Maxillary Carcinoma

MAXILLARY CARCINOMA
Paranasal sinus cancer is uncommon and represents only 0.2 to 0.8% of all malignancies.
  • Cancer of paranasal sinus constitutes 3% of all carcinomas of the aerodigestive tract.
  • The majority of paranasal sinus malignancies (50-80%) originate within the maxillary sinus antrum. Malignancies rarely occur within the other sinuses and originate in the ethmoid, frontal, and sphenoid sinuses in 10%, 1% and 1% respectively.
  • The cause of parasinus malignancy is unknown. However several risk factors have been associated and therefore it is seen more commonly in people working in hardwood furniture industry, 
  • nickel refining, leather work, and manufacturer of mustard gas.
  • More than 80% of the malignant tumours are of squamous cell variety. Rest are adenocarcinoma, adenoid cystic carcinoma, melanoma, and various type of sarcomas.
  • Workers of furniture industry develop adenocarcinoma of the Ethmoids and upper nasal cavity. While those engaged in Nickel refining get squamous cell and Anaplastic carcinoma.
CLINICAL FEATURES OF MAXILLARY CARCINOMA
  • It is seen more commonly in the 7th decade of life. Males are affected more commonly than females.

  • Early features of maxillary sinus malignancy are nasal stuffiness, blood-stained nasal discharge, facial paraesthesias or pain and epiphora. These symptoms may be missed or simply treated as sinusitis. Late features will depend on the direction of spread and extent of growth.
  • Medial spread to nasal cavity gives rise to nasal obstruction, discharge and epistaxis. It may also spread into anterior and posterior ethmoid sinuses and that is why most antral 
  • malignancies are antroethmoidal in nature.
  • Anterior spread causes swelling of cheeks.
  • Inferior spread leads to expansion of alveolus with dental pain, loosening of teeth, poor fitting dentures, ulceration of gingiva.
  • Superior spread invades the orbit causing proptosis, diplopia, ocular pain and epiphora.
  • Posterior spread is into pterygomaxillary fossa, pterygoid plate and the pterygoid muscles causing trismus.
  • Lymphatic spread in maxillary carcinoma is rare and occurs only in the late stages.
  • Most commonly involved lymph node is submandibular lymph node followed by jugular nodes.
PROGNOSIS IN A CASE OF MAXILLARY CARCINOMA
Ohngren's line is a line that connects the medial canthus of the eye to the angle of the mandible.
  • The line divides the maxillary sinus into (1) an anterior-inferior part, and (2) a superior-posterior part. Tumours that arise in the anterior-inferior part, i.e. below Ohngren's line, generally have a better prognosis than those in the other group
INVESTIGATIONS IN A CASE OF MAXILLARY CARCINOMA
  • Nasal endoscopy – If there is involvement of medial wall of maxilla the mass could be seen to present itself inside the nasal cavity. If the mass could be seen within the nasal cavity biopsy can be taken from the lesion. Under endoscopic vision inferior meatal antrostomy can be performed and the interior of the maxillary sinus can be examined and biopsy can be taken from the lesion.
  • X ray paranasal sinuses water's view – shows opacity with expansion of the involved maxillary sinus. Erosion of the floor /
  • anterolateral wall of the orbit can also be seen if present
  • CTscan paranasal sinuses – Shows the extent of lesion, involvement of adjacent areas, evidence of bone erosion if present.
  • MRI imaging shows better soft tissue delineation. Extension into pterygopalatine fossa can be clearly seen
  • Biopsy from the lesion is virtually diagnostic.
TREATMENT OF MAXILLARY CARCINOMA
  • For squamous cell carcinoma, the treatment of choice is a combination of radiotherapy and surgery.
  • Radiotherapy can be given before or after surgery. Very often, a full course of pre-operative Radiotherapy is given, followed 4 - 6 weeks later by surgical excision of the growth by total or extended maxillectomy.
  1. If the tumor is confined to the inferior portion of the maxilla the condition is best managed by partial maxillectomy followed by irradiation.
  2. Involvement of orbit can be managed by combining orbital exenteration along with total maxillectomy.
  3. Tumor involving the whole of the maxilla can be managed by total maxillectomy followed by irradiation.
  4. Neck dissection can be resorted to if neck nodes are involved.
  5. Chemotherapy:
  6. Cisplatin and 5flurouracil can be administered along with radiotherapy.
  7. This is preferred in advanced cases of malignancy involving the maxillary sinus.
Exam Question
  • Ohngren's line that divides maxillary sinus into superolateral and inferomedial zone is related to Maxillary cancer.
  • Early maxillary carcinoma presents as Bleeding per nose.
  • First lymph node involved in maxillary carcinoma is Submandibular.
  • In Maxillary carcinoma of a 60 year old patient involving anterolateral part of maxilla, the preferred treatment is Radiotherapy followed by total/extended maxillectomy.

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