Abtin Tabaee, MD
Tumors of the nose and paranasal sinuses are rare, accounting for fewer than 1% of all tumors. These tumors can be either benign or malignant, and they vary greatly in location, size and type. Care for these tumors is individualized to each patient and may involve a multi-disciplinary (team) approach for treatment. Possible treatments include surgery, radiation therapy and chemotherapy depending on the particular tumor and the needs of the patient.
The symptoms associated with nasal and sinus tumors are non-specific. This means they are often difficult to distinguish from other nasal conditions such as allergies or sinus infections. Symptoms may include nasal congestion, facial pain and pressure, runny nose, and post-nasal drip. More worrisome symptoms include recurrent and severe bleeding from the nose, facial swelling, associated eye symptoms and changes in sensation to the face. Any of these symptoms should prompt a visit to the doctor, especially symptoms that are only present on one side or symptoms that represent a significant change from before (especially in an elderly patient).
Evaluation and diagnosis
Evaluation of patients with nasal symptoms is often performed by an otolaryngologist and involves taking a complete medical history, performing an examination of the head and neck region, and often nasal endoscopy of the nasal and sinus areas (looking inside the nose with a small scope). If there is any concern for a tumor (mass or growth), imaging studies are performed and may include CT scan, MRI scan and in certain situations PET-CT scan. If a tumor is suspected, a biopsy is typically performed to determine exactly what sort of growth is present. A biopsy involves taking a small sample of the tissue of the nose, and this can be done either in the clinic or the operating room depending on the circumstances. A biposy is important since there are a number of different types of sinus and nasal tumors, and many are treated differently.
Figure: CT scan of a patient with a sinus cancer (esthesioneuroblastoma) on the patient's right side (left side of the picture).
Benign and malignant tumor types
A variety of benign and malignant tumors may occur in the nose and paranasal sinuses. The potentially benign lesions include papilloma (including inverted and squamous), fibro-osseous (meaning from bone structure) lesions (including osteoma, fibrous dysplasia), vascular (meaning from a blood vessel) tumors (including juvenile nasopharyngeal angiofibroma), neurogenic (meaning from a nerve) tumors (including schwannoma, neurofibroma) and tumors of minor salivary gland origin.
The World Health Organization has classified the malignancies in the nose and paranasal sinuses based on the type of tissue, with more than 25 specific types listed. Malignant lesions may include squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, melanoma, olfactory neuroblastoma (also known as esthesioneuroblastoma), sarcoma, and lymphoma. Malignant lesions from other body sites may metastasize (spread) to the nose and paranasal sinuses. A review of each of these different lesion types is beyond the scope of this article. However, differentiating between these lesions is critical for determining the proper sort of treatment, and a biopsy in necessary whenever a tumor is suspected.
The treatments for benign and malignant nasal and sinus tumors are highly complex and may involve evaluation by several medical specialties including otolaryngology, radiation oncology, medical oncology, neurosurgery and others. The treatment decisions are based on the overall health of the patient, the type of the lesion and the location and extension of the lesion. Involvement of the surrounding structures such as the orbit (eye socket), intracranial cavity (skull and brain), and soft tissues of the face is also relevant. The presence of spread of the lesion into the nearby lymph nodes or to other body sites additionally impacts treatment.
Surgery for nasal and sinus neoplasms
If surgery is contemplated, there are several different techniques currently available. Surgery is classified as “open surgery” or “endoscopic surgery”. "Open surgery" is done through a variety of incisions on the face and scalp. These techniques are associated with wide surgical access and may be preferred especially in patients with extensive tumors and certain anatomic areas of disease. "Endoscopic surgery" involves visualization and removal of the tumor through the nostrils and nasal cavity with the use of an endoscope and camera. (See Figure: arrow points to turbinate; arrowhead points to septum; asterisk is tumor.)
The benefits of the endoscopic approaches include avoidance of facial incisions and in certain situations improved ability to visualize and remove a tumor. The decision to use an open versus endoscopic approach is individualized based on a patient's needs. Increasingly, endoscopic approaches are used when possible.
Regardless of the surgical technique used, the goals of the surgery are: 1) a complete removal of the tumor, 2) removal of a margin of tissue around the tumor so that any microscopic spread is cleared, 3) preservation the critical nerves and arteries in the area, 4) maintenance of the function of the nose, sinuses and any other involved structures, and 5) maintenance of separation between the intracranial (brain) and sinonasal cavities. These surgeries are often complex and require a team approach with otolaryngology, neurosurgery and in some cases plastic-reconstructive surgery and ophthalmology.
One can think of the surgery as having three steps. The first step is pre-operative planning which involves extensive discussion between the patient and the different members of the treatment team, obtaining the appropriate diagnostic studies and detailed coordination of the surgical plan. The surgery itself is the second step. The surgery involves reaching and exposing the tumor, removing the tumor, and, finally, reconstructing any functionally important defects. The third step of the surgical procedure is the postoperative recovery and possibly additional treatment including radiation therapy or chemotherapy based on the patient’s individual needs. All patients require long term follow up which typically involves in-office examinations and additional imaging studies.
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