Anatomy Nose And Sine Paranasal.

Nasal Cavity is gap irregular Which there is between palate from original cavity And base cranii. Part lower Nasal Cavity Which most wide And in vertically is region the center, separated by septum rice become Nasal Cavity dextra And hereafter. Door enter from Nasal Cavity is nares, And in posterior will enter the nasopharynx through the choana. Almost all parts of the nasal cavity are lined by mucosa except area vestibule rice Which coated by skin. The nasal mucosa is attached to the periosteum and perichondrium of the bones that form the nasal cavity and the cartilage of the nose. ^4,5

The nasal mucosa also lines the structures that are connected to the nasal cavity such as: the nasopharynx posteriorly, the paranasal sinuses superiorly and laterally, and the lacrimal sac and conjunctiva superiorly. The inferior 2/3 of the nasal mucosa is the respiratory area and the superior 1/3 is the area olfactory. Area respiration from Nasal Cavity mucosa coated by pseudostratified ciliated epithelium with numerous goblet cells. There are numerous seromucous glands in the lamina propria of the nasal mucosa. Their secretions make the surface sticky so that it can trap particles contained in the inspired air. The mucosal film is constantly moved by ciliary action. (mucociliary escalator) posteriorly to the nasopharynx at a rate of 6 mm per minute. ^4.5

The lateral wall of the nasal cavity is uneven due to the presence of three conchae, namely: superior, middle, and inferior nasal conchae. These nasal conchae run in an inferimedial direction. Three concha nasal This to form 4 gap For the way air that is:

1. The sphenoethmoidal recess located above the superior concha of the nose receives the opening of the sphenoidal sinus. ^4,5

2. Meatus rice superior Which located between concha rice superior And medius receives the outlet from the posterior ethomidal sinus. ^4,5

3. The middle nasal meatus, located between the middle and inferior conchae, is longer and wider than the superior nasal meatus. Its anterosuperior part leads to the infundibulum ethmoidalis, a hole that connects to the frontal sinus via the ductus frontonasal. The frontonasal duct then empties into a semicircular gap, namely the hiatus semilunaris. Bulla ethmoidalis, a rounded elevation located higher than the hiatus semilunar (visible when the middle concha is lifted). Bulla is formed by cellulae ethmoidalis medium, Which to form sine ethmoidal. Sine maxillary pour the contents also got a share posterior hiatus semilunar. ^4.5

4. Meatus rice inferior Which located in lower concha rice inferior is a horizontal channel. The nasolacrimal duct from the lacrimal sac empties into the anterior part of this meatus. ^4,5

The paranasal sinuses are air-filled cavities found in the skull bones. The paranasal sinuses consist of 4 pairs, namely the maxillary sinuses, frontal sinuses, ethmoid sinuses and sphenoid sinuses. ⁵

The frontal sinuses are located in the frontal bone in the forehead. These sinuses are usually asymmetrical, Wrong One usually more big from Which others And separated by septum located in the midline. This sinus is usually septalized and the sinus margins are indented. The average dimensions of the frontal sinuses in adults are: height 3.2 cm; width 2.6 cm; depth 1.8 cm. Each usually has a frontal part that extends upward over the medial part of the eyebrow, and an orbital part that extends back to the medial part of the roof of the orbit. Each frontal sinus empties into the hiatus semilunaris of the middle meatus. The frontal sinuses are innervated by the supraorbital nerve (N. V1). ⁵

Sine ethmoidalis This is sine Which the smallest located in part lateral ethmoid bone between the middle concha and the medial wall of the orbit. This sinus consists of 2 based on its location that is sine ethmoid front Which empties into meatus medius and posterior ethmoid which open into the superior meatus. The ethmoidal sinuses are innervated by the anterior and posterior ethmoidal branches of the nasociliary nerve (N. V1). ⁵

Sphenoid sinus located in the sphenoid bone behind the superior ethmoid sinus. Only a thin plate of bone separates it from important structures, namely: the optic nerve and optic chiasma, the pituitary gland, the internal carotid artery, and the cavernous sinus. This sinus receives innervation and vascularization from the posterior ethmoidal nerve and artery. ⁵

The maxillary sinus is the largest of the paranasal sinuses. Its anterior wall is the facial surface of the maxilla called the canine fossa, its posterior wall is the infratemporal surface of the maxilla, its medial wall is the lateral wall of the nasal cavity, its superior wall is the floor of the orbit and its inferior wall is the is process alveolar And palate. Each sine The maxillary sinus drains into the middle meatus through the maxillary ostium through the hiatus semilunaris. Because the opening of this sinus is located superiorly, drainage from the sinus is impossible if the head is in an upright position unless sine in condition full. Sine maxillary get vascularization From the superior alveolar artery, a branch of the maxillary artery, the floor of the sinus is vascularized by the greater palatine artery. The mucosa of the sinus is innervated by the anterior, middle, and posterior alveolar nerves. ⁵

Definition And Epidemiology

Melanoma Malignant  is a tumor that originates from the transformation of melanocytes in the basal layer of the mucosa. Melanoma Malignant  has two types, skin melanoma and mucosal melanoma. The frequency of Melanoma Malignant  tumors in the head and neck is more than 90% in the skin, 5% in the eyes, 2.2% of primary lesions are unknown and only 1.3% occur in the mucosa. 25–50% of mucosal melanoma cases This happen in area head neck. Place Which most general from mucosal melanoma primary head And neck is cavity nose (50%), area maxillofacial (20%), cavity mouth (17%), followed by nasopharynx. ^1.2

Compared with cutaneous melanoma, mucosal melanoma is more often diagnosed at an older age (average age 70 years) and is associated with a significantly worse survival than cutaneous melanoma. The highest incidence on patient on decade fifth until eighth. With man more affected than women with a ratio of 2: 1. The area in the nasal cavity that is most often involved is the anterior septal mucosa and the maxillary antrum is the most common location for sinuses. 6

In Europe And in American Union, head And neck is location Which most common site for mucosal melanoma. They represent 40.6% of mucosal melanomas in Europe and 55.4% of mucosal melanomas in the United States. Among mucosal melanomas of the head and neck, the sinonasal site is the most common location in both populations. Mucosal Melanoma Malignant  is usually diagnosed at an advanced stage when metastases have occurred. 7

Etiology and Pathogenesis

Causes of Melanoma Malignant  on both the skin and the mucosa Not yet known with Certain. However various factor estimated as a supporter of the malignant process, including genetic factors, biology and also environment especially exposure ray ultra violet. Every melanocytic lesion benign can develop become melanoma, but melanoma Also can develop from normal melanocytes, without any obvious predisposing lesion. Melanocytes arise from neuro-ectodermal multipotent neural crest cells, which also develop into neurons, glial cells, chondrocytes, muscle cells and endocrine cells. Melanocytes mainly develop from dorsally migrating cells. The ventrally migrating melanocyte precursors travel along peripheral nerves and invade the dermis, and then the epidermis, along with the cutaneous nerve innervation. The presence of melanocytes on membrane mucosa Already known, but reason and its function has not been explained well. Although sunlight is a predisposing factor for skin melanoma, there is no definite predisposing factor. Which has identified about melanoma mucosa, But mutation Which related with exposure to sunlight (eg. BRAF mutations) have been identified in melanoma conjunctiva. Carcinogen Which inhaled, especially tobacco And formaldehyde has been suggested to be a predisposing factor for sinonasal melanoma. Most melanoma mucosa appear with new, except conjunctival melanoma of which 81% arise from acquired primary nevus or melanosis. ⁸ The presence of history family Which suffer condition similar increase the risk of 200 time. The occurrence melanoma malignant Also connected with the occurrence of malignancy other like retinoblastoma And a number of syndrome ferocity in family. Trauma Which prolonged is wrong One factor biology that supports the process of malignancy. ⁸

Melanoma malignant from mucosa Nasal Cavity And sine is disease which is rare and has a low survival rate. Diagnosis is often late due to sudden onset and patients have come at an advanced stage. In general histopathological most cell with eosinophil in amount many with cytoplasm surrounding the nucleus showing eosinophil or spindle cell nuclei. The etiology and pathogenesis are not much different from Melanoma Malignant . on skin, Because melanocytes there is on epidermis, dermis on skin and mucosa. ⁸

Diagnosis

Diagnosis melanoma malignant enforced based on anamnesis, clinical picture or physical examination, and supporting examinations in the form of radiological and histopathological examinations. A definitive diagnosis is made based on histopathological examination. The most common symptoms of melanoma of the nasal cavity are epistaxis, blockage nose And painful. Diagnosis often late because the symptoms are less specific. ^9,10

Melanoma Malignant  of the nasal mucosa can originate from the nasal septum (41%), middle concha (29%), inferior concha (23%), lateral wall of the nasal cavity (7%), And seldom on roof or part base cavity nose (1%). Description The clinical course of each individual patient depends on the primary location and direction and extent of the  distribution.  Melanoma  malignant  give  symptom  clinical  Which resemble other sinonasal tumors. Nasal cavity tumors present with nasal symptoms such as obstruction and epistaxis. Ethmoid tumors also present with nasal symptoms, but may also have orbital symptoms such as proptosis and epiphora, with diplopia being a late symptom. Frontal sinus tumors tend to present solely with orbital symptoms. Sphenoid sinus tumors generally present late to the neurologist with neurologic symptoms. ^9,10

Incidental involvement of the infraorbital nerve results in changes in facial sensation, or alternatively bleeding causes epistaxis. Any epistaxis in an adult patient without a history of hypertension requires radiological investigation, and if possible a CT scan of the head focusing on the nose and paranasal sinuses. When the tumor has destroyed the wall of the sinus antrum, the signs and symptoms certainly become more obvious. ^9,10

Invasion of the nasal cavity causing nasal obstruction and epistaxis and the tumor will certainly be clearly visible. Tumors rarely cause ethmoid polyposis and appear as ordinary polyps, so it is important to histologically examine all material removed from the nose. Inferior spread involves palate And alveoli can result in damage on palate and teeth. Distribution anterolateral into network soft face can cause epiphora with involving pocket lacrimal. Swelling face, disturbance sensation and pain are more common. Anterior spread is more likely to result in cervical lymphadenopathy and is usually palpable. Posterior spread into the infratemporal fossa and skull base may cause less obvious symptomatology, loss of trigeminal function and trismus due to involvement of the pterygoid muscles. Spread to the nasopharynx may result in deaf as consequence from dysfunction eustachian tube. Superior spread into the orbit causes early proptosis by increasing the volume of orbital contents. ^9,10

This tumor is rare, accounting for <1% of all malignancies (3% of head-neck tumors). The best hope for early diagnosis lies in the use of CT-scan imaging. The use of CT and MRI imaging allows for precise delineation of the extent of the tumor, and detailed planning. radiotherapy And resection surgery furthermore. According to Ascierto et al, Imaging in malignant mucosal melanoma should be performed with MRI. Analysis from signals in different sequences provide information patterns on the tumor, namely generally more more sophisticated than analysis CT-Scan density. So also with combination tall resolution spatial And contrast Which obtained with MRI 3D sequence allow depiction Which more accurate expansion tumor Which in. ¹¹ In microscopic, there is two pattern histopathological Which can depicted, the first, an in situ pattern in which the neoplasm is confined to the epithelium and connective epithelial tissue, and the second, an invasive pattern in which the neoplasm is found in the connective tissue. tie buffer. Cells tumor can in the form of plasmacytoid, sarcomatoid (spindle cells), or epithelioid. Histomorphological variations of melanoma often make it difficult to make a diagnosis of melanoma, especially because some melanoma specimens have low melanin levels. Therefore, it is necessary ^{immunohistochemical} analysis to rule out epithelioid or spindle cell malignancy.9,10

A definitive diagnosis is made only by immunohistochemistry of the surgical specimen with positive staining for S-100, HMB 45, tyrosinase, melan A, and vimentin, and negative results for cytokeratin and epithelial membrane antigen. Melanoma react hard with subunit alpha from S-100, Which is binding protein calcium found in network nerve. However protein This Also there is on various cell normal And cell neoplastic. Frequency immunoreactivity S-100 in mucosal melanoma varies between 86-100% ^.9,10

Diagnosis Appeal

Diagnosis appeal from melanoma mucosal malignancy including neoplasms of cells round small from channel sinonasal often produce difficulty diagnostic sufficient big. Differential diagnosis tumor cell round blue small on channel sinonasal including olfactory neuroblastoma, undifferentiated sinonasal neuroendocrine carcinoma, Ewing sarcoma or peripheral neuroectodermal tumors ^and rhabdomyosarcoma.7,8

The nasal cavity and paranasal sinuses are lined by a layer of mucosa-producing tissue with the following cell types: squamous epithelial cells, small salivary gland cells, nerve cells, infection-fighting cells, and blood vessel cells. Squamous Cell Carcinoma is the most common form of nasal cavity cancer and sine paranasal Which about sine maxilla And ethmoid. It is said reaching 20% of tumors in this area. Squamous cells are flat cells that make up the flat surface layers of the head and neck structures. The maxillary sinus is involved 70% followed by involvement deep nasal cavity 20% with the remainder being ethmoid. Primary lesions originating from the frontal and sphenoid sinuses are rare. These disorders mainly affect males and occurs most frequently in the sixth decade. Spread outward from the sinus is almost the direction of growth. When present more than 90% will invade at least one wall of the involved sinus. If metastases are present, the first-level nodal drainage is via the pre-tube plexus into the retropharyngeal nodes and then into the subdigastric nodes. Most of these cancers present at an advanced stage. Surgical resection followed by postoperative radiation is recommended as the management of resectable cases. ^7,8

Adenocarcinoma started in cell gland, is form second The most common cancers of the nasal cavity and paranasal sinuses are the maxillary and ethmoid sinuses, estimated to be 5-20% case. Lesion This tend more located superior with ethmoid sinus Which most Lots involved. Most relate with job description. Lesion This appear similar with carcinoma cell squamous And shared histologically into high and low grades. ^7,8

Neuroblastoma is a rare malignant tumor of the supporting elements of the olfactory epithelium. This tumor grows slowly and can metastasize to the lungs and cervix. Early symptoms are epistaxis and nasal obstruction. CT-scan important For set whether there is expansion on intracranial. ^7.8

Treatment

Treatment plans are made based on the results of histopathology examination and tumor stage. Until now, there is no official standard for classification and determination of stages. To make a treatment plan, it must be assessed on a case-by-case basis. Because response each type tumor No The same to a method treatment and also need to see how far the tumor has spread. ¹²

Surgery is still the mainstay of therapy, which is the first-line management option and is recommended if the primary lesion can be removed with a margin. Which clear without existence disease metastasis regional or Far. Conversely, tumors in which indistinct margins may be required should warrant consideration for other alternative treatment modalities. No surgery. Neck dissection done For patient with clinical involvement gland sap clear clear neck. ¹³

Procedure surgery Which can done like rhinotomy lateral, Maxillectomy, total rhinosurgery or craniofacial resection may be performed depending on the extent of the tumor. Surgery may be followed by radiation or systemic chemotherapy with or without immunotherapy. Postoperative radiotherapy should be considered to reduce the possibility of local-regional recurrence. Radiotherapy or chemotherapy with or without immunotherapy can increase number resilience life 5 year by 48%. ¹³

Chemotherapy/immunotherapy is usually used with adjuvant or palliative intent. The role of chemotherapy is small compared to systemic biologic and immunologic therapies. For example, dacarbazine-based chemotherapy was previously the preferred choice for treating patients with metastatic mucosal melanoma. However, the lack of association of chemotherapy with improved overall survival eventually led to its discontinuation as a standard treatment. Moment This, chemotherapy used as therapy additional systemic therapy in combination with other immunotherapy and biologic drugs after surgical resection of mucosal melanoma. Chemotherapeutic drugs, such as dacarbazine, are used in combination with MEK, PD-1, and CTLA-4 inhibitors, as well as with other drugs biochemotherapy, like interleukin-2 And interferon alpha-2b. Part Most of these combination treatments have yielded disappointing results, with no significant impact on overall survival. Given the rarity of mucosal melanoma and the limited benefit of treatment, chemotherapy is unlikely to be further developed as a monotherapy regimen. ¹⁴

Immunotherapy moment This effective only in percentage small from patient with melanoma malignant. Very A little study about immunotherapy in melanoma treatment mucosa Which has done. Anti-CTLA-4 it seems benefit patients in advanced mucosal melanoma. Anti-PD1/PD-L1 has been studied, but its effects have not been well proven. Due to the high morbidity of existing treatment modalities, immunotherapy is an interesting area of exploration in mucosal melanoma research, especially for the management of metastases, which often complicate the treatment of mucosal melanoma. ⁸

Mucosal melanoma is known to be partially sensitive to radiation. Radiotherapy post operation increase control local melanoma sinonasal. The best loco-regional control of head/neck melanoma is achieved by delivering at least three Gray (Gy) per fraction, and a total of at least 54 Gy. Radiation therapy toxicity Which tall in area head/neck must taken into account before perform treatment. More research is needed on the role of postoperative radiotherapy in mucosal melanoma. Newer radiation methods such as neutron radiation fast And radiation file proton has show results Which promising in the treatment of melanoma, and may hold promise in the future. ⁸

Prognosis

Melanoma malignant on mucosa is tumor Which aggressive And Overall prognosis and survival rates range from 10-40% with a median survival of 21-24 months. Poor prognostic factors can be seen from the presence of local and distant metastases, local recurrence, vascular invasion, cell Which mitosis, ulceration, And lesi primary second. Predictor most strong is the absence of regional lymph nodes. Other factors that play a role in worsening prognosis is delay in detect And diagnosis histopathological the less accurate consequence tumor rarity this. ¹³

In a study conducted by Wang et al., the prognosis of Melanoma Malignant  of the sinonasal mucosa was still poor despite advances in therapeutic modalities. The median 5-year survival rate of Melanoma Malignant  of the skin is around 70.0–80.0%. However, Melanoma Malignant  of sinonasal has a worse outcome with a 5-year survival rate not enough from 30 %, Which show invasive Which tall, relapse easy, and distant metastasis. ³

DISCUSSION

Melanoma Malignant  is a tumor that originates from the transformation of melanocytes in the basal layer of the mucosa. Melanoma Malignant  has two types, skin melanoma and mucosal melanoma. The frequency of Melanoma Malignant  tumors in the head and neck is more than 90% in the skin, 5% in the eyes, 2.2% of primary lesions are unknown and only 1.3% occur in the mucosa. 25–50% of mucosal melanoma cases This happen in area head neck. Place Which most general from mucosal melanoma primary head And neck is cavity nose (50%), area maxillofacial (20%), oral cavity (17%), followed by nasopharynx. ¹

The etiological factors are still not known for certain. The prevalence of melanoma mucosa is said No related with radiation sun, papillomavirus or herpes simplex virus. Smoking can be a predisposing factor for oral melanoma, and exposure to formaldehyde can predispose to paranasal sinus melanoma. Ascierto et al reported that smoking and exposure to formaldehyde can be risk factors for malignant mucosal melanoma. According to Yde et al., exposure to sunlight is not considered a risk factor for malignant mucosal melanoma because the location of the lesion is a place that is rarely exposed to sunlight. The relationship between viral infections (human papillomaviruses, human herpesviruses, and polyomaviruses) and the occurrence of malignant mucosal melanoma was also not found. ^7,11

Diagnosis melanoma malignant enforced based on anamnesis, clinical picture or physical examination, and supporting examinations in the form of radiological and histopathological examinations. A definitive diagnosis is made based on histopathological examination. The clinical picture of each individual patient depends on the primary site and the direction and extent of spread. Karbowska et al reported that the most common sites of primary mucosal melanoma of the head and neck were the nasal cavity (50%), maxillofacial region (20%), oral cavity (17%), followed by the nasopharynx. ²

According to Ascierto et al., imaging of malignant mucosal melanoma should be performed with MRI. Analysis of the signals in different sequences provides pattern information on tumor, that is generally more advanced than CT-Scan density analysis. Likewise, the high combination of spatial resolution and contrast obtained with 3D MRI sequences allows the depiction of Which more accurate expansion tumor Which in. In general Microscopically, there are two histopathological patterns that can be described, the first, a pattern in situ in where neoplasm limited on epithelium And network epithelium tie, And the second invasive pattern in which the neoplasm is found in the supporting connective tissue. The tumor cells can be plasmacytoid, sarcomatoid (spindle cells), or epithelioid. ¹¹

This tumor is rare, accounting for <1% of all malignancies (3% of tumors). head-neck). Hope best For diagnosis beginning located on the use of              CT-scan                        imaging .      The use of  CT                   and                        MRI imaging                 allows for precise depiction of the extent of the tumor, and detailed planning. radiotherapy And resection surgery furthermore. According to Ascierto et al. Imaging in malignant mucosal melanoma should be performed with MRI. Analysis from signals in different sequences provide information patterns on the tumor, namely generally more more sophisticated than analysis CT-Scan density. So also with combination tall resolution spatial And contrast Which obtained with MRI 3D sequence allow depiction Which more accurate expansion tumor Which in. ¹¹ On review Which written Ascierto et al. (2017) system staging for melanoma skin like Which set by classification Clark No can applied to staging melanoma on mucosa Because No existence landmark histopathologically analogous to the papillary dermis and reticular dermis as prognostic value of various level invasion. Following This is system Which Already Enough For determine staging melanoma mucosa: ¹¹

1. Stadium I : tumor localized

2. Stage II: metastasis to lymphatic area

3. Stadium III: metastasis Far

Treatment plans are made based on the results of histopathology examination and tumor stage. Until now, there is no official standard for classification and determination of stages. To make a treatment plan, it must be assessed on a case-by-case basis. Because response each type tumor No The same to a method treatment And also must see how far the expansion goes the tumor. ¹⁴

According to Ganti et al., surgery is still the main therapy, which is the first-line management option and is recommended if the primary lesion can be removed with clear margins without regional or distant metastatic disease. Surgery can be followed by radiation or systemic chemotherapy with or without immunotherapy. Postoperative radiotherapy should be considered to reduce the possibility of local-regional recurrence. ¹³

Chemotherapy/immunotherapy is usually used as adjuvant or palliative therapy. For example, chemotherapy based on dacarbazine previously is the preferred option for treating patients with metastatic mucosal melanoma. However, lack of connection chemotherapy with improvement continuity overall life ultimately led to its discontinuation as a standard of ^care.14

Immunotherapy moment This effective only in percentage small from patient with melanoma malignant. Very A little study about immunotherapy in melanoma treatment mucosa Which has done. Anti-CTLA-4 it seems benefit patients with advanced mucosal melanoma. Anti-PD1/PD-L1 has been studied, but its effects have not been well proven. ⁸

Mikkelsen et al. stated that more research is needed on the role of postoperative radiotherapy in mucosal melanoma. Newer radiation methods such as fast neutron radiation and proton beam radiation have shown promising results in the treatment of melanoma, and may be promising in the future.

Melanoma malignant on mucosa is tumor Which aggressive And Overall prognosis and survival rates range from 10-40% with a median survival of 21-24 months. In a study conducted by Wang et al., the prognosis of Melanoma Malignant  of the sinonasal mucosa was still poor despite advances in therapeutic modalities. Survival rates average 5 year from melanoma malignant mucosa own results less than 30% were obtained, indicating high invasiveness, easy recurrence, and distant metastasis. ³

CONCLUSION

Melanoma Malignant  is a common skin malignancy, with an incidence of approximately 15% to 33% of these tumors occurring in the head and neck region. Melanoma Malignant  of the sinonasal tract mucosa is rare, ranging from 0.3% to 2% of all Melanoma Malignant s and approximately 4% of melanomas of the head and neck .

Diagnosis melanoma malignant enforced based on anamnesis, clinical picture or physical examination, and supporting examinations in the form of radiological and histopathological examinations. A definitive diagnosis is made based on histopathological examination. Tumor This seldom, Which is < 1% from overall malignancy (3% of head-neck tumors). The best hope for early diagnosis lies in the use of imaging CT scan For evaluation Where description radiological will indicate the correct diagnosis. The use of CT and MRI imaging allows precise depiction of the extent of the tumor, and detailed planning of subsequent radiotherapy and surgical resection. A definitive diagnosis made based on results histopathological examination of tumor biopsy with immunohistochemical examination.

The primary therapy for patients with mucosal melanoma of the head and neck is surgery, which requires complete resection of the primary tumor and any positive cervical lymph nodes. Postoperative radiotherapy should be considered to reduce the likelihood of local-regional recurrence. Melanoma Malignant  in mucosa is tumor Which aggressive And in a way overall prognosis and level continuity life range between 10-40% with average survival 21-24 months. Poor prognostic factors can be seen from the presence of local and distant metastases, local recurrence, vascular invasion, mitotic cells, ulceration, and second primary lesions.

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6. Temmermand D, Kilic S, Michael M, Butler J, Unsal A A. Sinonasal mucosal melanoma: A population-based comparison of the EUROCARE and SEER registries. International Archives of Otorhinolaryngology. 2022;26(03).

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8. Mikkelsen LH, Larsen AIR CONDITIONING, from Buchwald C, Drzewiecki KT, Prause JU, Heegaard S. Mucosal Melanoma Malignant  - a clinical, oncological, pathological and genetic survey. APMIS. 2016;124(6):475–86.

9. Edmond M, Nenclares P, Harrington K, et a. What is the role of the surgeon in the management of head and neck mucosal melanoma in the immunotherapy era? Head & Neck. 2021;1-6.

10. Lombard N, Della Corte M, Pelaia C, The Piazzetta G, Lobster N, Del Duca E, et al. Primary mucosal melanoma presenting with a unilateral nasal obstruction of the left inferior turbinate. Medicina. 2021;57(4):359.

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