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

Malignant Tumors of the Nasal Cavity: Treatment

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

Treatment

Medical Therapy

Radiation is the primary treatment for lymphoreticular tumors (lymphoma) and sinonasal undifferentiated carcinoma (SNUC) and for patients who are poor surgical candidates, refuse surgical treatment, or have tumors that are deemed inoperable. Chemotherapy is adjunctive because of its cytoreductive effect.

As mentioned above, most sinonasal tract tumors present in an advanced stage and are managed with combined treatment that consists of surgery and preoperative or postoperative radiation therapy, with or without chemotherapy. Preoperative and postoperative radiation therapies are associated with similar survival rates. Preoperative radiation can help to decrease tumor burden in cases in which surgical resection of the initial tumor would result in severe morbidity. Otherwise, postoperative radiation is favored because the volume of tumor cells to kill is smaller, nonradiated tumor margins are better defined intraoperatively, and postoperative wound healing is more predictable.36

The role of chemotherapy in survival, local control, and development of distant metastases in sinonasal tumors is poorly defined because of the paucity of data in the literature. The addition of chemotherapy in the treatment of most sinonasal tumors is usually palliative in that it is used to help debulk a massive lesion and to relieve pain or obstruction. Chemotherapy protocols should be considered for patients at high risk for recurrence (ie, tumors with positive margins, perinerual spread, or extracapsular spread in regional metastasis).

Surgical Therapy

En bloc surgical resection is the primary treatment for most nasal cavity tumors, with the addition of postoperative radiation for tumors that extend into the paranasal sinuses, tumors larger than 2 cm, and tumors associated with positive surgical margins.36 Sisson proposed specific criteria for unresectability: extension of tumor to the frontal lobes (superior extension), invasion of prevertebral fascia (posterior extension), bilateral optic nerve involvement, and cavernous sinus extension (lateral extension).37 The new American Joint Committee on Cancer (AJCC) staging system for nasal cavity neoplasms also identifies criteria for unresectability in T4b tumors.

A discussion of the various surgical approaches is beyond the scope of this article. The type of surgical approach used depends on tumor size and local extension. Tumors confined to the nasal cavity can be accessed via transnasal endoscopic, sublabial, or lateral rhinotomy approaches. More advanced tumors may require partial or total maxillectomy via midfacial degloving, orbital exenteration, or anterior craniofacial resection (in the case of intracranial extension). A combination of some of the aforementioned approaches may be necessary to resect certain tumors adequately. Reconstruction can range from simple closure to the use of grafts (split-thickness skin or fascia), dental obturators, or other prostheses.

Surgical treatment of the neck (neck dissection) is indicated only in the event of clinically evident nodal disease. Surgery may also have a palliative role in some patients to alleviate pain or obstruction.

Follow-up

Routine, long-term follow-up is necessary for proper oncological surveillance. Examination of the treated site can help to identify recurrence or even a new primary tumor. Rigid or flexible endoscopy can help to facilitate this evaluation in a postoperative patient. Abnormal findings or new symptoms that are suspicious for recurrence warrant further radiological evaluation (CT scan, MRI, or both).

Complications

The close proximity of many vital anatomical structures to the nasal cavity is responsible for the possible complications due to local extension of the primary tumor or treatment (surgical resection and radiation therapy). Advancement of disease into the orbits, nasopharynx, skull base, intracranial fossae, pterygomaxillary fissure and pterygopalatine fossa, or infratemporal space can produce various secondary signs and symptoms. Some examples include ocular pain, proptosis, diplopia, hearing loss secondary to serous otitis media, cranial neuropathies, cheek hypesthesia, pain in maxillary dentition, and trismus. Surgical complications include bleeding, cerebrospinal fluid (CSF) leak, infection (skin and soft tissue infections, meningitis, intracranial abscess, osteomyelitis), pneumocephalus, blindness, and facial disfiguration due to extensive resections.

The orbit deserves special attention because of its functional and aesthetic importance. Sacrifice of the nasolacrimal duct during a maxillectomy or subsequent stenosis of the lacrimal sac opening can cause epiphora. This can be prevented with dacryocystorhinostomy during resection or cannulation of the lacrimal canaliculi in cases of recurrent stenosis or when the lacrimal sac is resected. Limitation of extraocular muscle movement can be caused by surgical trauma of the muscle or its motor innervation or by entrapment in the craniofacial osteotomies. Entrapment should be managed with urgent surgical release. the optic nerve can compress during mobilization of the specimen. High-dose steroids and emergent surgical decompression are recommended. Enophthalmos or hypophthalmos due to loss of orbital support can be prevented or minimized with appropriate reconstructive techniques.

Radiation therapy causes orbital complications in most patients. Shields and lateral fields can spare the anterior orbital segment (eyelids, conjunctiva, lacrimal gland and apparatus, cornea, lens, the rest of the anterior chamber); however, delayed vision loss can still develop in 3-5 years secondary to postradiation retinopathy or optic neuropathy. The incidence of these complications appears to be dose-related: rare below 3500 cGy, 50% to 65% with 6000 cGy to 7000 cGy, > 85% with 8000 cGy.36

Although the retina and optic nerve are radioresistant, the microvasculature is not. Chemotherapy or medical conditions such as diabetes or atherosclerosis can potentiate this effect. Complications of the anterior globe occur with full-eye irradiation. Dryness of the eye leads to severe keratitis, panophthalmitis, and blindness within one year. Enucleation is recommended for uncontrolled panophthalmitis or a painful eye. Bilateral blindness is rare (up to 8%) and is related to the irradiation of the contralateral posterior segment.36 Conformal radiation therapy reduces the percentage of radiation received by normal tissues and can decrease the incidence of optic nerve and optic chiasm complications. Osteoradionecrosis is also possible and can be managed with antibiotics, selective debridement, and hyperbaric oxygen therapy.

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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References

  1. Cody DT, Lawrence WD. Neoplasms of the nasal cavity. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head and Neck Surgery. Mosby;1999.

  2. Chow JM, Leonetti JP, Mafee MF. Epithelial tumors of the paranasal sinuses and nasal cavity. Radiol Clin North Am. Jan 1993;31(1):61-73. [Medline].

  3. Kim GE, Park HC, Keum KC, Lee CG, Suh CO, Hur WJ. Adenoid cystic carcinoma of the maxillary antrum. Am J Otolaryngol. Mar-Apr 1999;20(2):77-84. [Medline].

  4. Konno A, Ishikawa K, Numata T, Nagata H, Terada N, Okamoto Y. Analysis of factors affecting long-term treatment results of adenoid cystic carcinoma of the nose and paranasal sinuses. Acta Otolaryngol Suppl. 1998;537:67-74. [Medline].

  5. Pommier P, Liebsch NJ, Deschler DG, Lin DT, McIntyre JF, Barker FG 2nd. Proton beam radiation therapy for skull base adenoid cystic carcinoma. Arch Otolaryngol Head Neck Surg. Nov 2006;132(11):1242-9. [Medline].

  6. Shah UK, Hybels RL, Dugan J. Endoscopic management of low-grade papillary adenocarcinoma of the ethmoid sinus: case report and review of the literature. Am J Otolaryngol. May-Jun 1999;20(3):190-4. [Medline].

  7. Barnes L. Intestinal-type adenocarcinoma of the nasal cavity and paranasal sinuses. Am J Surg Pathol. Mar 1986;10(3):192-202. [Medline].

  8. Heffner DK, Hyams VJ, Hauck KW, Lingeman C. Low-grade adenocarcinoma of the nasal cavity and paranasal sinuses. Cancer. Jul 15 1982;50(2):312-22. [Medline].

  9. Vidal RW, Devaney K, Ferlito A, Rinaldo A, Carbone A. Sinonasal malignant lymphomas: a distinct clinicopathological category. Ann Otol Rhinol Laryngol. Apr 1999;108(4):411-9. [Medline].

  10. van de Rijn M, Bhargava V, Molina-Kirsch H, Carlos-Bregni R, Warnke RA, Cleary ML. Extranodal head and neck lymphomas in Guatemala: high frequency of Epstein-Barr virus-associated sinonasal lymphomas. Hum Pathol. Jul 1997;28(7):834-9. [Medline].

  11. Petrella T, Delfau-Larue MH, Caillot D, Morcillo JL, Casasnovas O, Portier H. Nasopharyngeal lymphomas: further evidence for a natural killer cell origin. Hum Pathol. Aug 1996;27(8):827-33. [Medline].

  12. Lund VJ, Howard DJ, Harding L, Wei WI. Management options and survival in malignant melanoma of the sinonasal mucosa. Laryngoscope. Feb 1999;109(2 Pt 1):208-11. [Medline].

  13. Batsakis JG, Regezi JA, Solomon AR, Rice DH. The pathology of head and neck tumors: mucosal melanomas, part 13. Head Neck Surg. May-Jun 1982;4(5):404-18. [Medline].

  14. Batsakis JG, Suarez P, El-Naggar AK. Mucosal melanomas of the head and neck. Ann Otol Rhinol Laryngol. Jul 1998;107(7):626-30. [Medline].

  15. Blotta P, Carinci F, Pelucchi S, Cavazzini L, Martini A. Chondrosarcoma of the nasal septum. Ann Otol Rhinol Laryngol. Feb 2001;110(2):202-4. [Medline].

  16. Downey TJ, Clark SK, Moore DW. Chondrosarcoma of the nasal septum. Otolaryngol Head Neck Surg. Jul 2001;125(1):98-100. [Medline].

  17. Chidambaram A, Sanville P. Mesenchymal chondrosarcoma of the maxilla. J Laryngol Otol. Jul 2000;114(7):536-9. [Medline].

  18. Sabini P, Josephson GD, Yung RT, Dolitsky JN. Hemangiopericytoma presenting as a congenital midline nasal mass. Arch Otolaryngol Head Neck Surg. Feb 1998;124(2):202-4. [Medline].

  19. Abdel-Fattah HM, Adams GL, Wick MR. Hemangiopericytoma of the maxillary sinus and skull base. Head Neck. Jan-Feb 1990;12(1):77-83. [Medline].

  20. Marianowski R, Wassef M, Herman P, Huy PT. Nasal haemangiopericytoma: report of two cases with literature review. J Laryngol Otol. Mar 1999;113(3):199-206. [Medline].

  21. McElroy EA Jr, Buckner JC, Lewis JE. Chemotherapy for advanced esthesioneuroblastoma: the Mayo Clinic experience. Neurosurgery. May 1998;42(5):1023-7; discussion 1027-8. [Medline].

  22. Diaz EM, Johnigan RH, Pero C, El-Naggar AK. Olfactory neuroblastoma: the 22-year experience at one comprehensive cancer center. Head Neck. Feb 2005;27(2):138-49. [Medline].

  23. Gorelick J, Ross D, Marentette L, Blavias M. Sinonasal undifferentiated carcinoma: case series and review of the literature. Neurosurgery. Sep 2000;47(3):750-4; discussion 754-5. [Medline].

  24. Buchwald C, Franzmann MB, Tos M. Sinonasal papillomas: a report of 82 cases in Copenhagen County, including a longitudinal epidemiological and clinical study. Laryngoscope. Jan 1995;105(1):72-9. [Medline].

  25. Lawson W, Ho BT, Shaari CM, Biller HF. Inverted papilloma: a report of 112 cases. Laryngoscope. Mar 1995;105(3 Pt 1):282-8. [Medline].

  26. Mansell NJ, Bates GJ. The inverted Schneiderian papilloma: a review and literature report of 43 new cases. Rhinology. Sep 2000;38(3):97-101. [Medline].

  27. Michaels L, Hyams VJ. Objectivity in the classification of tumours of the nasal epithelium. Postgrad Med J. Oct 1975;51(600):695-707. [Medline].

  28. Schlosser RJ, Mason JC, Gross CW. Aggressive endoscopic resection of inverted papilloma: an update. Otolaryngol Head Neck Surg. Jul 2001;125(1):49-53. [Medline].

  29. Vrabec DP. The inverted Schneiderian papilloma: a 25-year study. Laryngoscope. May 1994;104(5 Pt 1):582-605. [Medline].

  30. Weber RS, Shillitoe EJ, Robbins KT, Luna MA, Batsakis JG, Donovan DT. Prevalence of human papillomavirus in inverted nasal papillomas. Arch Otolaryngol Head Neck Surg. Jan 1988;114(1):23-6. [Medline].

  31. Syrjänen S, Happonen RP, Virolainen E, Siivonen L, Syrjänen K. Detection of human papillomavirus (HPV) structural antigens and DNA types in inverted papillomas and squamous cell carcinomas of the nasal cavities and paranasal sinuses. Acta Otolaryngol. Sep-Oct 1987;104(3-4):334-41. [Medline].

  32. Brandwein M, Steinberg B, Thung S, Biller H, Dilorenzo T, Galli R. Human papillomavirus 6/11 and 16/18 in Schneiderian inverted papillomas. In situ hybridization with human papillomavirus RNA probes. Cancer. May 1 1989;63(9):1708-13. [Medline].

  33. Furuta Y, Shinohara T, Sano K, Nagashima K, Inoue K, Tanaka K. Molecular pathologic study of human papillomavirus infection in inverted papilloma and squamous cell carcinoma of the nasal cavities and paranasal sinuses. Laryngoscope. Jan 1991;101(1 Pt 1):79-85. [Medline].

  34. Beck JC, McClatchey KD, Lesperance MM, Esclamado RM, Carey TE, Bradford CR. Human papillomavirus types important in progression of inverted papilloma. Otolaryngol Head Neck Surg. Nov 1995;113(5):558-63. [Medline].

  35. McCulloch TM, Smith R. Extra-axial tumors involving the anterior and middle cranial fossa. In: Cummings CW, et al, eds. Otolaryngology-Head and Neck Surgery. Mosby; 2005.

  36. Carrau RL, Myers EN. Neoplasms of the nose and paranasal sinuses. In: Bailey BJ, et al, eds. Head & Neck Surgery - Otolaryngology, Lippincott, Williams & Wilkins;. 3rd edition. 2001.

  37. Sisson GA, Toriumi DM, Atiyah RA. Paranasal sinus malignancy: a comprehensive update. Laryngoscope. Feb 1989;99(2):143-50. [Medline].

  38. Billroth T. Ueber dem Bau der Schleimpolyp. Berlin:. 1855.

  39. Imola MJ, Schramm VL. Orbital preservation in surgical management of sinonasal malignancy. Laryngoscope. Aug 2002;112(8 Pt 1):1357-65. [Medline].

  40. Pedersen E, Hogetveit AC, Andersen A. Cancer of respiratory organs among workers at a nickel refinery in Norway. Int J Cancer. Jul 15 1973;12(1):32-41. [Medline].

  41. Taxy JB. Squamous carcinoma of the nasal vestibule: an analysis of five cases and literature review. Am J Clin Pathol. Jun 1997;107(6):698-703. [Medline].

  42. Wright ST, Pou A. Neoplasms of the nose and paranasal sinuses. Dr. Quinn's Online Textbook of Otolaryngology (Grand Rounds archive), UTMB Dept. of Otolaryngology. May 2004. http://www.utmb.edu/otoref/Grnds/Nose-sinus-CA-040519/Nose-sinus-CA-040519.pdf.

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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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