Kevin C. Welch, MD
Tumors found within the nose and sinuses can be either benign (not cancer) or malignant (cancer). In all cases, how these tumors are treated depends upon what specific type of tumor it is. We diagnose tumors by using a combination of methods, including CAT scans, MRI scans and by taking biopsies. The CAT scans and MRI scans help us understand how big the tumor is, where in the sinuses it is located and to narrow down the type of tumor it is. Despite this helpful information, a pathologist typically will have to look under a microscope at a biopsy to tell us what type of tumor it is. This is important since tumors are treated in many different ways.
Benign (non-cancerous tumors) typically are not life threatening; however, they can cause disabling symptoms. Often these benign tumor may block the drainage of the sinuses, and this can result in repeat sinus infections that need to be treated with antibiotics. Blocked sinuses may also cause facial pain and pressure. In addition to those symptoms, occasionally a benign tumor may block the nasal passages making it difficult to breathe. There are certain benign tumors that grow rapidly, and these may grow into the muscles around the upper jaw and around the nerves causing pain or numbness. Even more rarely, some benign tumors, such as inverted papilloma, may turn into cancer. Examples of benign tumors include: osteoma, inverted papilloma, neuroma, schwannoma, juvenile nasopharyngeal angiofibroma, hemangioma, fibrous dysplasia, hamartoma and adenoma.
Sinus tumors that are cancers typically grow and cause similar symptoms as do the benign sinus tumors. However, it is more common that cancerous tumors cause pain, numbness, bleeding and changes in vision. Cancerous tumors are more likely to invade nearby tissues such as the muscles of the upper jaw, the eye socket or the brain. Cancerous tumors are more likely to spread to the lymph nodes of the neck or the lung or brain. Unlike benign tumors, cancerous tumors need to be treated more aggressively and more quickly.
Treatment options for tumors
The treatment of sinus tumors depends upon the type of tumor. Some tumors are treated with surgery alone. Some tumors are treated with surgery and radiation. Some tumors are treated with radiation and/or chemotherapy. Still others are treated with surgery, radiation and chemotherapy together. If a diagnosis cannot be made by looking at the tumor using a nasal endoscope or CAT/MRI scans, a biopsy will need to be performed. If a biopsy needs to be performed, your ENT physician may want to perform a CAT scan or MRI scan before taking the biopsy. In some situations, an MRI or CAT scan is not necessary before the biopsy. A biopsy can be performed through the nose using the nasal endoscope, or it may be performed by the surgeon as he or she uses a head mirror or head light. Occasionally a needle biopsy may be done to sample lymph node tissue if the neck lymph nodes are enlarged. Once the pathologist reviews this information, your ENT physician will be able to tell you what treatment plans are necessary. In some circumstances, a meeting among the ENT surgeon, medical oncologist and radiation oncologist will occur and a joint decision will be made concerning the best treatment options.
Endoscopic surgery for tumors
In many cases, both benign tumors and sinus cancers can be removed entirely through the nostrils with the use of an endoscope. For some tumors, only an ENT surgeon is involved. For other tumors, and ENT surgeon and a neurosurgeon may be involved. In several instances, both the ENT surgeon and the neurosurgeon work side-by-side through the nostrils to remove the tumor, even parts of the tumor that are close to the brain or involving the lining of the brain. In some instances, brain tumor that do not enter the sinuses (such as pituitary tumors, craniopharyngiomas or olfactory groove meningiomas) may be removed entirely through the nostrils without incisions on the face or on the scalp.
Prior to endoscopic surgery to remove benign or cancerous tumors, your surgeon may request that you get a specialized CAT scan or MRI. These scans are known as "stereotactic" scans, "stealth" scans, "VTI" scans or "image-guidance" scans. The exact name of the type of scan is not important. However, these CAT scans and MRI scans are used by your surgeons during the procedure to identify the precise locations of the tumor and to identify important organs and nerves around the tumor. During the surgery, the surgeon may use a probe to point at a specific object in the nose or sinuses, and a computer will use the CAT scan or MRI to show the surgeon in three dimensions where the probe is located. The below picture is an example of this technology.
To complete the surgery, a graft and/or "flap" of tissue may be needed to repair any loss of bone between the sinuses and the brain. In order to remove some tumors completely, the layers of tissue and bone between the brain and the sinuses must also be removed. In these situations, the barrier that naturally exists between your brain and sinuses must be replaced. This is done with a combination of grafts (fat, synthetic tissues, glue, bone, cartilage) and "flaps" (septal flap, pericranial flap). A graft is simply tissue or synthetic tissue which has no blood supply and is placed between the brain and the sinuses. The graft eventually grows blood vessels or turns into scar tissue so that the brain is separated from the sinuses. A "flap" is tissue that is still attached to its arteries and veins. Therefore, it is "alive." A flap is moved from one area (a.k.a. "harvested") and is moved to another area to cover the defect created (See below).
You may have some packing in your nose following the surgery. The packing can be placed for a variety of reasons: bleeding, support the graft or flap, prevent airflow through the nose or prevention of scarring. Your surgeon will discuss this with you.
Following the surgery, you may go home the same day, be observed overnight or be admitted to the hospital. This depends on the type of the tumor, the extent of surgery and many factors.
open sinus surgery
In some cases, a benign sinus tumor or a sinus cancer may be in a difficult-to-reach location or may need to be removed along with bone, fat and even skin. Again, the amount of surgery and the route of surgery depends on what type of tumor you have and on whether it can be safely and adequately removed. In some cases, an incision must be made on the face or scalp to assist in removing tumors completely. In the case of sinus cancers, incisions on the face or scalp may need to be done in order to remove all the tumor successfully.
If the tumor is benign, it is unlikely that you will need any other medical therapy following the removal of the tumor. The ENT surgeon may request that you return for additional visits so exams can be performed. You may also need to have additional CAT scans or MRIs to determine if the tumor has come back (recurred).
If the tumor is malignant (cancer) and you have undergone surgery, you may need to have radiation treatments and/or chemotherapy. These additional treatments will be discussed with you and depend largely on the type of tumor removed and in some cases based on how much tumor remains behind.
Sinus tumors can be benign or malignant (cancer). The treatment of sinus tumors depends upon the type of tumor that is growing. Therefore, a biopsy is needed. In all cases, successful treatment of sinus tumors depends upon the right combination of surgery, radiation and chemotherapy. In many cases, these tumors can be removed through your nostrils with the assistance of the nasal endoscope rather than incisions.
©American Rhinologic Society