Benign Tumors of External Nose

Benign Tumors of the External Nose

• Rhinophyma: a slow-growing tumor characterized by hypertrophy of the sebaceous glands of the tip of the nose, often seen in longstanding cases of acne rosacea
• Clinical features: middle-aged men, pink lobulated mass over the tip of the nose with superficial vascular dilatation, nasal obstruction
• Treatment: tumor debulking and grafting the defect

Malignant Tumors of the External Nose

• Basal cell carcinoma (Rodent ulcer):
  • Most common skin tumor
  • Equally affects male and female
  • Affects age group 50-60 years
  • Common sites are the tip and ala
  • Remains confined to the skin for a long time, may involve underlying cartilage and bone, with rare nodal metastasis
  • Treatment: surgical excision with safety margins and reconstruction of the defect
• Squamous cell carcinoma:
  • Second most malignant tumor
  • Infiltrating nodule or ulcer with rolled out edges
  • Nodal metastasis in 20%
  • Treatment: early lesions treated by radiotherapy, late lesions with nodal metastasis require wide surgical excision and neck dissection + plastic repair of the defect
• Malignant melanoma:
  • Least common variety
  • Clinically: superficial spreading type, nodular infiltrating type
  • Treatment: surgical excision, repair of the defect

Sinonasal Tumors

• Rare tumors, carcinomas account for 3% of head and neck carcinomas
• Male: Female ratio 2:1
• 5th-7th decades
• Benign tumors:
  • Epithelial: papilloma, adenoma
  • Non-epithelial: fibroma, osteoma, neurofibroma, hemangioma
• Malignant tumors:
  • Epithelial:
    • Squamous cell carcinoma
    • Transitional cell carcinoma
    • Adenocarcinoma
    • Adenoid cystic carcinoma
    • Melanoma
    • Olfactory neuroblastoma
    • Undifferentiated carcinoma
  • Non-epithelial:
    • Rhabdomyosarcoma
    • Leiomyosarcoma
    • Fibrosarcoma
    • Liposarcoma
    • Angiosarcoma
    • Myxosarcoma
    • Hemangiopericytoma
    • Chondrosarcoma
    • Osteosarcoma
  • Lymphoreticular tumors: Lymphoma, Plasmacytoma, Giant cell tumor

Inverted Papilloma

• 5-4% of all sinonasal tumors
• Human papilloma virus
• 5th-6th decade, more common in male, usually unilateral
• High tendency for recurrence
• Presenting symptoms: unilateral nasal obstruction, epistaxis, or non-specific symptoms
• Primary site: lateral nasal wall, followed by maxillary and ethmoid sinuses
• Investigations: CT scan, MRI in case of intracranial extension, biopsy for histopathology
• Treatment: complete surgical resection, endoscopic removal for selected patients

Juvenile Angiofibroma

• Rare, vascular benign tumor, 0.5% of all nasal tumors
• Most commonly affects male of teenage or young adults
• Arises from area superior to sphenopalatine foramen
• Histologically: multiple vascular channels surrounded by fibrous connective tissue
• Unilateral epistaxis, nasal obstruction, or both
• Unilateral middle ear effusion, proptosis, diplopia, cheek swelling with or without pain
• On examination: reddish, smooth polypoid mass
• Investigations: CT scan, MRI, arteriography, feeding vessels, and pre-operative embolization
• Treatment: surgical removal by external or endoscopic approach, irradiation, and chemotherapy for poor surgical candidates

Nasopharyngeal Carcinoma

• Squamous cell carcinoma (SCC) arising from the epithelial lining of the nasopharynx
• Fossa of Rosenmuller, ethnic Chinese in the southern part of China, and Western Sudan
• Genetic, ethnic, and environmental factors may play a role in the etiology of the disease
• The consumption of salted fish (nitrosamine) and Epstein-Barr virus (EBV) may play a role in the etiology
• First-degree relatives of patients with NPC have a higher incidence of developing this malignancy
• Three forms: proliferative (mass), ulcerative (epistaxis, blood-stained discharge), and infiltrative (cranial nerves affection)
• WHO classification:
  • Type I: typical keratinizing SCC with intercellular bridges
  • Type II: non-keratinizing epidermoid carcinomas
  • Type III: undifferentiated or poorly differentiated carcinomas
• Presenting symptoms: painless neck mass (Level V/II cervical LN), nasal obstruction, discharge, unilateral deafness, otalgia, cranial nerve involvement, and symptoms related to distant metastasis
• Diagnosis: clinical picture, estimation of antibody levels against EBV, imaging studies, endoscopic examination of the nasopharynx, and taking a biopsy, FNA cytology from the involved cervical lymph node/s
• Treatment: chemotherapy, radiation, and role of surgery for debulking or recurrent disease

Oropharyngeal Malignancies

• Tobacco products, alcohol, and genetic factors
• Precancerous lesions: leukoplakia and erythroplakia
• Most common: Squamous cell carcinoma (90%)
• Other: Lymphoma, spindle cell carcinoma, and minor salivary gland tumors
• Base of the tongue and tonsils are the most involved sites
• Presenting symptoms: sore throat, otalgia, dysphagia, feeling of lump, and neck swelling
• On examination: mass or ulcer, cervical lymph node (level I/II)
• Investigations: biopsy, FNA cytology, CT scan neck
• Treatment depends on the histopathology and stage: surgery, radiation, and chemotherapy

Hypopharyngeal Malignancies

• Tobacco products, alcohol, acid reflux, and Plummer-Vinson disease/ postcricoid carcinomas
• Most common: Squamous cell carcinoma
• Most frequent involved subsite: pyriform fossa, followed by postcricoid area, and least frequent is the posterior pharyngeal wall
• Presenting symptoms: dysphagia, otalgia, neck swelling, and chronic sore throat
• May be past history of anemia and web
• On examination: mass, immobile vocal cord, pooling of saliva in the pyriform fossa
• Cervical lymph nodes (level II/III)
• Investigations: biopsy, FNA cytology from lymph node, CT scan, and Barium Swallow study
• Treatment: radiation/chemotherapy, surgery

Laryngeal Tumors

• Most common benign tumor: Squamous papillomas
• Human papillomavirus
• Recurrent respiratory papillomatosis: children
• Adult-onset papillomas: solitary or localized
• Treatment: surgical (laser)
• Most common malignant tumor: Squamous cell carcinoma
• Male predominance
• Alcohol, smoking, acid reflux, Human papilloma virus, and industrial carcinogens
• Glottic and supraglottic are the most common subsites, subglottic is rare
• Presenting symptoms: hoarseness of voice, stridor, dysphagia (supraglottic)
• Cervical lymph node metastasis incidence is more in supraglottic
• Examination: mass, vocal cord mobility
• Biopsy, CT scan neck
• Chemoradiation/surgery