eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Malignant Tumors of the Nasal Cavity

Author: Weiru Shao, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine
Coauthor(s): Adarsh Vasanth, MD, Resident Physician, Department of Otolaryngology, New England Medical Center
Contributor Information and Disclosures

Updated: Nov 16, 2007

Introduction

Sinonasal malignant neoplasms are diverse and uncommon diseases. Large clinical studies with adequate patient population are scarce. Because of a lack of sufficient clinical data, many treatment regimens remain empirical and controversial. This article discusses the considerations in the evaluation and treatment of the malignancies that arise in the nasal cavity.

Malignant tumors of the sinonasal tract include the following:

  • Epithelial
    • Squamous cell carcinoma (SCCA)
    • Transitional cell carcinoma
    • Adenocarcinoma (AC)
    • Adenoid cystic carcinoma (ACC)
    • Undifferentiated carcinoma
  • Nonepithelial
    • Soft tissue sarcoma
      • Rhabdomyosarcoma
      • Leiomyosarcoma
      • Fibrosarcoma
      • Liposarcoma
      • Angiosarcoma
      • Myxosarcoma
      • Hemangiopericytoma
    • Connective-tissue sarcoma
      • Chondrosarcoma
      • Osteosarcoma
    • Lymphoreticular tumors
      • Lymphoma
      • Plasmacytoma
      • Giant cell tumor
  • Metastatic carcinoma

Frequency

Epidemiologic studies estimate that the annual incidence of nasal tumors in the United States is less than 1 per 100,000 people. Sinonasal neoplasms represent approximately 3% of all upper aerodigestive tract tumors, and only a fraction of these arise from the nasal cavity. Tumors of the nasal cavity are equally divided between benign and malignant types, while most paranasal sinus tumors are malignant. Approximately 55% of sinonasal tumors originate from the maxillary sinus, 35% from the nasal cavity, 9% from the ethmoid sinus, and the remainder from the frontal and sphenoid sinuses. The site of origin may be difficult to identify with large tumors.1 Sinonasal malignancies are seen predominantly in the fifth to sixth decade of life. The incidence in males is twice that in females.

Most series document SCCA as the most common histologic type, with an incidence of roughly 80%. ACC and AC are next in frequency (approximately 10%). Numerous other tumors complete the list in small numbers.1

Except for nonepithelial neoplasms, malignant nasal tumors are diseases of adults.

Etiology

Many environmental factors have been implicated in the carcinogenesis of certain types of sinonasal malignancies, including exposure to industrial fumes, wood dust, nickel-refining processes, and leather tanning. Exposure to mineral oils, chromium, lacquer paint, soldering, and welding has also been associated with an increased incidence of sinonasal malignant tumors. Although tobacco and alcohol are well known risk factors for head and neck malignancy, no significant association has been shown with sinonasal cancers (with the exception of cigarette smoking for SCCA).

Presentation

The clinical symptoms in most sinonasal tumors lack specificity for a particular tumor type and are often indistinguishable from benign sinonasal diseases. This can lead to a delay in diagnoses of a malignancy. Sinonasal cancer is especially challenging in a patient who has been diagnosed with chronic sinusitis with temporary improvement and recurrent symptoms. Common presenting symptoms include nasal obstruction, unilateral facial, cheek and nasal swelling or pain, diplopia or blurred vision, epistaxis, headache, nasal discharge or repeated infection, unilateral proptosis, and cranial neuropathies. Tumors of the nasal cavity tend to be diagnosed earlier than those of the paranasal sinuses because of the earlier presentation of obstructive symptoms and epistaxis.

Patients who present with unilateral nasal symptoms, prolonged symptoms resistant to routine treatments, and radiologic evidence of bony erosion require a high index of suspicion for sinonasal cancer. Tumor invasion is frequently underestimated based on clinical evaluation. Knowledge of the relevant anatomy of the nasal cavity and surrounding structures can help in the proper evaluation of a patient, and this knowledge is paramount in the surgical treatment of such tumors.

Relevant Anatomy

By examining the close relationship of the nasal cavity to the oral cavity, paranasal sinuses, orbit, nasopharynx, pterygomaxillary fissure and pterygopalatine fossa, infratemporal fossa, skull base, and intracranial fossae, one can understand the myriad signs and symptoms caused by sinonasal tumors.

The paired nasal cavities are separated by the nasal septum. Local tumor invasion can breach the boundaries of the nasal cavity. The lateral wall of each nasal cavity is made up of the medial wall of the maxillary sinus and the inferior, middle, and superior turbinates. Lateral extension of tumor can infiltrate the maxillary sinus, ethmoid air cells, or even the orbit (through the lamina papyracea). Orbital involvement can present as ocular pain, fullness of the eyelid, unilateral epiphora, diplopia, exophthalmos, or proptosis. The floor of the nasal cavity is the hard palate of the oral cavity; inferior extension of nasal cavity tumors can present as palatal fullness and pain.

The roof of the nasal cavities is formed by the cribriform plate, which shields the dura in the anterior cranial fossa from the nasal cavity. This is a potential area of intracranial tumor spread, and violation of this barrier during surgery can cause a cerebrospinal fluid (CSF) leak and an increased risk for meningitis and intracranial abscess. The nasal cavities open externally via the nares and communicate posteriorly with the nasopharynx via the choanae. The eustachian tubes open into the nasopharynx at the level of the choanae. Tumor extension into the nasopharynx may cause eustachian tube obstruction and secondary serous otitis media that presents as hearing loss.

Except in the nasal vestibule, the nasal cavity is lined with pseudostratified columnar ciliated epithelium. The nasal vestibule, which corresponds to the ala of the nose, is lined with squamous epithelium and contains vibrissae and sweat and sebaceous glands. A small part of the superior portion of the nasal cavity (bound by the superior nasal concha laterally) is lined by olfactory epithelium.

The pterygopalatine and infratemporal fossae are important considerations, as they contain various sensory and motor nerves and blood vessels that supply the nasal cavity, oral cavity, maxillary teeth, and pharynx. Tumor extension into these areas can cause myriad symptoms, such as the following:

  • Trismus (involvement of the pterygoid muscles or motor branches of the mandibular division of the trigeminal nerve)
  • Facial hypesthesia (involvement of the infraorbital nerve or other sensory branches from the maxillary and mandibular divisions of the trigeminal nerve)
  • Pain in the maxillary dentition (involvement of the anterior, middle, or posterior superior alveolar nerve branches of the maxillary division of the trigeminal nerve)
  • Uncontrollable epistaxis (involvement of the sphenopalatine artery)

The pterygopalatine and infratemporal fossae are also potential routes for intracranial tumor spread, via direct extension or hematogenous spread.

Contraindications

Contraindications to surgery include the following:

  • Lymphoma, unless the tumor mass spreads to critical structures, which can cause significant loss of function or, potentially, death
  • Extensive intracranial involvement
  • Significant comorbid disease that poses a high perioperative risk

More on Malignant Tumors of the Nasal Cavity

Overview: Malignant Tumors of the Nasal Cavity
Workup: Malignant Tumors of the Nasal Cavity
Treatment: Malignant Tumors of the Nasal Cavity
Follow-up: Malignant Tumors of the Nasal Cavity
References
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Further Reading

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Keywords

malignant tumors of the nasal cavity, epithelial tumors, squamous cell carcinoma, SCCA, glandular tumor, adenocarcinoma, AC, adenoid cystic carcinoma, ACC, undifferentiated carcinoma, soft-tissue tumors, malignant lymphoma, chondrosarcoma, osteosarcoma, hemangiopericytoma, metastatic carcinoma (kidney, lung, breast), miscellaneous tumors, malignant melanoma, esthesioneuroblastoma

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Contributor Information and Disclosures

Author

Weiru Shao, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine
Weiru Shao, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Adarsh Vasanth, MD, Resident Physician, Department of Otolaryngology, New England Medical Center
Adarsh Vasanth, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

William M Lydiatt, MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center
William M Lydiatt, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Head and Neck Society, and Nebraska Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Department of Surgery, Division of Otolaryngology, George Washington University
Nader Sadeghi, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Federation of Medical Specialists in Quebec, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: UST Grant/research funds Consulting

 
 
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