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TITLE:   Neoplasms of the Maxilla and Sinuses  
SOURCE:  Dept. of Otolaryngology, UTMB, Grand Rounds
DATE:    October 18, 1995
RESIDENT PHYSICIAN:     Kelly D. Sweeney, M.D.
FACULTY:                Byron J. Bailey, M.D.
SERIES EDITOR:          Francis B. Quinn, Jr., M.D.
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"This material was prepared by resident physicians in partial fulfillment 
of educational requirements established for the Postgraduate Training 
Program of the UTMB Department of Otolaryngology/Head and Neck Surgery 
and was not intended for clinical use in its present form.  It was 
prepared for the purpose of stimulating group discussion in a conference 
setting.  No warranties, either express or implied, are made with respect 
to its accuracy, completeness, or timeliness.  The material does not 
necessarily reflect the current or past opinions of members of the UTMB 
faculty and should not be used for purposes of diagnosis or treatment 
without consulting appropriate literature sources and informed professional 
opinion." 

Introduction 

Tumors of the paranasal sinuses are uncommon in the general population.
The incidence of sinonasal carcinoma is about one case per 100,000 people
per year, which represents 3% of the upper aerodigestive tract
malignancies and less than 1% of all malignancies in the body.  Males are
affected two to three times more often than females, and most patients are
in their fifth to seventh decade at the time of diagnosis.  The majority
of paranasal sinus tumors arise in the maxillary sinus (80%).  Twenty
percent arise in the ethmoid sinuses, and the remainder (<1%) originate in
the frontal and sphenoid sinuses.  Eighty percent of these lesions are
squamous cell carcinomas; fifteen percent are adenocarcinomas, with the
remaining five percent composed of all other types.  The high mortality
rate and poor prognosis associated with these tumors is related to late
diagnosis secondary to the early symptomatic latency of these lesions.
Most lesions are at an advanced stage at the time of definitive diagnosis.
However, in recent years the widespread use of systematic nasal endoscopy
and high resolution computed tomography have contributed to earlier
diagnosis.  

In spite of these advances and aggressive surgical management, the
mortality rate of these lesions continues to be high.  The primary cause
of death from paranasal sinus tumors is failure of local control.
Surgical treatment alone may be sufficient for stage I or stage II lesions
provided adequate resection margins are obtained.  However, for advanced
tumors combined therapy with radical surgical excision and postoperative
radiotherapy has been shown to improve the five year survival rate.

Epidemiology

Several occupational groups have been noted to have an increased risk of
developing sinonasal tumors.  These include nickel refiners, woodworkers,
manufacturers of isopropyl alcohol, chromium, radium, and leather, and
textile workers.  It is unclear whether these factors cause cancer by
direct carcinogenesis or by altering the normal nasal epithelial
physiology.  Wood dust has been shown to slow mucociliary transport in
nasal epithelium allowing prolonged exposure to potential carcinogens.  In
addition, turbulent flow has been implicated in the pathogenesis as
chronic occlusion of one nostril can induce squamous metaplasia on the
opposite side.  Nickel workers primarily develop squamous cell carcinomas
which usually arise in the nasal cavity.  Woodworkers, however, primarily
develop adenocarcinomas which usually arise in the ethmoidal sinuses.  The
incidence of development of adenocarcinomas in these workers is 1000 times
higher than that of the general population.  Tobacco and alcohol use have
not been demonstrated conclusively as a causative factor in the
development of paranasal sinus tumors.


Anatomic Routes of Spread

Tumors of the maxillary sinus can spread anteriorly to involve the skin
and soft tissues of the cheek, medially to involve the nasal cavity,
posteriorly to involve the pterygomaxillary space, or superiorly to
involve the orbit.  Ethmoidal sinus tumors can spread superiorly into the
cribriform plate and brain, laterally into the lamina papyracea and orbit,
or posteriorly into the posterior ethmoids, sphenoid sinus, and base of
skull.  Frontal sinus tumors can spread posteriorly or superiorly to
involve the brain, inferiorly to involve the orbit, or anteriorly to
involve the skin and soft tissues of the forehead.  Tumors of the sphenoid
sinus can spread superiorly into the cavernous sinus, optic chiasm, and
brain, or posteriorly into the skull base.

Clinical Presentation

Tumors of the paranasal sinuses require a high index of suspicion for
accurate diagnosis.  Seventy-five percent of all paranasal sinus tumors
are T3 or T4 at the time of diagnosis.  These lesions can grow silently
for several months with no significant symptoms until the tumor has spread
beyond the sinus boundaries.  In addition, the initial symptoms of
paranasal sinus tumors mimic those of inflammatory disorders resulting in
unsuccessful treatment regimens until the diagnosis becomes clear.  The
average delay from symptom onset to definitive diagnosis is eight months.
When symptoms do become evident, these result from growth of the tumor
outside of the sinus of origin and are directly referable to the
structures into which the tumor invades.  

Nasal symptoms are the most common and include: unilateral nasal
obstruction, epistaxis, anosmia, nasal drainage, and hyponasal speech.
Facial symptoms are the next most common and include: loss of definition
of the nasolabial fold of the involved side, facial asymmetry, obvious
cheek mass, cutaneous fistula, facial edema, and pain.  Hypesthesia of the
cheek may also occur secondary to invasion of the infraorbital nerve.
Oral cavity symptoms include: ill fitting upper dentures, widened
alveolus, dental pain, or an obvious palatal mass.  

Many patients undergo dental extractions as treatment for their pain which
may result in an oroantral fistula and lead to the definitive diagnosis.
Orbital symptoms include: proptosis, eyelid edema, diplopia secondary to
extraocular muscle involvement, epiphora resulting from obstruction or
destruction of the lacrimal drainage apparatus, or visual loss from direct
involvement of the optic or oculomotor nerves at the orbital apex.
Hearing loss can develop from nasopharyngeal extension of the tumor
leading to eustachian tube obstruction or dysfunction and serous effusion.
Symptoms resulting from posterior extension include severe, deep-seated
pain due to skull base invasion, trismus due to pterygoid muscle invasion,
or cranial neuropathies.

Diagnosis

Any patient who presents with symptoms suggestive of a paranasal sinus
tumor requires a complete head and neck examination.  Examination of the
oral cavity must include careful inspection and palpation of the palate,
teeth, upper alveolar ridge, and gingivobuccal sulcus.  The nasal cavity
should be carefully and thoroughly examined using a rigid nasal endoscope.
The nasopharynx must be evaluated using either mirror examination or a
flexible nasopharyngoscope.  Transillumination can be performed to assess
the aeration of the sinus cavities.  A careful orbital examination must be
performed with evaluation of the extraocular motility, pupillary
reactivity, and to detect possible proptosis, enophthalmos, or diplopia.
A careful cranial nerve assessment must also be performed with particular
attention to the branches of the trigeminal nerve.  Corneal reflexes
should be assessed as an absent or decreased corneal reflex usually
indicates involvement of the sphenopalatine ganglion.  Cranial nerve
involvement is an indication of advanced disease and usually denotes a
poor prognosis.

Radiologic Evaluation

Radiologic imaging is essential during the initial work-up of a patient
suspected of having a sinonasal tumor.  These studies should be obtained
prior to biopsy of the lesions to avoid surgical artifact.  Plain sinus
films are usually the first study obtained when evaluating patients with
symptoms of sinonasal disease.  With advanced lesions, bony destruction
and a soft tissue mass may be evident.  However, findings are often
nonspecific and differentiating early malignant lesions from inflammatory
diseases is usually not possible with plain films.  For this reason it is
important to maintain a high index of suspicion when evaluating patients
with a history of exposure to known sinonasal carcinogens who present with
significant symptoms so that further imaging studies can be obtained.

The advancement of high resolution computed tomography with thin sections
and intravenous contrast has greatly improved the clinicians ability to
diagnose paranasal sinus lesions, allowing for earlier detection and more
accurate staging.  Extension of the tumor into the intracranial cavity,
orbit, pterygomaxillary fossa, or into the soft tissues of the face is
easily demonstrated on CT.  In addition, bony erosion is well illustrated
by CT.  In spite of these properties, it is not always possible to
distinguish tumor from mucosal edema secondary to sinus obstruction by the
lesion on CT.  In addition, CT cannot always clearly determine whether the
tumor has invaded the periorbita (important for planning need for orbital
exenteration).

Magnetic resonance imaging provides excellent delineation of tumor from
the surrounding soft tissues, inflammation, and retained secretions.  This
characteristic in combination with the multiplanar ability of MRI and lack
of radiation exposure give MRI a distinct advantage over CT.  In addition,
tumor spread into the brain and orbit are better evaluated with MRI.  By
using T1 and T2 weighted images with gadolinium enhancement, an
experienced neuroradiologist can predict with considerable accuracy the
tumor extent.  The combination of CT for evaluating bony erosion/extension
and MRI for evaluating soft tissue extension of disease has greatly
improved preoperative planning.

Biopsy

When a mass is present in the nose, this may represent a primary nasal
lesion or extension of a tumor from the paranasal sinuses.  Biopsy in the
nasal cavity can be performed in the office under topical and local
anesthetic.  Adequate lighting, suction, and surgical assistance are key.
Lesions that appear vascular should only be biopsied in a controlled
setting (operating room).  It is important to obtain adequate tissue
samples especially from the deep portion of the lesions because many of
these tumors are inflamed and necrotic at the periphery. Care must be
taken to avoid crush artifact.  Packing may be necessary after biopsy to
control bleeding.  For maxillary sinus masses with no abnormal tissue
present intranasally, an exploratory antrostomy will usually be needed to
obtain tissue for diagnosis.  This can be performed under local or general
anesthesia with an incision in the gingivobuccal sulcus.  This will allow
removal of the biopsy site at the time of the definitive procedure.
Alternatively, these lesions can be approached via a nasoantral window.
     
Staging

The American Joint Committee on Cancer has developed standard TNM staging
for maxillary sinus tumors.  Ohngren's Line is an imaginary line extending
from the medial canthus of the eye to the angle of the mandible which
divides the maxillary antrum into the infrastructure (anteroinferior) and
suprastructure (posterosuperior and is significant in determining the
stage of antral tumors.  In general, tumors below this line have a better
prognosis than tumors above it.

T1- confined to the antral mucosa of the infrastructure, no bone erosion

T2- confined to mucosa of suprastructure without bone erosion, or confined
to the infrastructure with destruction of the anterior or medial walls

T3- invasion into the orbit, anterior ethmoid, pterygoid muscle or cheek

T4- massive lesion with involvement of the cribriform plate, posterior
ethmoid, sphenoid, nasopharynx, pterygoid plates or skull base.
     
Nodal (N) and metastatic (M) staging are identical to that of other head
and neck tumors.

Benign Tumors

Osteomas:

These are slow growing tumors composed of mature bone.  They are most
commonly found in the frontal sinus.  Surgical removal is only indicated
for symptomatic patients, or when sinus drainage is affected by the
lesions.  A rim of normal bone may need to be removed to allow extraction
of the tumor.

Ameloblastoma:

Eighty percent of these tumors occur in the mandible, but twenty percent
are seen in the maxilla.  Of those found in the maxilla, half are found in
the molar area, one third are found adjacent to the antrum, and the
remainder occur at other sites.  Histologically, these tumors mimic the
enamel organ.  Simple curettage is not effective and results in a high
recurrence rate.  Therefore, these lesions must be excised with wide
surgical margins and may require a radical maxillectomy.  

Fibrous dysplasia:

This disease process is characterized by replacement of normal bone by
tissue containing collagen, fibroblasts, and osteoid material.  The
maxilla is the most frequently involved bone in monostotic fibrous
dysplasia.  Radiologically, this lesion is characterized by mottled or
ground glass appearance of the affected bone with no discrete borders.
This lesion is slow growing and tends to stabilize during adulthood.
Complete surgical excision is usually impossible.  Excision is usually
reserved for symptomatic patients and should be as conservative as
possible to limit functional morbidity.  Ossifying fibroma is a rarer more
aggressive variant of fibrous dysplasia which should be completely
excised.  Radiotherapy is not effective for these lesions and has been
associated with malignant transformation into osteogenic sarcoma.  

Nerve sheath tumors:

These tumors (schwanommas and neurofibromas) arise from the first and
second division of the trigeminal nerve and from autonomic nerves.
Schwanommas characteristically push and remodel bone.  The presence of
aggressive bone destruction should therefore be considered as an
indication of malignant degeneration.  Ninety percent of these lesions
show a benign histology.  These are best treated with complete surgical
excision.  However, partial excision is recommended for massive
neurofibromas involving vital structures.  Inverted papilloma: This is a
benign but locally aggressive disease process.  These lesions extend
beyond their site of origin, destroy bone, recur when not completely
excised, and may degenerate into malignant tumors at a rate of about 8%
(squamous cell carcinoma).  These are most common in caucasian males
during the fifth to seventh decade and are best treated with complete
removal via a medial maxillectomy.
     
Malignant Tumors

Squamous cell carcinoma:

These lesions account for the majority of malignant sinonasal tumors
(80%).  Seventy percent are located in the maxillary sinus; twenty percent
are found in the nasal cavities, and the remaining ten percent are located
in the other sinuses.  These lesions are common in nickel refinery workers
and are twice as common in males as females.  More than 95% of these
patients are >45 years old.  Treatment for these lesions involves radical
surgical excision with postoperative radiotherapy for positive margins or
advanced stage.

Adenocarcinomas:

These lesions are second only to SCCA in incidence and show strong
occupational associations in woodworkers and leather-workers.  These
usually arise in the ethmoid sinuses or high in the nasal cavity where
particles preferentially deposit.  These can be divided into high and low
grade tumors based on their histological characteristics and behavior.
Low grade tumors have a uniform glandular architecture with rare mitotic
figures, or perineural invasion.  Distant metastasis are uncommon with
these low grade tumors and they tend to recur locally.  High grade
adenocarcinomas have a solid growth pattern with poorly defined margins,
multiple mitotic figures, and prominent pleomorphism.  Approximately 33%
of these patients will have distant metastasis at the time of
presentation.

Treatment for these lesions is radical surgical excision usually via a
craniofacial approach with postoperative radiation.  Adenoid cystic
tumors: This is the most predominant salivary gland tumor of the paranasal
sinuses.  These are divided into low and high grades based on the amount
of solid anaplastic conformation.  The incidence of perineural invasion is
similar in both but high grade tumors have a higher incidence of local
recurrence and metastasis.  Treatment for these tumors is primarily
surgical, but combined therapy with surgery and XRT seem to yield better
local control.  These tumors have a very insidious course with many
patients living for several years even with distant metastasis.

Mucoepidermoid carcinoma:

These tumors are rare in the paranasal sinuses.  They tend to present very
late in their disease course with 25% of patients having distant mets at
the time of diagnosis.  Complete resection of these tumors is difficult
due to the propensity for widespread local invasion.  Combined treatment
with surgery and XRT offer the best chance of cure for most patients.
Melanoma: These lesions may be primary or metastatic.  Less than 2% of all
melanomas arise in the sinonasal tract.  The maxillary antrum is the most
frequently involved site.  The hallmark of sinonasal melanoma is local
multicentricity with early metastases.  In most cases, patients present
with disease confined to the site of origin.  However, these tumors show a
tendency toward early vascular and lymphoid invasion which accounts for
the high incidence of local recurrence after excision.  These lesions have
a poorer prognosis than cutaneous melanoma with prognosis related to the
disease extent and completeness of surgical removal.  Treatment is wide
surgical excision with neck dissection for clinically positive nodes.
Postoperative XRT may be of benefit.  The five year survival with these
tumors is 25%.

Esthesioneuroblastoma:

These are rare neoplasms of neuroectodermal origin which arise from
olfactory epithelium in the cribriform, upper septum, and ethmoids.  These
lesions are slow growing with high destructive and invasive potential.
They usually present with epistaxis, anosmia, and nasal obstruction, On
examination, a red, fleshy mass may be visible high in the nasal vault.
These lesions exhibit a characteristic finding histologically consisting
of an intercellular matrix of neurofibrils with clusters of round to ovoid
cells grouped in nests by vascular septa.  These round clusters are called
zellballen.  Death from this lesion usually results from CNS extension.
Prognosis is related to disease extent and resectability of the lesion on
initial presentation.  Treatment is primarily surgical via craniofacial
resection with XRT.

Hemangiopericytoma:

This rare lesion usually presents with nasal obstruction and epistaxis.
The classic cell involved is the pericyte of Zimmermann which is a small
spindle-shaped cell with branching cytoplasmic processes that envelope
capillaries and lie external to the reticulin sheath surrounded by the
basement membrane.  These cells are thought to regulate the size of the
capillary lumen through contractile properties and to synthesis collagen.
These tumors metastasize by invading blood vessels.  Treatment for these
lesions is surgical.


Fibrosarcoma:

This tumor is of fibroblast origin.  Trauma and XRT have been implicated
as a possible etiologic factor.  Low grade lesions respond well to
surgical excision, bur recurrences are common and can be treated with XRT.
High grade lesions tend to behave more aggressively with more frequent
mets.  Treatment is wide surgical excision with XRT for positive margins
or recurrent or inoperable lesions.

Angiosarcoma:

These lesions tend to be slow growing but locally aggressive and are
characterized by wide horizontal spread with poorly defined margins.
Treatment is surgical with XRT for positive margins.  

Osteosarcoma:

These lesions are much less common in the maxilla than in the long bones.
These tend to occur in a younger age group than other paranasal sinus
tumors- third decade.  On plain films these tumors exhibit a
characteristic sunburst sign which refers to the tumor bone erosion and
bone formation with spicules.  Treatment is surgical with postoperative
XRT and/or chemotherapy as indicated.  

Chondrosarcoma:

These are slow-growing but locally aggressive lesions which arise from
cartilaginous structures.  These tend to remain asymptomatic until they
reach a large size.  Treatment involves surgical removal with wide
margins.  For those tumors involving vital structures, gross tumor removal
with postoperative XRT is recommended.  Lymphoma: These lesions may arise
in the maxillary antrum or ethmoid sinuses with local extension into the
soft tissues of the face usually present at the time of diagnosis.  These
can be easily confused with infectious or granulomatous processes.
Treatment of these lesions is XRT and/or chemotherapy.  

Leiomyosarcomas:

These tumors originate from smooth muscle and are rare in the paranasal
sinuses.  Prognosis with these lesions depends upon the completeness of
surgical excision.  Orbital invasion indicates a poor prognosis. XRT and
chemotherapy are usually reserved for inoperable or recurrent tumors.  The
five year survival rate for these tumors is <20% with over half of these
patients dead of disease within the first year.  

Extramedullary plasmacytoma:

These lesions are four times more common in men than women.  These tumors
tend to spread locally with a highly variable clinical behavior.  The
prognosis of these lesions is unpredictable.  It is important to rule out
multiple myeloma during the work-up of these lesions.  These lesions are
highly radiosensitive, with conservative surgical intervention reserved
for recurrences after primary XRT.  

Metastatic tumors:

Tumors metastasizing to the paranasal sinuses produce symptoms similar to
those of primary sinonasal tumors.  The maxilla is the most commonly
involved site.  The most common primary source is renal cell carcinoma,
followed by lung and breast cancer.  Treatment for these lesions is
palliative with XRT, chemotherapy, or surgery to relieve
obstructive/compressive symptoms or for pain relief.

Cervical Metastasis

The incidence of cervical nodal mets on initial presentation is around
10%.  Subdigastric and retropharyngeal nodes are usually the first to be
involved.  Patients with tumors extending into the oral cavity have a
higher cervical metastatic rate.  During the course of disease, the
presence of cervical mets increases and is most common in the first 48
months after treatment.  Recurrence from cervical mets is the second most
common cause of treatment failure, following local recurrence.  The low
incidence of nodal mets from sinonasal tumors does not justify the use of
elective neck dissection.
 
Treatment

The treatment of malignant paranasal sinus tumors is primarily surgical
and requires careful preoperative planning including CT and MRI imaging.
The choice of surgical approach depends upon tumor extension into adjacent
structures.  It is important to select an approach which will provide
adequate exposure while preserving function and cosmesis when possible.
Unless palpable nodal disease is present, a neck dissection is not
routinely performed.  Prognosis for survival depends on the size and
extent of the primary with most treatment failures due to local control.
Therefore, aggressive surgical excision should be undertaken with generous
margins.

Maxillectomy is the standard surgical procedure for tumors involving the
maxillary sinus.  A medial maxillectomy may be possible for early lesions
(rare), but most patients will require a radical maxillectomy +/- orbital
exenteration.

In regards to orbital preservation, there has been a general trend toward
a more conservative approach.  Many surgeons agree that the orbit may be
preserved unless frank erosion through the periorbita is seen at the time
of surgery.  The reported indications for orbital exenteration include
bone erosion, invasion of the posterior ethmoid, involvement of the
orbital apex or infraorbital nerve, and invasion of the periorbita.  It is
important to prepare patients preoperatively for the possibility of
orbital exenteration with the decision made intraoperatively based on
tumor extent and findings.  

For tumors with questionable margins or for advanced lesions, combined
therapy with aggressive surgery followed by postoperative XRT provides for
improved five year survival rates and better local control.

For tumors involving the ethmoid or frontal sinuses, craniofacial
resection with the assistance of a neurosurgeon will provide excellent
exposure with the best chance for total tumor resection and negative
margins.  Involvement of the dura, brain parenchyma, sphenoid sinus, or
nasopharynx have a poor prognosis and are usually considered unresectable.

Patients with unresectable or otherwise incurable disease can benefit from
palliative decompression, debulking, and drainage via a large antrostomy.
Palliative XRT and chemo are also helpful.

Conclusions

Tumors of the paranasal sinus cavities are rare lesions which usually
present late in the course of disease.  Diagnosis is further complicated
by the fact that these lesions can grow silently for months, only becoming
symptomatic when erosion into adjacent structures occurs.  In addition,
the symptoms are identical to those of benign sinonasal disease which
delays definitive diagnosis.  It is important for otolaryngologists to
keep a high index of suspicion when treating patients with sinonasal
symptoms, especially in patients with a history of exposure to known
paranasal sinus carcinogens.  Suspicious lesions should be biopsied and
appropriate imaging studies obtained in order to avoid prolonged delay in
definitive diagnosis.  The primary cause of death from paranasal sinus
malignancies is failure of local control.  Adequate surgical treatment
requires wide en bloc surgical resection of the tumor and adjacent
structures.  In recent years, combined treatment with surgery followed by
postoperative XRT has improved the five year survival rate.  Further
improvement will depend on earlier diagnosis and adequate intensive
initial treatment.
			   
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                           BIBLIOGRAPHY 

Alvarez I. et al.  Prognostic Factors in Paranasal Sinus Cancer.  Am J
Otolarngol 1995; 16 (2) 109 - 114.

Graamans K, Slootweg PJ.  Orbital Exenteration in Surgery of Malignant
Neoplasms of the Paranasal Sinuses.  Arch Otolaryngol Head Neck Surg 1989;
115: 977 - 980.

Kraus DH, et al.  Factors Influencing Survival in Ethmoid Sinus Cancer.
Arch Otolaryngol Head Neck Surg 1992; 118: 367 - 372.

Krespi YP, Levine TM.  Tumors of the Nose and Paranasal Sinuses.  In:
Paprella MM, et al, eds.  Otolaryngology.  Philadelphia, W.B. Saunders
Company, 1991.

Meyers EN, Carrau RL.  Neoplasms of the Nose and Paranasal Sinuses.  In:
Bailey BJ, et al, eds.  Head and Neck Surgery- Otolaryngology.
Philadelphia: J.B. Lippencott, 1993.

Miller RH.  Neoplasms of the Nose and Paranasal Sinuses.  In: Ballenger
JJ.  Diseases of the Nose, Throat, Ear, Head, and Neck.  Philadelphia: Lea
and Febiger, 1991.

Stern SJ, et al.  Squamous Cell Carcinomas of the Maxillary Sinus.  Arch
Otolaryngol Head Neck Surg 1993; 119: 961 - 969.

Stern SJ, et al.  Orbital Preservation in Maxillectomy.  Otolaryngol Head
Neck Surg 1993: 109: 111 - 115.

Sisson GA, Becker SP.  Cancer of the Nasal Cavity and Paranasal Sinuses.
In: Suen JY, et al, eds.  Cancer of the Head and Neck.  New York:
Churchhill Livingstone, 1981.

Weymuller EA.  Neoplasms.  In: Cummings CW, et. al, eds.  Otolaryngology -
Head and Neck Surgery.  Mosby Year Book, 1993.  
--------------------------------END----------------------------------------


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1.  Sinonasal cancer accounts for approximately which percentage of all 
    upper aerodigestive tract malignancies:
    a.  less than 1%
    b.  3%
    c.  12%
    d.  21%
    e.  34%

2.  Diagnosis of sinonasal cancer occurs later than most head and neck 
    cancers because:
    a.  the patients are much older
    b.  symptoms occur later in the disease process
    c.  radiographic imaging is ineffective
    d.  tumor serology is seldom employed
    e.  inadequate usage of nasal endoscopy examination

3.  Sinonasal cancer is increased in all of the following occupations
    EXCEPT:
    a.  nickel refining
    b.  woodworking
    c.  isopropyl alcohol production
    d.  leather production (tanning)
    e.  grain silo storage

4.  At the time of diagnosis, the percentageof patients with T3 or T4
    sinus cancer is:
    a.  15%
    b.  35%
    c.  55%
    d.  75%
    e.  95%
5.  Maxillary sinus cancer frequently causes which of the following
    neurological signs/symptoms: 
    a.  numbness of the lateral tongue
    b.  numbness of the auricle
    c.  numbness just above the eye
    d.  numbness of the cheek
    e.  numbness of the chin
    
6.  Hearing loss may be a presenting symptom for sinonasal cancer and it
    results from
    a.  extension to the cochlear nucleus
    b.  extension to the middle ear
    c.  extension to the external auditory canal
    d.  extension to the  Eustachian tube
    e.  middle ear effusion

7.  Optimal imaging of sinonasal cancer is accomplilshed by:
    a.  plain sinus films and arteriography
    b.  plain sinus films and CT scan
    c.  CT scan and ateriography
    d.  plain sinus films and MRI
    e.  CT scan and MRI

8.  A patient with maxillary carcinoma involving the sinus
    infrastructure with destruction of the anterior sinus wall is
    staged as:
    a.  T1
    b.  T2
    c.  T2b
    d.  T3
    e.  T3b

9.  Inverting papilloma will "degenerati into (or coexist with) squamaous
    cell carcinoma in what percentage of patients:
    a.  1-2%
    b.  4-8$
    c.  10-14%
    d.  15-20%
    e.  20-25%

10. Radiation therapy is the preferred treatment for which of the
    following sinonasal malignancies:
    a.  lymphoma
    b.  hemangiopericytoma
    c.  melanoma
    d.  esthesioneuroblastoma
    e.  angiosarcoma

11. The most common cause for treatment failure with sinonasal cancer is:
    a.  failure of local control
    b.  CNS metastasis
    c.  cervical node metastasis
    d.  pulmonary metastasis
    e.  bone metastasis

12. The best results (highest cure rate) for advanced sinonasal cancer 
    (T3, T4) are obtainedwith which of the following:
    a.  surgery alone
    b.  radiation therapy alone
    c.  surgery combined with radiation therapy
    d.  surgery combined with chemotherapy
    e.  radiation and chemotherapy

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    the issues presented in the body of the Grand Rounds segment?

	yes		no opinion		no

5.  Do you consider the presentation to be timely with regard to
    current information available in both the lay press and the
    professional literature?

	yes		no opinion		no

6.  Are the questions submitted with the Grand Rounds element 
    meaningful in that they stimulate thought and perhaps 
    further inquiry?

	yes		no opinion		no

7.  Is the method of submitting the subscriber's answers to these
    questions expeditious and convenient?

	yes 		no opinion		no

8.  Would you recommend this method of completing the general
    requirment for Continuing Education Activity to your 
    colleagues?

	yes		no opinion		no

10. How much money (U.S. dollars) would you be willing to pay for
    each award of 10 or more CME Category I credits earned through 
    this type of online CME activity?

    $100  $50  $25  $12.50  $6.25  $3.00  $1.50  $0.75  $0.35  $0.15

Please submit any comments, criticisms and suggestions which you
may have in the space below.  They will be given thoughtful
consideration, especially if they are favorable comments, gentle 
criticisms, or constructive suggestions. ;-)

/s/ The Editor.

===========================================================================
   Francis B. Quinn, Jr., M.D.    
   University of Texas Medical Branch
   Dept. of Otolaryngology
   Galveston, TX 77555-0521      Internet addresses:
     409-772-2706, 772-2701        fbquinn@UTMB.edu
     409-772-1715 FAX              fbquinn@phil.utmb.edu
   "If a patient looks like his passport photo, he is not well enough
    to travel."
============================================================================