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Tumors of the Nose and Paranasal Sinuses

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Tumors of the nose are rather rare disease entities. They are divided into benign and malignant. Benign lesions include osteomata, most of the inverted papillomas, angiofibromas of childhood etc. Malignant tumors include tumors of the minor salivary glands, the adenocarcinomas, tumors of the olfactory epithelium, the esthesioneuroblastomas, as well as mucosal melanomas, etc. In addition malignant tumors include metastatic tumors from distant organs.

The patient usually visits the doctor complaining about difficulty in nasal breathing, in particular in one of the nostrils. He/she may present bleeding episodes in the nose or a feeling of fullness at the ipsilateral ear. He / she may also show symptoms of a sinus blockage. In rather advanced cases vision disorders may occur such as diplopia, disturbances of the maxillary denture, facial swelling and pain.

The endoscopic examination of the nose and nasopharynx reveals the tumor in a sufficient percentage. Even if the tumor does not protrude into the nasal chamber or in the nasopharynx, signs from the area where it is located may be revealed, such as purulent or bloody discharge. A physical examination may reveal areas of hypoesthesia of the face, loosening of the upper teeth, serous otitis, and rarely swollen lymph nodes in the neck.

The imaging study with CT and MRI is an important part of the examination of the patient. The accuracy of both examinations should be high and it should be possible to use them in the three-dimensional space in case the use of a navigator system is required in a possible surgery. The imaging study will detect the tumor, it will reveal its borders and possible extensions beyond the nose and the paranasal cavity, in the eye orbit, in the foramina of the base of the skull or in the brain. It will also provide us with information on whether the extension of the tumor to the adjacent organs has the nature of pressure or infiltration, and it will help in the planning of a possible surgery.

With few exceptions, the identity of the tumor will be revealed by performing biopsy. Osteomata have a characteristic appearance on CT and their location may be such that their biopsy is feasible only after their removal trough surgery. On the other hand, angiofibroma is a vascular tumor whose biopsy, if performed under local anesthesia, would cause significant bleeding. Its location, though, its appearance and the population group that it attacks are enough for the diagnosis. It is important that the biopsy be taken from the right spot, because some tumors show polypoid degeneration in their circumference. It is also important that the biopsy be taken without violating some barriers that restrain the tumor, thus leading to its undesirable expansion.

The determination of the tumor location, of its boundaries and identity completes the diagnostic study. Based on these data, special examinations and collaborations with colleagues of other disciplines will be planned and, if possible, the tumor will be surgically removed. Otherwise, the patient will be referred for another therapeutic method.

Angiofibroma requires an angiography and embolization before its surgical removal. For a tumor of the maxilla, whose removal will create an open communication between the oral cavity and the nasal cavity, a special obturator should have been built in advance. In case the tumor of our patient is metastatic, we will collaborate with the oncologist, whereas if the tumor extends in the eye or the brain cavity, it is necessary to cooperate with an ophthalmologist and a neurosurgeon, respectively.

If the tumor of our patient is benign, every effort must be made in order to remove it endoscopically. Given that the techniques and tools have evolved a lot over the last years, endoscopic removal is feasible in most cases. Today we can reach even areas such as the frontal sinus, the anterior wall of the maxillary sinus and infratemporal fossa, which until a few years ago were considered endoscopically inaccessible. As a result we can guarantee a radical tumor removal at a rate that rivals the removal rates using the traditional external approaches.

However, in a significant percentage, malignant tumors can also be removed endoscopically. If, however, a tumor is malignant, what matters most is that it be removed radically, to the greatest possible extent. To make this possible, we may use conventional external approaches, sacrifice important anatomic elements or organs and cause large tissue deficits. In most cases, the surgical removal will be followed by radiation therapy and perhaps chemotherapy and our patient will be put under regular medical monitoring.

Cancer of the nose and paranasal sinuses is a difficult nosological entity. Our task is to perform early diagnosis, establish a proper sequence of actions and treat it with adequacy and flexibility.