Sinonasal Tumors Alexander G Chiu, Vijay R Ramakrishnan, Jeffrey D Suh
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1Sinonasal Tumors2
3Sinonasal Tumors
Alexander G ChiuMD Professor and Chief Division of Otolaryngology-Head and Neck Surgery Department of Surgery University of Arizona Tucson, AZ Vijay R RamakrishnanMD Assistant Professor Department of Otolaryngology-Head and Neck Surgery University of Colorado Aurora, CO Jeffrey D SuhMD Assistant Professor Division of Otolaryngology-Head and Neck Surgery University of California, Los Angeles Los Angeles, CA Foreword Eugene N MyersMD FACS FRCS Edin (Hon)
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Sinonasal Tumors
First Edition: 2012
9789350252826
Printed at Ajanta Press
5Dedicated to
This book is dedicated to my parents Paul and Elizabeth, my wife Michelle and children Nicolas and Aidan in whom words are never enough to recognize the support, sacrifice and inspiration they have given me throughout my life. I would also like to recognize my mentors Drs Vaughan and Kennedy for their lessons in medicine, humility and compassion, and my former partners Drs Palmer and Cohen for their advice, friendship and support.
Alexander G Chiu
This book would not exist without the tireless efforts of prior generations of surgeons and researchers, and their patients—who have provided the wealth of information inside. I must personally acknowledge the many professors whose time and patience have contributed to my professional development, and are too numerous to single out. Special thanks to my parents and brother, who have also sacrificed many things along the way, and to CMM who has always inspired me to do great things.
Vijay R Ramakrishnan
I would like to dedicate this work to my parents Hong Won and Kilja Suh and my brother Brian and thank them for their love and support throughout the years. To my wife Anne, thank you for being my inspiration and for your patience and understanding during the drafting of this book. I would also like to show my deepest appreciation to Drs Kennedy, Chiu, Palmer, Cohen, and Blackwell, and thank them for their outstanding teaching and invaluable mentorship.
Jeffrey D Suh
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7Contributors 9Forword
In 1933, Ringerts described the management of inverted papillomas of the nasal and paranasal sinuses. He pointed out that this tumor was characterized by a substantial rate of recurrence. However, a close reading of his paper suggests that he felt that this was not so much recurrence as persistent disease. In hindsight we can see why because these patients were treated the same as a patient with nasal polyps by removal of the lesion by a snare or by evulsion. During my residency in the decade of the 60s, the same techniques were used. Patients with multiple recurrences had a radioactive substance inserted into the nasal cavity. The recurrence rate was still substantial, again related to the lack of exposure by these surgical approaches.
In the 1970s, as the maturation of the ENT surgeon into a head and neck surgeon occurred, several others and I gained adequate exposure in this area using principles of cancer surgery, particularly the lateral rhinotomy. The recurrence rate described by Vrabek, Calcaterra, and Myers in their series had recurrence rates close to zero. However, this was at a cost to the patient of a midfacial scar and often deformity related to displacement of the medial central ligament. Technological advances have enabled us to improve the curability of both benign and malignant tumors when applied to the sinonasal area. This includes improvement in imaging techniques (CT scanning was not even available until the decade of the 1980s), the evolution of endoscopic equipment for endonasal surgery, microvascular reconstructive techniques, and more precise pathological diagnosis based upon improvements and new developments in special tests we are now able to perform on these tissues. While these technological advances certainly play a fundamental role in the changing treatment algorithms of these patients, still one cannot overlook the surgical training both in the external and intranasal approaches to these tumors. From the earliest days in residency training, otolaryngologists are taught to use the nasal endoscope in functional endoscopic sinus surgery for benign inflammatory diseases.
Later on, in their training come more advanced techniques for advanced conditions such as the recently introduced and highly successful techniques for endoscopic endonasal skull base surgery. However, not all the tumors that are encountered can be managed solely with endonasal techniques and it will evolve that some patients will need to be treated endoscopically, some by external procedures, and some by both. It is important to continue to train our Residents and Fellows both in the endoscopic and the open techniques for removal of sinonasal tumors.
In Sinonasal Tumors, there are many chapters elaborating on some of the scientific advancements in diagnosis such as improved imaging techniques and pathological diagnosis, as well as ample space devoted to the operative technique and adjunctive treatment with radiation and/or chemotherapeutic techniques. We are able to offer a more personalized treatment program for the individual patient now that we have a better way of defining the parameters of involvement and have more precise diagnosis. The editors of this book have brought together a highly qualified group of specialists both in diagnosis and treatment to bring these new paradigms of treatment of sinonasal tumors into perspective.
Eugene N Myers md facs frcs edin (hon)
Distinguished Professor and Emeritus Chair
Department of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, PA10
11Preface
Sinonasal tumors have traditionally been a difficult disease process to treat, let alone cure. Although fairly rare, this heterogeneous group of cancers often carry a guarded prognosis given their aggressive nature and close proximity to the brain and orbit. Traditional studies and techniques have focused on radical resections, but even these surgeries have often resulted in less than optimal disease-free rates.
Over the past decade, we have seen an evolution in the management of these tumors. Although radical surgeries are still needed for advanced cases, minimally invasive techniques using endoscopic equipment, computer-guided navigation, and specialty tools built for the sinuses and skull base have changed the way we often operate on these tumors. Combined with earlier detection methods, improved diagnostic imaging, tissue sparing radiation protocols, more effective chemotherapy and increased experience with endoscopic skull base and neurovascular techniques, we are seeing improved morbidity and mortality rates.
The purpose of this book is to present a modern way to treat sinonasal tumors with respect to traditional tumor extirpation principles and the need for radical excisions when the indications arise. As technology improves and our long-term follow-up grows, we expect further successes in the management of tumors long thought to be difficult to treat.
Alexander G Chiu md
Vijay R Ramakrishnan md
Jeffrey D Suh md