Clinical Case Discussion: Carcinoma Maxilla (CA Maxilla)
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๐ Clinical Case Discussion: Carcinoma of Maxilla
Today, we'll have a clinical case discussion on a very important case: Carcinoma of Maxilla.
This is a case that very commonly comes as a long case for postgraduates, with a large number of viva questions attached to it.
We'll go through the patient's history and the questions arising from it, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis with staging, and outline the management plan.
๐ค Patient Profile
- Age: 55 years
- Sex: Male
- Religion: Hindu
- Occupation: Carpenter
- Residence: Bangalore
๐ฃ๏ธ Chief Complaints
- Bilateral nasal obstruction since 2 months
- Nasal discharge from the left side since 1.5 months
- Swelling in the left cheek since 1 month
What is the importance of Age in a case involving the nose?
What is the importance of Gender in a case involving the nose?
What is the importance of Occupation in a case involving the nose?
What does Hard wood dust VS Soft wood dust exposure lead to in a case of sinonasal malignancy?
๐ History of Present Illness
Bilateral Nasal Obstruction
- Patient was apparently asymptomatic 2 months back
- Insidious onset, initially involving only the left side
- Rapidly progressive to involve the right side within the next 20 days
- Obstruction is complete on the left and partial on the right
- Continuous throughout the day
- No aggravating or relieving factors
When can you see Bilateral nasal obstruction in a case of CA Maxilla?
What does Gradually Progressive VS Rapidly Progressive indicate?
Left Sided Nasal Discharge
- Since 1.5 months
- Insidious onset
- Mucoid in type
- Occasionally blood stained, spontaneous
- Non foul smelling
- Continuous in nature
- No aggravating or relieving factors
What are the causes of Blood stained Nasal discharge?
What does Unilateral Foul smelling, blood stained nasal discharge in children & adult indicate?
Swelling in the Left Cheek
- Since 1 month
- Insidious onset, gradually progressive to attain the current size
- Associated with numbness of the left cheek
- No aggravating or relieving factors
What is the Di๏ฌerential diagnosis of cheek swelling?
What does cheek numbness indicate?
Associated Complaints
- Mouth breathing
- Snoring
- Hyponasal speech
What does mouth breathing and snoring indicate in a case of CA Maxilla?
What is hyponasality of speech also known as?
State the differences between Rhinolalia Clausa VS Rhinolalia Aperta.
โ Relevant Negative History (with Clinical Significance)
โญ Negative history is not written as a separate heading in the case sheet. It is presented here to show the complaints that must be enquired about in such a case.
| Negative History Point | Clinical Significance |
|---|---|
| No frank nasal bleeding | Suggests the mass is not highly vascular or friable (angiofibroma, hemangioma, hemangiopericytoma) |
| No sneezing or post nasal drip | Points away from an allergic or inflammatory mass such as a polyp; may also suggest absence of posterior growth with secondary sinus infection |
| No headache | No intracranial spread; no raised pressure from an obstructed sinus |
| No double vision | Extraocular muscles not involved; no cavernous sinus thrombosis with 3rd, 4th or 6th nerve involvement |
| No protrusion of the eye | No extension of tumour into the orbit |
| No decreased vision | No compression or invasion of the optic nerve; no orbital apex involvement (a red flag sign) |
| No watering of the eye | No obstruction of the nasolacrimal duct |
| No difficulty in mouth opening | No posterior spread into the infratemporal fossa involving the medial and lateral pterygoid muscles |
| No loosening of tooth | No alveolar bone or socket invasion |
| No discharge from alveolus | No secondary infection of an eroded socket, hence no bone destruction |
| No history of tooth extraction | No non-healing socket suggestive of underlying malignancy |
| No ill-fitting dentures | No alveolar ridge resorption or distortion (an early sign that is easily missed) |
| No swelling or ulceration in the palate | No inferior spread of tumour to the hard palate; no oroantral fistula |
| No smell abnormalities | Olfactory mucosa and cribriform plate not involved; no superior extension |
| No swelling in the neck | No cervical lymph node metastasis (regional spread) |
| No nasal regurgitation | No palatal involvement, palatal fistula or perforation |
| No difficulty or pain in swallowing | No oropharyngeal or soft palate extension; no advanced local disease |
| No fever and cough | Lung metastasis unlikely; also points away from tuberculosis and granulomatous disease |
| No significant weight loss or appetite loss | Constitutional symptoms of malignancy absent |
| No bone pain | No distant metastasis to bone |
| No nausea and vomiting | No intracranial extension |
| No personality changes | Frontal lobe not involved; no anterior skull base breach |
| No ear complaints | No nasopharyngeal extension blocking the eustachian tube opening, hence no serous otitis media |
| No radiation exposure | Excludes radiation as a risk factor for malignancy |
๐ฐ๏ธ Past History
- No history of similar complaints in the past
- No history of diabetes, hypertension, bronchial asthma, tuberculosis, epilepsy or thyroid disorders
- No history of surgeries in the past
- No history of drug allergy or blood transfusion
- No significant family history
๐ค Personal History
- Sleep: Reduced
- Appetite: Normal
- Diet: Non-vegetarian
- Bladder and bowel movements: Normal
๐ฌ Addiction History
- Bidi smoking: 10/day for 35 years
Which nasal masses have a Bimodal age distribution?
๐ฉบ Local Examination
Examination of the Nose
Inspection
- Facial asymmetry present
- Left nasolabial fold obliterated
- Skin normal
- External osteocartilaginous framework normal
- Bilateral ala and columella normal
- Left vestibule: Mucoid discharge present
- Right vestibule normal
Anterior Rhinoscopy
- Septum deviated to the right side
- Left side: Pale, irregular mass filling the entire left nasal cavity, with everted margins, covered with mucoid discharge
- On probing: sensitive to touch, friable, bleeds on touch, firm in consistency
- Probe can be passed all around except laterally
Posterior Rhinoscopy
- Pale irregular mass seen in the left choana
- Right choana free
- Eustachian tube opening free on both sides
- Posterior end of the septum free
Paranasal Sinuses
- All non-tender
Functional Tests
| Test | Finding |
|---|---|
| Cottle's test | No improvement on both sides |
| Cold spatula test | Decreased misting on the right, absent misting on the left |
| Cotton wool test | Reduced movement on the right, absent movement on the left |
| Smell | Present on both sides |
Cranial Nerve Examination
- Reduced sensation over the left cheek
- All other cranial nerves intact
Examination of the Cheek
Inspection
- Diffuse swelling of the left cheek
- Size: approximately 2 x 3 cm
- Globular in shape
- Ill-defined borders
- Skin over the swelling appears normal
Palpation
- Inspectory findings confirmed
- Extent:
- Vertically: 1 cm from the lower eyelid to 3 cm above the lower border of the mandible
- Horizontally: from 5 cm from the tragus, continuing medially onto the lateral wall of the nose, blunting the nasolabial fold
- Ill-defined borders
- No local rise of temperature
- No tenderness
- Hard in consistency
- Skin free and pinchable
- Swelling fixed to the underlying bone, does not move independently of maxillary movement
Other Examinations
Eye, oral cavity, oropharynx, indirect laryngoscopy, ear and neck examination: Normal
๐ง Interpretation of Examination Findings
Septum Deviated to the Right
The mass has grown large enough to push the septum across the midline, explaining the bilateral nasal obstruction.
Pale, Irregular Mass
โญ Irregularity distinguishes a malignant from a benign mass.
A benign mass such as a nasal polyp is described as pale, glistening and smooth. Disordered tissue growth in malignancy produces an irregular surface.
Everted Margins
A feature of malignancy.
Covered with Mucoid Discharge
Suggests secondary obstructive changes, where the tumour obstructs the sinus outflow tract causing secondary sinusitis.
Sensitive to Touch
The malignant lesion invades the underlying mucosa and its sensory nerve supply, producing pain on touch.
โญ A polyp is insensitive to touch, as edematous hypertrophic mucosa has very few sensory nerve endings.
Friable and Bleeds on Touch
Due to abnormal neovascularization of tumour tissue. Tumour vessels are thin walled and lack normal supportive stroma, so they rupture with minimal trauma.
Name some conditions where it bleeds on touch on probing.
Firm in Consistency
Reflects the solid cellular nature of malignant tissue.
โญ A polyp feels soft and boggy, being hypertrophic edematous mucosa.
Probe Passes All Around Except Laterally
Indicates the point of origin or attachment of the mass.
๐ The mass arises from the lateral wall of the nose, where the maxillary sinus opens into the middle meatus through its ostium.
Posterior Rhinoscopy Findings
| Finding | Interpretation |
|---|---|
| Mass in the left choana | Tumour spans the entire anteroposterior length of the nasal cavity |
| Right choana free | Disease still confined unilaterally at the level of the choana; no septal crossing or bilateral posterior spread |
| Eustachian tube opening free | No nasopharyngeal extension |
| Posterior end of septum free | No posterior septal invasion |
Cheek Swelling
- Diffuse swelling with ill-defined borders and hard consistency suggests infiltration of the subcutaneous tissue from the maxillary sinus
- Skin free and pinchable indicates the skin of the cheek is not involved, so the tumour is not T4
- Fixed to underlying bone indicates bony involvement
๐๏ธ Importance of Examining Other Regions
Eye Examination
Looks for proptosis, diplopia and extraocular muscle involvement.
โญ The direction of proptosis indicates the sinus of origin.
What is the direction of Proptosis in CA Maxilla VS CA Ethmoid?
Oral Cavity & Oropharynx
Extension of the tumour from the nasopharynx to the soft palate causes restriction of soft palate movement, lowering of the soft palate, or a mass hanging into the oral cavity.
Indirect Laryngoscopy
To rule out a synchronous lesion in the larynx.
Ear Examination
Nasopharyngeal extension blocks the eustachian tube opening in the lateral wall of the nasopharynx, impairing ventilation and drainage of the middle ear, leading to serous otitis media.
Neck Examination
Cervical lymph node involvement in sinonasal malignancy upstages the tumour and changes the treatment protocol.
๐ Case Summary
- 55-year-old male, carpenter by occupation, chronic bidi smoker
- Bilateral nasal obstruction for 2 months, initially left sided and rapidly progressive to the right within 20 days, complete on the left and partial on the right
- Left sided nasal discharge for 1.5 months, mucoid, occasionally blood stained, non foul smelling
- Left cheek swelling for 1 month, gradually progressive, with cheek numbness, mouth breathing, snoring and hyponasal speech
- Anterior rhinoscopy: pale irregular mass filling the left nasal cavity with everted margins, sensitive to touch, friable, bleeds on touch, firm in consistency, probe passes all around except laterally
- Posterior rhinoscopy: pale irregular mass in the left choana, rest free
- Cheek swelling with ill-defined borders, hard in consistency, skin free and pinchable, fixed to underlying bone
๐ฉบ Provisional Diagnosis
Left sided malignant growth of the maxilla, Clinical stage: T3N0MX (Stage III)
What are the points in Favour of the Diagnosis?
What are the staging systems in CA Maxilla?
What is Ohngrenโs line?
What is Ohngrenโs Classification?
What is Lederman's Classification?
What are Horizontal Lines of Sebileau?
Is Suprastructure & Infrastructure the same in Ohngren & Lederman Classification?
๐ TNM Classification of Maxillary Sinus Carcinoma
T Staging
| Stage | Description |
|---|---|
| TX | Tumour cannot be assessed |
| Tis | Carcinoma in situ |
| T1 | Tumour limited to the antral mucosa, with no bony erosion or destruction |
| T2 | Tumour causing bony erosion or destruction, including extension into the hard palate or middle meatus, except extension into the posterior wall of the maxillary sinus and pterygoid plates |
| T3 | Involvement of any of: posterior wall of maxillary sinus, subcutaneous tissue, floor or medial wall of orbit, pterygoid fossa, ethmoid sinus |
| T4a | Moderately advanced local disease. Involvement of any of: anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinus |
| T4b | Very advanced local disease. Involvement of any of: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than the maxillary division of the trigeminal nerve, nasopharynx, clivus |
N Staging
| Stage | Description |
|---|---|
| NX | Regional nodes cannot be assessed |
| N0 | No lymph node metastasis |
| N1 | Metastasis in Single ipsilateral lymph node, 3 cm or less in greatest dimension, without extranodal extension |
| N2a | Metastasis in Single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, without extranodal extension |
| N2b | Metastasis in Multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, without extranodal extension |
| N2c | Metastasis in Bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension, without extranodal extension |
| N3a | Metastasis in a lymph node more than 6 cm in greatest dimension, without extranodal extension |
| N3b | Metastasis in a single or multiple lymph nodes with clinical extranodal extension |
โญ Any clinical extranodal extension immediately places the tumour in N3b, regardless of number, laterality or size.
M Staging
| Stage | Description |
|---|---|
| M0 | No distant metastasis |
| M1 | Distant metastasis present |
โญ Staging Matrix
| Stage | Criteria |
|---|---|
| Stage 0 | Tis, N0, M0 |
| Stage I | T1, N0, M0 |
| Stage II | T2, N0, M0 |
| Stage III | T3 (N0, N1) M0, or T1/T2 with N1 M0 |
| Stage IVA | T1/T2/T3 with N2 M0, T4a with N0/N1/N2 M0 |
| Stage IVB | T4b any N M0, or Any T N3 M0 |
| Stage IVC | Any T, Any N, M1 |
๐ก Points to remember the matrix
- Any metastasis goes directly to Stage IVC
- With no nodal or distant spread, Stage I and II depend only on T1 and T2
- T3 or N1 takes the tumour to Stage III
- T4a or N2 takes it to Stage IVA
- T4b or N3 takes it to Stage IVB
โญ This case is T3, N0, MX, falling under Stage III.
What is the Differential Diagnosis of Unilateral Nasal Mass? How will you differentiate between each one of them?
What is the Rate of malignant transformation of inverted papilloma?
What is the most common histology of malignant transformation of inverted papilloma?
What is the Etiology of Carcinoma of Maxilla?
What is Thorotrast?
What are the tumour spread patterns of carcinoma of maxilla in detail?
What are the sites of Distant Metastasis in carcinoma of maxilla?
What are the groups of symptoms seen in CA Maxilla?
What is the most common and earliest cranial nerve involved in CA Maxilla?
Which are the last cranial nerves to be involved in CA Maxilla?
๐ Robbin's Phases of Carcinoma of Maxilla
| Phase | Features |
|---|---|
| Phase I | Patient presents with sinusitis |
| Phase II | Bony erosion or periostitis, with dull aching pain |
| Phase III | Neurological involvement, with deep pain |
| Phase IV | Distant metastasis present |
๐จ Management Plan
โญ Management always consists of two parts: Investigations and Treatment.
๐ฌ Investigations
1- Routine Blood Investigations
2- Diagnostic Nasal Endoscopy
- Assesses the origin and extent of the tumour
- Checks posterior spread into the nasopharynx
- Guides the site for biopsy
3- Contrast Enhanced CT of Paranasal Sinuses and Orbits
๐ก The three E's on CT
- Extension of the tumour
- Erosion of the bony sinus walls
- Expansion of the bony sinus walls
Why is CT scan done before biopsy in CA Maxilla?
What is the role of contrast in CA Maxilla?
4- Biopsy
โญ Gold standard for confirming the diagnosis.
- Determines the pathological type, which guides treatment options
Which pathological type of sinonasal malignancy has a good prognosis despite pulmonary metastasis?
Which is the most common and the second most common pathological type of sinonasal malignancy seen?
5- MRI of Paranasal Sinuses and Orbits
- Better soft tissue detail
What all is checked in MRI in a case of CA Maxilla?
6- PET-CT
- To rule out distant metastasis
๐ธ X-rays (Historical Importance)
X-rays are not used nowadays, as CT is far superior, but they remain important from a viva perspective.
- X-ray paranasal sinuses, Water's view
- X-ray lateral skull
- X-ray base of skull
What are the findings seen on X-ray PNS Water's View in Sinonasal Malignancy?
What is Triple Line of Baclesse?
๐ฉป Treatment
โญ Radiological staging must be confirmed before finalizing treatment, as the stage may change on imaging.
Treatment Plan for This Case
๐ Left total maxillectomy with postoperative radiotherapy and reconstruction
Orbital Preservation
As there are no orbital symptoms such as diplopia, decreased vision or proptosis, an orbit preserving total maxillectomy can be planned once imaging confirms no orbital invasion.
Neck Management
The neck is clinically N0.
โ Elective neck dissection has no role in a clinically or radiologically N0 neck in maxillary sinus carcinoma, because of the low rate of cervical nodal metastasis.
What are the Surgical Approaches to Carcinoma of Maxilla?
What is Moure's Incision?
What is Weber Fergusson Incision?
What are the different Modifications of the Weber Fergusson Incision?
What is Maxillectomy?
What are the different types of Maxillectomy?
What is craniofacial resection?
What are the Steps of Total Maxillectomy?
Which vessel is responsible for bleeding after removal of the maxilla in Total Maxillectomy?
What is the Brown and Shaw Classification of Maxillary and Mid-facial Defects? How is reconstruction done based on this classification?
What are the Reconstruction options After Total Maxillectomy?
What is an Obturator? What are the advantages & disadvantages of Obturator?
What are the different types of Obturator? When is each one of them used?
What are the different types of flaps used in reconstruction after Total Maxillectomy? Give examples of each one of them.
What are the indications of Post operative Radiotherapy in CA Maxilla?
What is the Type and Dose of Radiotherapy used in CA Maxilla?
How will you follow up a case of CA Maxilla?
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