classification is used for most sinonasal malignant tumors, and the modified Kadish staging system is used for olfactory neuroblastoma.

Patient Selection and Information

Selection of patients who are suitable for endoscopic surgery should be based on factors related to the tumor (histology, extent, and involvement of critical anatomical structures), the patient (concomitant diseases and the patient′s preferences), and the surgeon (specific experience in endoscopic surgery). One of the key issues when planning an endoscopic approach is the identification of the point of origin of the lesion and the adjacent areas involved. Although this information is more easily provided by imaging studies in fibro-osseous lesions, as endoscopic examination is often meaningless, assessment of all the other benign and malignant tumors may benefit from either endoscopic or imaging examination. However, at endoscopy the lesion may fill most of the nasal cavity, thus hampering the assessment of its relationships with adjacent structures even after a thorough decongestion. Furthermore, even high-quality MRI can fail to identify the site of origin of the lesion. This is not the case for juvenile angiofibroma, which invariably has its epicenter of growth at the level of the pterygopalatine fossa, but applies to many osteomas and inverted papillomas, and, in general, to malignant tumors. In recent years, the identification in inverted papilloma at CT of focal hyperostosis or bony strut has been suggested to predict the area of origin of the lesion ( Fig. 43.2 ).27 These features can be detailed even by MRI.28

Staging system for nasal cavity and ethmoid sinus tumors


Restricted to one subsite of nasal cavity or ethmoid sinus, with or without bony invasion


Invading two subsites in a single site or extends to involve an adjacent site within the nasoethmoidal complex, with or without bony invasion


Extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate




Invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses

Invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than V2, nasopharynx, or clivus

Adapted from Sobin LH, Gospodarowicz MK, Wittekind CH, eds. International Union Against Cancer (UICC). TNM Classification of Malignant Tumors. 7th ed. Oxford, UK: Wiley-Blackwell; 2009.

Staging system for olfactory neuroblastoma according to Kadish et al23 and modified by Morita et al26


Limited to the nasal cavity


Involving the nasal and paranasal sinuses


Extending beyond the nasal cavity and paranasal sinuses, including involvement of the cribriform plate, base of the skull, orbit or intracranial cavity


With metastasis to the cervical nodes or distant sites

Most patients with inverted papilloma are nowadays amenable to endoscopic surgery. Only frontal sinus involvement can be a critical issue in the selection process. If a marginal extension of an ethmoid lesion into the frontal or even a frontal lesion originating from the lower part of the sinus can be managed endoscopically, inverted papillomas massively filling the sinus are challenging. Even MRI, in fact, often fails to identify the degree of mucosal involvement. In this specific situation, the actual extent of inverted papilloma can be assessed only at surgery; consequently, the possible need for an extended endoscopic procedure such as a Draf III median sinusotomy or even a combined procedure (transnasal endoscopic in association with a frontal sinusotomy through a coronal osteoplastic approach) should be considered by the surgeon and discussed with the patient. A similar situation is faced when a massive opacification of an extensively pneumatized supraorbital cell of the ethmoid is present.

The indications for endoscopic surgery in juvenile angiofibroma have rapidly evolved so that, at present, the number of patients requiring an external approach is decreasing.29,30 Many authors concur that stage I to IIIA lesions according to Andrews et al20 and stage I to IIC according to Radkowski et al21 can be managed by an endoscopic technique.2933 Limitations do exist, however, and are mostly related to the relation of the lesion with the internal carotid artery, such as encasement or the presence of extensive afferences ( Fig. 43.3 ) or an extensive growth lateral to the paraclival portion of the vessel. In these situations, an endoscopic assisted anterior (through midfacial degloving) or lateral infratemporal approach is recommended. The possibility to stage the resection to minimize morbidity coming from excessive blood loss should also be considered.29 Recurrent lesions that have evident contact with critical structures, such as the internal carotid artery, optic nerve, cavernous sinus, clivus, and dura of the middle cranial fossa, can be challenging due to scar adhesions coming from previous surgery. In all of these cases, the possible need to intraoperatively switch to a combined procedure should be discussed with the patient.

Coronal multislice computed tomography (CT) and magnetic resonance imaging (MRI) SET2 scans showing a maxillary sinus inverted papilloma. Both techniques clearly depict a bony spur (partly sclerotic) hanging on the maxillary sinus roof (arrows), representing the site of attachment of the lesion.
Juvenile angiofibroma. Digital subtraction angiography shows a nest of subtle feeders (arrows) arising from the internal carotid artery (ICA) and supplying the lesion.

In general, the indications for surgery in fibro-osseous lesions vary according to the specific histology. In osteoma and fibrous dysplasia, surgery is recommended when the patient is symptomatic or when severe aesthetic deformities are present, whereas in the case of ossifying fibroma resection is always indicated in view of the more aggressive behavior of lesions involving the sinonasal tract compared with mandible localizations. Schick et al34 precisely established indications and limits of endoscopic removal of osteomas. Lesions involving the ethmoid, sphenoid, medial wall of the maxillary sinus, and, in some selected cases, even the inferior and medial wall of the orbit can be transnasally resected. Frontal osteomas are amenable to endoscopic surgery if they are located medial to a virtual sagittal plane through the lamina papyracea ( Fig. 43.4 ) (see Video 25, Draf III for Large Frontal Sinus Osteoma Removed Endoscopically ), if they originate from the inferior portion of the posterior frontal sinus wall, and when the anteroposterior diameter of the frontal sinus is at least 10 mm. Performing a Draf III procedure may sometimes help to resect the lateral part of an osteoma of the frontal infundibulum extending over the orbit. However, in the case of lesions that extend far laterally in a well-pneumatized frontal sinus, radical removal cannot be achieved with a purely endoscopic procedure. Such a lesion can be completely exposed and drilled out by combining an endoscopic approach with an image-guided frontal trephination35 or, in more extensive cases, with osteoplastic flap sinusotomy ( Fig. 43.5 ). The latter technique alone is usually indicated in lesions located far laterally in the sinus or that originate from the anterior wall.

Coronal multislice CT scan showing an ivory frontoethmoidal osteoma located medial to a virtual sagittal plane through the lamina papyracea (dotted line), thus meeting the criteria for endoscopic resection.


The lateral limits of endonasal endoscopic approaches for lesions of the frontal sinus are debatable and are constantly being revised. A combination endonasal endoscopic/external approach can be useful in some cases (see also Chapter 22).

The analysis of criteria for selecting patients with sinonasal malignancies for endoscopic surgery requires some special considerations. The therapeutic strategy should be devised by a multidisciplinary team including surgeons, medical oncologists, radiation oncologists, pathologists, and head and neck radiologists; additionally, the otolaryngologists involved should have a flawless understanding of the biology of the numerous lesions that can be encountered, of basic oncologic principles, and of the role, if any in the specific, of neoadjuvant or nonsurgical treatment. Whenever surgery is planned, it should be performed by a team with experience in endoscopic and external procedures who can cope with the need to modify the surgical strategy according to intraoperative findings. Cooperation with neurosurgeons is obviously required with any patient with a tumor encroaching upon the anterior skull base.

Sagittal (a) and coronal (b) multislice CT scans. The left frontal osteoma almost completely fills the sinus cavity, obstructing its drainage pathway. Both the limited anteroposterior width of the sinus cavity and the encroachment of the orbital roof contraindicate a purely endoscopic resection.

The first experiences in endoscopic resection of sinonasal malignancies were, in general, limited to lesions involving the nasoethmoidal box, but not abutting the anterior skull base ( Fig. 43.6a ). In recent years, indications have been expanded to include tumors eroding the anterior skull base or invading the dura ( Fig. 43.6b–d ).3638 The major contraindications to performing an exclusively endoscopic removal are nowadays extensive involvement of the brain and the need to extend dura resection well over the orbital roof, which limits the possibility of obtaining an adequate duraplasty ( Fig. 43.7 ). In these cases, as well as in tumors largely involving the frontal sinus, a subfrontal craniotomy needs to be combined (cranioendoscopic approach). Extension to the maxillary sinus walls besides the medial wall, nasal floor, soft tissues of the orbit, and/or lacrimal pathways requires that an external approach be used ( Fig. 43.8 ).


Current major contraindications of endoscopic approaches for malignant tumors include extensive brain (not just dura) involvement, extensive frontal sinus, lateral maxillary sinus, nasal floor, and orbital involvement, as well as extension laterally over the orbital roof.

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Jun 28, 2020 | Posted by in OTOLARYNGOLOGY | Comments Off on The Role of Endoscopy in the Management of Benign and Malignant Sinonasal Tumors

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