Definition: It is development of malignant (cancer) cells in the tissues of the nasal cavity and paranasal sinuses.
Predisposing factors:
- Exposure to wood dust (adenocarcinoma) and nickel fumes (squamous cell carcinoma).
- Smoke of burnt wood (Hydro carbons).
Incidence:
- 3% of all head and neck tumors. 1% of all malignancies of the body, commoner than benign tumors.
- Male: female is 2: 1.
- Age: Carcinoma affects old age group while sarcoma affects young age group.
- Site: maxilla 60%, lateral nasal wall 20%, ethmoid 10%.
Pathology and types
- Squamous cell carcinoma is the most common type, it occurs in the thin cells lining the inner aspect of the nasal cavity and paranasal sinuses.
- Sarcoma: this is cancer that starts in the layer of connective tissue.
- Melanoma: this arises from the melanocytes, which are the cells that synthesize Melanin, the substance that gives our skin its normal color.
- Inverted papilloma: this is a locally malignant tumor.
Clinical picture:
Depends upon primary site & direction of spread
a. Cancer maxilla
Oral & palatal manifestations:
- Unexplained dental pain
- Loosening and falling of teeth.
- Oro-antral fistula.
- Swelling and ulceration of palate or alveolus.
Nasal manifestations:
- Unilateral blood stained discharge.
- Unilateral nasal obstruction.
- Cacosmia.
- Epistaxis.
- A mass or polyp is seen attached to the lateral nasal wall. It has a friable, ulcerating, necrotic surface which easily bleeds.
Orbital manifestations:
- Unilateral epiphora.
- Proptosis (upward in maxillary, lateral in ethmoidal, and inferolateral in frontal tumors).
- Diplopia due either to proptosis, invasion or paralysis of the extraocular muscles.
- Ophthalmoplegia: invasion of 3rd, 4th, 5th cranial nerves at the superior orbital fissure.
- Diminution of vision due to optic nerve affection at orbital apex.
Facial manifestations:
- Facial swelling.
- Skin ulceration.
- Facial numbness, pain and anesthesia due to involvement of infraorbital nerve.
Manifestations of posterior extension (pterygopalatine & infratemporal fossae)
- Trismus; pterygoid muscles.
- Numbness over face and palate (maxillary nerve).
Neurological manifestations:
- Intracranial extension causes headache, vomiting and blurring of vision (papilledema).
- Infraorbital nerve in the roof of maxilla.
- Maxillary nerve in the pterygopalatine fossa.
- 3rd, 4th, and 5th cranial nerves in the superior orbital fissure and 2nd cranial nerve in the orbital apex.
- 9th,10th,11th and 12th cranial nerves at their exit from the jugular foramen if retropharyngeal node is affected by secondary deposit.
Nodal manifestations:
- The first station is the retropharyngeal nodes located near the jugular foramen THEN to upper deep cervical which indicates a late presentation.
- Submandibular nodes are affected if the palatal or sublabial mucous membrane or skin of vestibule is affected.
- The preauricular nodes are affected if the skin of the face is involved.
b. Cancer ethmoids
- Early nasal manifestations.
- Lateral proptosis and swelling at inner canthus.
- Possible intracranial extension causing C.S.F. rhinorrhea.
c. Cancer sphenoid
- Early neurological symptoms: headache.
- Early orbital: diplopia, vision.
Stages of Paranasal Sinus and Nasal Cavity Cancer
this is the staging of maxillary sinus cancer, as there is no standard system for staging of sphenoid and frontal sinuses cancers.
- Stage 0 (Carcinoma in Situ): There are abnormal cells in the inside lining of nasal cavity and paranasal sinuses, well defferentiated and they can turn into malignant cells and invade nearby organs.
- Stage I: Cancer cells in the mucosa (mucous membranes) only of the nose and paranasal sinuses.
- Stage II: Spread of cancer to the bone around the maxillary sinus including the roof of the nose and the mouth, BUT didn't spread to bone at the back of the maxillary sinus or the base of the skull.
- Stage III: There is spread to the bone at the back of the maxillary sinus and the base of the skull, Tissues under the skin, the eye socket and the ethmoid sinuses. Or there is spread to ONE lymph node on the same side of the neck (less than 3CM).
- Stage IV: It is divided into stages IVA, IVB, and IVC as follows:
Stage IVA: Spread to One or More than one lymph node on the same side of the neck or on both sides (Cancer and lymph node are more than 3 CM and less than 6 CM), Plus spread to other parts as in stage III).
Stage IVB: Spread to any of the following: the back of the eye, the brain, middle parts of the skull, nerves in the head that go to the brain, upper part of the throat behind the nose and the base of the skull Or Cancer is found in a lymph node larger than 6 centimeters.
Stage IVC: Spread anywhere in or near the maxillary sinus and to lymph nodes plus metastasis.
Prognosis:
In general, tumors of the nose and paranasal sinuses carry bad prognosis (30% 5 years survival). This is due to:
- Complex anatomy of the P.N.S.
- Nearby important structures.
- Similarity of symptoms to the more common chronic sinusitis.
- Late appearance of symptoms (average is 6 month between early presentation and diagnosis).
Investigations:
- Radiology: CT and MRI (bone erosion is an early important sign)
- Endoscopic examination: Any patient with unexplained or persistent sinonasal symptoms should be thoroughly examined endoscopically
- Biopsy.
- Metastatic work up.
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| CT scan |
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| MRI Scan |
Treatment:
- Combined surgery & radiotherapy
- Alveolectomy and palatectomy in localized inferior lesions.
- Medial maxillectomy in localized medial maxillary and lateral nasal wall lesion.
- Total maxillectomy in extensive lesion.
- Orbital excentration if orbital periosteum is involved.
Palliative treatment:
If bilateral, distant metastasis, irresectable structures (extensive skull base), old age or bad general condition.
→ Radio or chemotherapy, palliative resection, pain killers and adequate feeding.
Key points
- Tumors of the nose and paranasal sinuses are common among the extremes of age.
- Similarity of symptoms to other common sinonasal diseases including sinusitis leads to late discovery and poor prognosis.
- Persistent unilateral nasal obstruction, cacosmia, discharge, epistaxis should attract the attention to sinonasal tumors.
- Unexplained orbital or dental problems should attract the attention to sinonasal tumors.
- Early detection allows for conservative surgery.
- Cervical nodal deposits is a late manifestation.