Anthony Cheesman – Problems and Prospects of Patients with Sinus Neoplasia

RSM Archives

Over the two last decades the management of tumours of the paranasal sinuses has changed from an essentially palliative combination of debulking surgery and radiotherapy to a hopefully curative combination of radiotherapy and modern surgery.
In 1973, Frazell and Lewis commenting on the unsatisfactory results for this site, attributed failure to cure on a number of factors:
– The disease was invariably advanced on presentation
– The complex anatomy of the region and its close relationship with the orbit and skull base
– The reluctance of surgeon and radiotherapist to treat aggressively for fear of increasing the natural mutilation of the disease
Over this same period, with the dramatic improvements in imaging and anaesthesia, many surgeons have been encouraged to treat these tumours more aggressively. The development of craniofacial resection and orbital exenteration often enabled extensive tumours to be salvaged after the failure of conventional therapy. Ketcham and his co-workers in North America were the real pioneers, but Shaheen and Clifford in the United Kingdom showed that such heroic surgery did not always need the direct assistance of our neurosurgical colleagues and had equally successful outcomes.
The Head and Neck teams at both Charing Cross and the Professional Unit at Grays Inn Road were impressed by the superior results obtained by salvage surgery, compared with conventional treatments, and by the low morbidity of such craniofacial resections. They resolved to routinely offer craniofacial resection as the primary surgical procedure (along with radiotherapy as an adjunctive modality) in those cases where the tumour reached the skull base.
Over this period, an audit of our results has resulted in an evolution of the surgical technique. As each new imaging technique has become available, it has been modified to give us more and more information regarding both the extent and spread of the disease. We have developed a better understanding of both the anatomy and pathology of the anterior and central skull base and are now in turn able to help our neurosurgical colleagues with some of their problems. The recent advent of neuronavigation is proving useful in our surgical approaches and bodes well for further improvements in the future.
A review of over 200 tumours of the paranasal sinuses has enabled us to make some recommendations in the management of these challenging tumours of many different pathologies, each with a different natural history. There remain, however, many problems that will require solution in the new Millennium.