| disease | Malignant Tumor of the Ethmoid Sinus |
The incidence of ethmoid sinus tumors ranks second only to maxillary sinus tumors, with squamous cell carcinoma and adenocarcinoma being the most common types. There have also been reports of fleshy tumors, malignant melanoma, and others.
bubble_chart Clinical Manifestations
Due to the small volume of the ethmoid sinus, the thinness of its bony walls, and its close connection to the orbit and anterior cranial base—sometimes with congenital defects in the bony plates—tumors in the ethmoid sinus are more prone to spread. Early-stage malignant tumors of the ethmoid sinus are difficult to detect. Clinical symptoms only appear when the tumor enlarges and involves surrounding tissues, such as destruction of the lamina papyracea leading to proptosis, impaired eye movement, diplopia, and vision disorders; invasion of the cribriform plate or dura mater may cause worsening headaches; tumor growth into the nasal cavity or other sinuses can result in nasal obstruction, bloody mucopurulent discharge, and olfactory dysfunction; outward tumor expansion may cause swelling at the inner canthus or nasal root. Primary malignant tumors of the ethmoid sinus in advanced stages may coexist with cancers of other sinuses.
It is clinically difficult to determine which sinus the tumor primarily originates from. Imaging studies such as X-rays or CT scans can clarify the tumor's extent and the presence of intracranial metastasis, but determining the tumor's nature still requires a biopsy.
bubble_chart Treatment Measures
The current treatment for this disease still advocates surgical resection as the primary approach, supplemented by comprehensive therapies such as radiotherapy or chemotherapy. Particularly for early-stage patients, there is no consensus on whether radiotherapy should be administered preoperatively, postoperatively, or in stages before and after surgery. Generally, it is recommended to perform preoperative radiotherapy for 4 to 5 weeks, with a dose of 3/4 of the total amount, followed by radical tumor resection. The remaining 1/4 of the radiation dose is administered postoperatively. Chemotherapy or other biological therapies can be determined based on the pathological type of the tumor and the patient's systemic or localized condition.
The surgery often employs a lateral nasal approach, suitable for tumors confined to the ethmoid sinus or those invading the nasal cavity, maxillary sinus, and sphenoid sinus. This method provides a wide field of view, allowing direct visualization to assess whether the tumor involves the cribriform plate or the orbital fascial sac. If the tumor has extended to the anterior skull base and the orbit, a combined craniofacial approach should be used for resection. In 1953, Smith first successfully applied this technique to treat a case of advanced-stage sinus cancer. Subsequently, Malecki (1956), Sisson (1976), and Ketcham (1973) also reported similar cases. In China, this approach began in the initial stage of the 1980s and has developed rapidly in recent years. Ketcham (1973) summarized the experience of 54 cases of combined craniofacial approach surgery for sinonasal cancer, highlighting the following advantages: ① It allows direct intraoperative assessment of the tumor's intracranial invasion, providing more direct and reliable information than imaging studies. ② It protects brain tissue, avoiding injury caused by blind surgery. ③ It reduces or prevents the occurrence of cerebrospinal fluid rhinorrhea and naso-orbital fistula. ④ It enables thorough hemostasis during surgery. ⑤ Due to the wide surgical field, the tumor can be resected en bloc in one procedure. ⑥ It effectively preserves orbital contents and reduces orbital complications. Owing to these advantages, the 5-year survival rate for this disease has reached 50%.Malignant tumors of the nasal cavity, ethmoid sinus, and frontal sinus that have invaded the bone of the anterior cranial fossa and the dura mater are all suitable for the combined craniofacial approach.
2. Depending on the need, choose an extradural or intradural approach, retract the frontal lobe of the brain, and expose the floor of the anterior cranial fossa. At this stage, administer 20% mannitol to reduce intracranial pressure or insert a catheter into the subarachnoid space to drain cerebrospinal fluid, thereby providing a clearer surgical field for the anterior cranial fossa. The tumor invading the skull base will then be exposed in the surgical field and can be resected from top to bottom.
3. On the face, make a lateral nasal incision or a modified Weber-Fergusson incision to remove the nasal and sinus tumor from bottom to top. After the combined en bloc resection of the tumor from both directions, the skull base and the nasal cavity/sinuses become continuous.
4. Repair the skull base and dura mater defects. If the skull base defect exceeds 2 cm, autologous bone or pedicled cranial periosteum is often recommended to prevent postoperative herniation of intracranial contents into the nasal cavity and sinuses. Alternatively, materials like plexiglass or artificial bone cement can be used to reconstruct the skull base and dura mater defects. Regardless of size, meticulous repair is essential to prevent postoperative cerebrospinal fluid rhinorrhea and intracranial complications. The dura mater can be repaired using temporal fascia, fascia lata, or periosteum. Small needles and fine sutures are recommended for a higher success rate.
5. The surgical cavity should be packed with antibiotic-soaked iodoform gauze, which is removed 7 to 10 days postoperatively.
7. Place drainage tubes in the wound and apply pressure bandaging.
Whether to perform orbital exenteration for malignant tumors of the ethmoid sinus remains controversial. It is generally believed that the periorbita (orbital periosteum) offers strong resistance to tumor invasion. When this barrier remains intact or when orbital apex or superior orbital fissure syndrome is absent, orbital exenteration is usually not recommended. However, if the tumor has breached the periorbita and invaded the orbit, radical resection of the orbital contents, including the orbital bones, should be performed to improve the 5-year survival rate. The resulting defects in the orbital walls and contents can be reconstructed using pedicled myocutaneous flaps.
The main complications after craniofacial combined approach surgery include incision infection, hemorrhage, cerebrospinal fluid nasal fistula or orbital fistula disease, as well as meningitis and brain abscess.
