Nasal and Sinus Cancer
What Is Nasal Cancer?
The nose and sinuses that surround the nasal cavity may in rare circumstances develop cancer. The nasal cavity is defined by the area within the nose, excluding the skin; whereas the sinuses are collectively known as the paranasal sinuses and include: the maxillary sinuses, ethmoid sinuses, sphenoid sinuses, and the frontal sinuses. The sinuses are air filled pockets of bone that sometimes can harbor both malignant and benign tumors. Most often, growths within the nasal and paranasal sinuses are benign. However, the most common malignant tumor is squamous cell carcinoma, usually occurring in the maxillary sinus.
What Are The Different Types Of Nasal And Sinus Cancer?
Sinonasal tumors vary considerably from benign to malignant with treatment highly contingent on pathology, location, and extent of disease. It is important to recognize the different types of malignancies and their different behavioral patterns. The types of cancers can be categorized on the cells that they originate from. Epithelial based cancers come from the skin lining of the sinonasal cavities, whereas non-epithelial based cancers originate from soft tissue and bone.
- Cancers of epithelial origin. Originate from the lining (or mucosa) of the sinonasal cavities
- Squamous Cell Carcinoma (SCC). These are malignancies that originate from the skin lining inside the nose and sinus cavities. Behavior is highly dependent on the nature of the pathology.
- Salivary Gland Tumors. Like other regions of the head and neck, minor salivary glands may give rise to cancers that have different degrees of aggression. (see Salivary Gland Cancer).
- Mucosal Melanoma. Melanoma, similar to the type of melanoma found in the skin, may also manifest in the sinonasal cavities.
- Esthesioblastoma (olfactory neuroblastoma). This is a type of cancer that arises from the region of the nose that is responsible for smell detection.
- Sinonasal Undifferentiated Carcinoma. This type of cancer is very aggressive. It is deemed “undifferentiated” because its cell of origin is unclear.
- Cancers of Non-Epithelial origin.
- Lymphoma. Lymphoma may present as a lesion in the sinonasal cavity due to the diffuse distribution of lymphoid tissue.
- Soft Tissue Cancers. Soft tissue cancers may present in the sinonasal cavity, although rare. These involve sarcomas that may arise from muscle, fat, or joint spaces.
What Are The Causes Of Nasal Cancer?
Nasal and sinus cancer are exceedingly rare, making it difficult to pinpoint the exact causes in most circumstances. As with other cancers of the head and neck, smoking seems to be a risk factor. Researchers also believe that genetic predisposition in addition to occupational exposures with nickel, chromium, leather, and wood workers may also contribute to the development of cancer in this region.
What Are The Signs And Symptoms Of Sinus Cancer?
Sinonasal cancers frequently present with symptoms related to their location within the nasal airway. However, the symptoms are oftentimes non-specific, and may mimic other more common conditions. Tumors in the area can present as breathing problems, vision changes, bleeding from the nose, or recurrent infections. Below are the most common presenting signs:
- Lump in the Neck. Nasal and paranasal sinus cancers may sometimes present as a mass in the neck if the disease has already spread via lymphatics.
- Nose Bleeds. The presence of a tumor within the sinonasal tract may present as bleeding, particularly from one side
- Sinus Problems. Oftentimes presence of a tumor may result in obstruction that causes infections, usually localizing to one side. Patients may also present with sinus pressure or headaches.
- Vision Problems. Due to the close proximity of the sinonasal tract to the eyes, patients may present with blurry or double vision.
- Nasal Obstruction. Patients may report longstanding feelings of nasal congestion or change/loss of smell.
- Neurological Problems. Loss of facial sensation in regions of the face and mouth may occur if the tumor has spread to involve nerves.
- Lesions in the Mouth. Cancers may extend in from the sinonasal tract and involve parts of the palate or mouth.
How Is Nasal Cancer Diagnosed?
In addition to routine history and physical examination, the physician may perform ancillary tests and procedures in order to confirm the presence and type of sinonasal cancer, as well as to determine the presence of second primary cancers (SPC) or the spread of malignant disease elsewhere.
- Biopsy. Oftentimes the first step in the diagnosis of sinonasal cancer is to perform a biopsy. Taking a biopsy will confirm the presence of abnormal cells under the microscopic view, and is imperative in making the diagnosis of sinonasal cancer.
- In-Office Biopsy. If the lesion can be visualized directly it may be determined that an in-office biopsy is the most efficient and effective method of obtaining tissue for analysis. This can be performed under local anesthesia with minimal discomfort to the patient.
- Operative Biopsy. If the area to be biopsied is too difficult to access in the office a biopsy may be performed under general anesthesia in the operating room.
- Lymph Node Biopsy. If a patient presents with a neck mass, particularly in the setting of no identifiable lesion, the physician may sample tissue from lymph node. There are several types of lymph node biopsy.
- Fine Needle Biopsy (FNB). If the mass can be felt by the clinician, then a small needle can be introduced with an attempt at extracting cells for microscopic assessment. The appearance of abnormal cells will help support the diagnosis of cancer. Sometimes, not enough cells are extracted, and repeat biopsies may need to be performed. This may also be performed with the help of ultrasound or computed tomography (CT) guidance
- Core Biopsy (CB). Similar to the Fine Needle Biopsy, a core biopsy is performed by introducing a larger caliber needle, with extraction of tissue as opposed to cells. This core biopsy allows for extraction of more tissue and can be more useful, but oftentimes not necessary, as an FNB is sufficient. This can also be done with or without ultrasound or CT-guided assistance
- Operative Biopsy. If the location of the node is too deep, or not readily felt by a clinician, the surgeon may elect to perform biopsy under general anesthesia in an operating room.
- Blood Work. The physician may elect to perform routine blood analysis to assist in determining the presence of sinonasal cancer or other diseases. Blood work may not be necessary, and the decision to obtain blood work is individualized to every patient.
- Liver Function Tests (LFTs): Can be utilized to determine the presence of concurrent liver disease that may be associated with risk factors for the development of sinonasal cancer (alcohol consumption, hepatitis). Furthermore, abnormal values may indicate the presence of metastatic liver disease.
- Complete Blood Count (CBC): This will identify the presence of any anemia that can sometimes be associated with poor nutrition, or chronic illness.
- Nutritional Blood Work: If a patient seems nutritionally depleted, particularly in advanced cases, the clinician may elect to obtain laboratory work up to measure nutrition markers in the blood work. This may assist in determining if a patient requires supplemental nutrition.
- Imaging. Often times a physician may elect to obtain imaging that will help in better understanding the presence of cancer and any other underlying issues. Imaging may be performed of the primary site, or of the general region to better define disease extent. The physician may elect to obtain further imaging in situations in which they are concerned for local invasion (e.g. into bone, muscle, adjacent sites), or regional invasion (to the neck).
- Chest X-rays: Chest radiography may be obtained in order to define the presence of disease in the lungs. Often times patients with sinonasal cancer, have a longstanding history of smoking may have associated lesions in their lungs that should be identified.
- Computed Tomography (CT): CT-Scans usually provide a more detailed image of the head and neck region, identifying parts of the tumor that is not readily seen on exam, as well as the presence of regional disease not readily detected (e.g. in the neck). CT-Scans can be obtained with or without contrast. Given the complexity of the region, usually CT scans are obtained with contrast, to help in identify the vascular architecture within the neck. However, this is not always necessary, and CT scans may be obtained without contrast in circumstances that preclude patient receiving contrast (iodine allergies, kidney disease).
- Magnetic Resonance Imaging (MRI): MRI can also be utilized with or without contrast in order to provide superior visualization of soft tissue as well as the brain. Often times an MRI may be needed if there is indeterminate findings on other imaging modalities, with a need for more accurate mapping. MRI can also assist in determining if there is involvement of nerves or the eye which is important in counseling patients regarding future directions of targeted therapies.
- 18-Fluorodeoxyglucose Positron Emission Tomography (18-FDG PET): FDG-PET scans may be performed with CT or MRI imaging modalities and are utilized for the identification of regional or distant metastases.
- Ultrasound (US): Ultrasound may be utilized to better characterize neck masses, or used in conjunction with biopsy techniques. US can indicate suspicious characters of lesions that would direct a physician to more aggressive workup (biopsy, excision).
What Are The Possible Treatments For Nasal Cancer?
Depending on the site of disease, the clinical staging, and patient factors (comorbid health conditions, patient preferences) a patient-specific treatment plan should be outlined. Tumors located within the maxillary sinus, and nasal/ethmoid cavities may be managed differently. Furthermore, the management of sinonasal malignancies further depends on the pathology, with different management protocols for squamous cell carcinoma, esthesioneuroblastoma, and mucosal melanoma. Broadly speaking there are 3 types of treatment that can be used in combination or separately depending on the type and stage of cancer. The decision to embark on a particular treatment plan should be made involving a multidisciplinary team of physicians (surgeons, radiation oncologists, and medical oncologists) and the patient.
Surgery. Surgery may be performed in the treatment of sinonasal malignancies, with the extent and type of surgery guided by the location and degree of local invasion.
- Endoscopic. Tumors limited in the extent of local invasion and to certain subsites can be approached through the use of cameras and instruments introduced into the nose.
- Lateral Rhinotomy. For larger lesions that extend further back in the nose that cannot be easily accessed through endoscopic approaches, maybe approach by making an incision on the side of the nose.
- Anterior Maxillary Punch (Culdwel-Lac). This approach involves entering the sinus through the mouth, drilling a hole into the front of the maxillary sinus.
- Craniofacial Resection. For extensive lesions that are high in the nose or with extensive involvement of the skull base, a craniofacial resection may be performed.
Radiation. Radiation is another option for the treatment of sinonasal cancer.
- Definitive Radiation (with or without chemotherapy). This type of radiation treatment involves using radiation as the primary mode to treat the tumor. The goals of definitive radiation therapy are complete removal of all tumor with external sources of radiation.
- Adjuvant Radiation (with or without chemotherapy). This refers to the use of radiation in combination with surgery. The goal of adjuvant radiation is to treat any remaining disease after surgical removal (e.g in circumstances with positive margins).
Chemotherapy. The use of systemic medications is used adjunctively with either surgery or radiation and is used to target disease distant from the local site. It is not used as a primary treatment modality as it does not facilitate eradication at the primary site. Chemotherapy is often used in circumstances of advanced disease (Stage III or IV), or when certain risk factors for distant disease are present. Such risk factors include lymph nodes with a disease that have extended out of their capsule (not contained), positive surgical margins, or involvement of nerves and blood vessels.
- Induction Chemotherapy. This refers to chemotherapy performed prior to surgery or radiation. This may be used to determine the biological response of the tumor to chemotherapy, as well as “shrink” tumors to a manageable size that can be better removed with surgery or radiation.
- Adjuvant Chemotherapy. This refers to chemotherapy given after definitive treatment with another modality was performed (either surgery or radiation).
- Concurrent Chemotherapy. This refers to the decision to administer chemotherapy and radiation concurrently after surgery. This may be the case in situations of predictors of aggressive disease on pathology.
Other Considerations. Specific attention should be given to the presence or absence of neck disease in the patient.
- Therapeutic Neck Interventions. If there is any presence of disease within the neck it should be addressed with some type of therapeutic intervention. Positive neck disease is usually treated through surgical resection or radiation of the actual positive nodes, and all intervening nodes in the neck. This is to ensure accurate pathological characterization of the nodes in the neck and prevent recurrence in the neck (from missed disease).
- Elective Neck Interventions. In the absence of any clinical evidence of disease, an elective neck intervention may be performed. This means treating the neck (with radiation or surgery) due to the potential for “occult” or hidden disease that is not clinically apparent. If there is a high likelihood (>15%) of occult disease, an elective neck dissection may be performed.
- Orbital Involvement. The involvement of the eye may necessitate surgical removal of the eye in order to fully eradicate the disease. This should be thoroughly discussed with the surgeon.
What Is The Prognosis Of Nasal And Sinus Cancer?
The prognosis and survival associated with laryngeal cancer are heavily influenced on the stage of the disease, spread to surrounding structures, as well as response to radiation and chemotherapy.
Stage. The factor with the highest impact on survival. The staging incorporates lymph node status, spread to local and vital tissues, as well as primary disease characteristics.
Nasal Cavity Prognosis Table
Paranasal Sinuses Prognosis Table
What Are The Risks If Nasal Cancer Is Left Untreated?
Given the location of the nose and paranasal sinuses, cancer in the region can have an extremely detrimental impact to the overall health and safety of the patient. Cancer in this area can easily extend to the eye or brain. This can lead to vision changes, blindness, stroke, intracranial infections, and ultimately death. Most importantly, the longer the cancer is left untreated the worse the overall cure rate and prognosis.
Are There Other Related Conditions To Nasal Cancer?
Sinus cancer can mimic other types of conditions that affect the nose and sinuses often leading to delay in diagnosis. Symptoms may mimic acute and chronic sinus disease, normal headaches, seasonal allergies, or nasal congestion. Your physician should maintain a high index of suspicion and perform a thorough examination, including nasal endoscopy for all sinus and breathing-related complaints.
- Early diagnosis is key to ensuring the best outcome. Patients may present with complaints that mimic other conditions such as allergies, sinus infections, or nasal breathing problems. It is important for your physician to maintain a high index of suspicion and take a thorough history and perform a complete physical exam (including nasal endoscopy).
- Smoking and environmental exposures represent risk factors for developing sinus cancer. It is important to discuss with your physician ways to prevent such exposures, mitigating the risk of developing cancer.
- There are multiple options to the treatment of nasal and sinus cancer. It is important to know the differences, and discuss with your physician the optimal treatment plan for your specific cancer.
What Makes You The Right Doctor For Nasal And Sinus Condition?
Dr. Mourad has advanced training in the surgical management of all cancers of the nose, sinuses, and skull base. He is trained in both open and minimally invasive techniques, as well as reconstructive surgery. Dr. Mourad is an expert in the area of head and neck cancer, having authored more than 40 scientific articles, book chapters, and presentations (link to CV). Most importantly, Dr. Mourad is empathetic to the needs of his patients. He views the ability to treat his patients to be nothing short of an honor and a privilege.
Select Relevant Publications
Kadakia S, Mourad MW, and Ducic Y. Supraclavicular Flap Reconstruction of Cutaneous Defects Has Lower Complication Rate than Mucosal Defects. Journal of Reconstructive Microsurgery. 2017 May; 33(4):275-280. Link to Article.