Sinonasal Malignancies Summary

Sinonasal Malignancies

Introduction/Epidemiology

  • Rare: Less than 1% of all malignancies; 3% of head & neck tumors.
  • Common in 40-60 yr age group, male preponderance.

Aetiology

  • Largely unknown, some environmental factors identified.
  • Causal factors:
    • Hardwood furniture industry.
    • Nickel refining.
    • Leather work.
    • Mustard gas manufacture.
    • Squamous cell carcinoma
    • Aflatoxins, dust chromium, asbestos, nickel, mustard gas, polycyclic hydrocarbons
    • Adenocarcinoma: Wood dust, leather tanning, industrial fumes, lacquer paint, soldering & welding, radium dial painting.

Sites of Sinonasal Tumours

  • Maxillary > Nose > Ethmoid > Frontal > Sphenoid sinus.

Clinical Presentation

  • Nasal obstruction, rhinorrhoea, epistaxis, nasal mass, facial/sinus pain, anosmia.
  • Facial paraesthesia/anaesthesia, epiphora, trismus, diplopia/vision loss, neck mass, hearing loss.
  • Late features depend on spread and growth direction.

Investigations

  • Plain radiographs, naso-endoscopy, CT scans, MRI.
  • Biopsy: Nasal mass, intranasal antrostomy, endoscopic approach.

Classification

  • Staging not well established.
  • Methods:
    • UICC (International Union Against Cancer Classification).
    • AJCC.

Maxillary Sinus Staging Criteria

  • T1: Tumour limited to maxillary sinus mucosa, no bone erosion.
  • T2: Bone erosion, extension to hard palate/middle nasal meatus (except posterior wall/pterygoid plates).
  • T3: Invades posterior wall of maxillary sinus, subcutaneous tissues, floor/medial wall of orbit, pterygoid fossa, ethmoid sinuses.
  • T4a: Invades anterior orbital contents, cheek skin, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid/frontal sinuses.
  • T4b: Invades orbital apex, dura, brain, middle cranial fossa, cranial nerves (other than V2), nasopharynx, clivus.

Nasal Cavity and Ethmoidal Sinus

  • T1: Tumour restricted to one subsite, with/without bony invasion.
  • T2: Invades two subsites in a region or extends to adjacent region in nasoethmoidal complex, with/without bony invasion.
  • T3: Extends to medial wall/floor of orbit, maxillary sinus, palate, or cribriform plate.
  • T4a: Invades anterior orbital contents, skin of nose/cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid/frontal sinuses.
  • T4b: Invades orbital apex, dura, brain, middle cranial nerves (other than V2) nasopharynx or clivus.

Treatment

  • Curative, Palliation.
  • Goals assessed individually.
  • Factors: Tumour histology, stage, resection feasibility, patient condition, treatment risks.
  • Multidisciplinary approach: Otolaryngologist, neurosurgeons, oculoplastic surgeons, facial plastic surgeons, oral surgeons, neuroradiology, radiation oncology.

Modalities of Treatment

  • Surgery, Radiotherapy, Chemotherapy.

Surgery

  • Approaches: Endoscopic, lateral rhinotomy, transoral/transpalatal, midfacial degloving, Weber-Fergusson, combined craniofacial.
  • Extent: Medial/inferior/total maxillectomy.

Radiation

  • Single modality, adjunct to surgery, or palliative.
  • Preoperative or postoperative.

Chemotherapy

  • Adjunctive to radiotherapy (radiosensitizer) or palliative.

Reconstruction

  • Goals: Wound healing, facial contour, oronasal separation, separation of nasal/cranial cavity.

Follow Up

  • Routine, long term surveillance.

Prognosis and Outcome

  • Factors: Tumour histopathology, extent of disease, surgical margins.
  • Maxillary sinus cancer: 5-year survival ~40%. Early-stage, cure rate up to 80%.
  • Unresectable tumors (radiation): Survival < 20%.
  • Ethmoid tumors: Improved survival with skull-base surgery.

Conclusion

  • Rare tumors with varied lesions.
  • Common nasal symptoms initially, high suspicion needed.
  • Advanced stages at presentation, multimodality therapy required.
  • Multidisciplinary approach for treatment and rehabilitation is advocated.