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This group of tumors affect nasal cavities and paranasal sinuses (air-filled cavities that surround the nasal cavity). There are several paranasal sinuses: the maxillary sinuses, located in the upper jaw and the ethmodial sinuses that are located between the nasal cavities and orbits; a frontal sinus, located in the frontal bone; and the sphenoidal sinus, which is located between the nasopharynx (the upper part of the pharynx).
Epidemiology
Tumors in the nasal and sinus area are rare and, according to the global studies, form less than 1% of all malignant tumors and around 3% of the head and neck tumors. The most frequent ones are in the maxillary sinuses, then in nasal cavities, ethmodial sinuses, and the rarest ones occur in the frontal and sphenoidal sinuses. The tumor of this region can be benign (papilloma, adenoma, osteoma, chondroma, hemangioma, nerve sheath tumors) and malignant (the plate cells tumor, adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, sarcoma, teratoma, lymphoma, etc…). Nearly 80% of the nasal and sinus cancers consist of the plate cells tumor (planocellular carcinoma, Squamous-cell carcinoma).
Etiology, risk factors
Nasal and sinus tumors most frequently occur in persons who are professionally exposed to certain harmful substances (sawdust, nickel, chrome), in smokers, and it is assumed that the environmental pollution plays a role in the appearance of these tumors. They occur twice as frequently in men, between the ages of 50 and70.
Symptoms
The tumors of this region are usually discovered in the early stages of illness, and that is also when the unspecific symptoms are manifested, such as the feeling of the difficult nasal breathing and nasal secretion. If these symptoms persist for more than 4 weeks, a detailed specialist examination and diagnostics are needed. The symptoms in the later stages of the illness are more alarming for the patient: recurrent nasal bleeding (epistaxis), swelling or pain in the nasal area, sinuses, face, or in the palate and mouth area, the inability to open the mouth, and neurological impairments. If the tumor spreads towards the eye, seeing double images is possible, as well as the decreased eye mobility in certain directions.
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Diagnostics
The first step in the nasal and sinus cancer diagnostics is the otorhinolaryngologic examination: the discovery of larger tumors is sometimes possible just by performing the frontal rhinoscopy. A better insight in the status of nose and sinus tumors is provided by an fiberscopic examination (flexible endoscope), which provides a detailed insight in the status of the nasal cavities, nasal barrier, nasal septums, and it also enables doctors to spot the initial changes to the nasal mucosa, as well as to discover the sinus cancers in the stage of their expansion towards the nasal cavities. Besides the nasal examination, an otorhinolaryngologist should perform a detailed examination of the oral cavity, the soft and hard palate, on which the changes in the case of the nasal and sinus tumor can be visible, and to palpate the neck and the parotid gland area, because of the eventual metastasis.
In the case of the neurological deficits, a neurologist examination might be taken into consideration and, in the case of the ocular manifestations of the illness (impaired vision, eye mobility, etc…); visiting the ophthalmologist should be considered. The specialist should indicate any further examinations, which are, by a modern protocol, a CT scan or the MRI sinus scan, or both diagnostic tests. The CT sinus scan provides an excellent insight into the relationship of the tumor with the bone structures of the head, while the MRI gives a more detailed description of the soft tissue structure, which is what the sinus tumors most frequently are.
Both diagnostic methods give us the information about where the tumor is located, his relationship with the larger arteries, and the local outspread of the tumor. When the doubt about the tumor spreading towards the larger blood vessels or about the tumor’s blood supply itself exists, a specialist can ask for a CT scan or the MR angiography (a technique that uses the intravenous contrast application, which images the major arteries in the head and neck, their branches, as well as the arteries that supply the brain itself).
Treatment
The treatment of sinonasal tumors is difficult, because of their proximity to the vital structures such as skull base, brain, and orbital and carotid arteries, which is why the surgical possibilities are demanding and limited, and require a multi-disciplinarian approach (otorhinolaryngologist, neurosurgeon, maxillofacial surgeon). The nasal and sinus tumor treatment can be surgical, radiation (radiotherapy) or chemotherapy.
Several methods of surgical treatment exist. The endoscopic approach is possible with some benign tumors and tumors in the early stages, which envelop the wall of the nasal cavity, ethmodial or sphenoid sinus. The advantage of this kind of a treatment lies in the fact that it is performed without any incisions on the face; it is minimally invasive. However, the patient should still be warned about the possibility of the transition from the endoscopic technique to some of the more open techniques during the course of the surgery, if the removal of the tumor is not possible by the endoscopic technique.
With tumors in less approachable places, those in close proximity to the vital structures (base of the skull, orbital artery, major arteries), and tumors that are deeply enveloped across the bone structures, one of the open surgical techniques is recommended: “degloving” technique is used to lift the nasal structures by making incisions in the central line of the face and it enables the approach to the nasal tumors, maxillary sinuses, and nasopharynx; in the lateral rhinotomy, through the access through the skin on the lateral side of the nose, the access to tumors of the upper part of the ethmodial sinus, the frontal sinus, and tumors that spread towards the orbital artery and towards the base of the skull, is enabled.
This approach also enables the exenteration of the orbital artery (the removal of the eyeball), if that has been indicated. The access to the frontal sinus can be gained through the incision in both eyebrows and the scalp. When it comes to the more extensive tumors, various types of craniotomy (access through the skull) approaches are considered. The radiotherapy treatment can be one way of treatment if the tumor is inoperable, and radiotherapy represents the most frequent continuation of the treatment after the surgery. Chemotherapy, as a method of treating the nasal and sinus tumors in order to avoid a large surgical procedure, is still under discussion.