Nasal Obstruction

INDIAN DENTAL ACADEMY

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History
CC: I cant breath through the left side of
my nose

What else do you want to ask the patient?

HPI:
6-8 mo h/o left nasal obstruction.
Slowly progressive
Occasional epistaxis when bends over
Decreased sense of smell left nasal passage
No visual changes, no headaches

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Physical Exam
Eyes: EOMI, PERRL, no diplopia, no
proptosis
Ears: TMs clear
Nose: Left nasal mass, edematous,
obstructing almost entire nasal passage
OC/OP: No masses/lesions
Neck: no LAD
CN: II-XII intact
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Diagnostic Studies
CT: evaluate bony destruction
MRI: evaluate soft tissue, differentiate
mucous from mass
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Differential Diagnosis
V hemangioma, AVM, juvenile nasoangiofibroma, hamartoma
I sinusitis, nasal polyposis, mucocele, allergic rhinitis,
T acquired nasal deformity
A Wegeners granulomatosis, relapsing polychondritis
M none
I Sarcoid, rhinitis medimentosum
N mucosal melanoma, lymphoma, nasopharyngeal carcinoma,
extramedullary plasmacytoma, adenoid cystic carcinoma, adenocarcinoma,
squamous cell ca, papillomas, fibrous dysplasia, osteoma,
hemangiopericytoma, esthesioneuroblastoma, sarcomas, SNUC
C teratomas, dermoid,
D none

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Esthesioneuroblastoma
Epidemiology:
Male:female (1:1)
Bimodal distribution 2
nd
and 6
th
decades
Pathophyisiology:
Neuroectodermal origin
Arise from olfactory mucosa
Common symptoms:
Unilateral nasal obstruction (70%)*
Epistaxis (46%)*

* Irish J, Dasgupta R, Freeman J, et al. Outcome and analysis of the surgical management of
esthesioneuroblastoma J Otolaryngol 1997; 26:1-7.

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Spectrum of lesions
Broad range of lesions arise
from the olfactory mucosa
Diverse cell poplulation in the
olfactory mucosa
Sensory neurons
Sustentacular cells
Basal cells
Within olfactory neuroblastoma
a spectrum exists
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Histology
Histologic grading based on Hyams criteria
Grade I: 14% Grade III: 21%
Grade II: 48% Grade IV: 17%
Prognostically grouped as high or low grade
Low grade: 56%, High grade 25%
*Pilch B. Head and Neck Surgical Pathology. Lippencott. Philadelphia. 2001 www.indiandentalacademy.com
Immunohistochemistry
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Histology
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Grading System
Kadish system
Stage A: limited to nasal cavity
Stage B: Extends into paranasal sinuses
Stage C: Extends beyond nasal cavity and paranasal sinuses

Dulguerov and Calcaterra*
T1: nasal cavity/paranasal sinuses (not sphenoid or superior most ethmoids)
T2: includes sphenoid w/ extension to/erosion of cribiform plate
T3: extends into orbit or anterior cranial fossa w/o dural invasion
T4: tumor involving brain

N0: no cervical lymphadenopathy
N1: any cervical metastasis

M0: no metastases
M1: distant metastases

* Dulguerov P, Allal A, Calcaterra T. Esthesioneuroblastoma: a meta-analysis and review. Lancet Oncol.
2001; 2:683-690.
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Grading Systems
5 year survival:
Kadish
Stage A 72%
Stage B 59%
Stage C 47%
Dulguerov and Calcaterra
T1 81%
T2 93%
T3 59%
T4 48%
N0 64%
N1 29%
Distribution of Patients:
Kadish
Stage A 12%
Stage B 27%
Stage C 61%
Dulguerov and Calcaterra
T1 25%
T2 25%
T3 33%
T4 17%
N1 5%
*Dulguerov P, Allal A, Calcaterra T. Esthesioneuroblastoma: a meta-analysis and review.
Lancet Oncol. 2001; 2:683-690.

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Treatment
Surgery and Radiation therapy is most commonly
accepted modality of treatment
Chemotherapy may be indicated for advanced
lesions but is controversial*
Treatment of the neck is controversial**


*Eden BV, Debo RF, Larner JM, et al. Esthesioneruroblastoma: long-term
outcome and patters of failure-the University of Virginia experience. Cancer.
1994;73:2556-2562.
** Davis RE, Weissler MC. Esthesioneuroblastom and neck metastasis. Head
Neck. 1992;14:477-482.

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