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

Malignant Tumors of the Sinuses: Treatment

Author: Christopher Klem, MD, Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center
Coauthor(s): Jared M Theler, MD, Resident Physician in Otolaryngology-Head and Neck Surgery, Department of Surgery, Tripler Army Medical Center
Contributor Information and Disclosures

Updated: Mar 3, 2009

Treatment

As with other types of cancers, a multimodality approach in consultation with a tumor board is recommended, including head and neck surgeon and a neurosurgeon when indicated and a neuroradiologist, pathologist, radiation oncologist, and medical oncologist as active members. Although multiple surgical and adjuvant approaches are available, a balance should be found in attempting to preserve cosmetic, oral, and nasal function. When possible, the orbit should be preserved and reconstructed. Despite these seemingly competing needs, first and foremost should be the goal of a safe and complete eradication of disease, when possible.

Although the detailed operative approaches for theses tumors are beyond the scope of this text, the authors have outlined the different options below.

A surgical review of techniques is as follows:

1 – Medial maxillectomy endoscopic
2 – Lateral rhinotomy
3 – Anterior maxillary punch
4 – Craniofacial resection
5 – Transfacial with midface degloving
6 – Infratemporal fossa approach

Treatment for recurrence includes surgery, chemotherapy, and/or radiation therapy.

Complications

Complications of treating sinus malignancies are related to the surgery and reconstruction. Surgical complications include clinically significant bleeding, CSF leak, infection, anosmia, dysgeusia, and other cranial nerve damage.

Bleeding

Bleeding may occur if control of the large vessels is overlooked. This problem may occur if the artery is initially in vasospasm and if no active bleeding is noted until after surgery. The anterior and posterior ethmoid and sphenopalatine arteries may be cauterized, clipped, or ligated to prevent or control bleeding. If needed, interventional radiology may be requested to assist with intra-arterial coiling to control bleeding.

CSF leaks

During surgery, CSF leaks may occur near the skull base. Appropriate management starts with identification. Symptoms may include clear rhinorrhea, salty taste in the mouth, halo sign, or reservoir sign. Once noted, identification of the leak can be made endoscopically or with intrathecal injection of fluorecin. Tests, such as a test for tau or beta transferrin, may be most specific but may take days for results to be processed.

Conservative management with bed rest and a lumbar drain can be used for the first 5 days in addition to placement on antibiotics. If resolution has not occurred, surgical intervention should be used, including patching with a dermal allograft, turbinate bone, and nasal mucosa. Mucosal flaps can be elevated and used to close the leaks with interpositioned bone or cartilage. For large leaks, a spinal drain may be necessary to allow grafts and sealing techniques to solidify and integrate.

Epiphora

Epiphora is a common complication of surgery caused by obstruction in the lacrimal outflow tract. This can happen because of damage to the lacrimal puncta, sack, or duct. Care should be taken to marsupialize the lacrimal duct if it is lacerated or damaged in surgery to prevent outflow obstruction. Follow-up endoscopic or open dacryocystorhinostomy may be necessary.

Diplopia

Diplopia is a known complication in any surgery involving the orbital cone. Proper repair of the orbital floor is a key to prevent this complication, but in some cases it is unavoidable even with meticulous reconstruction. In cases of diplopia, prism lenses are usually the simplest method for correction, as surgical correction by ophthalmology can be complicated by prior scarring from surgery and radiation treatment. Ophthalmology consultation is standard of care.

Reconstruction

One of the most difficult decisions made during surgery is when to take or leave the orbit. Suarez (2007) reviewed the literature and had 3 recommendations.66 First, close scrutiny of the periorbita is key when deciding for or against exenteration. Although the lamina papyracea and lacrimal bones can be invaded and destroyed quite quickly, the periorbitum is a much better barrier to invasion. So despite bony destruction, if the periorbita is considered intact, they make the argument for orbital preservation and reconstruction.

Once the periorbital has been violated, orbital exenteration is required because few barriers to spread exist within the orbital contents. Second, take into account the cancer histology. When dealing with more aggressive histology such as adenocarcinoma and SCCA, a lower threshold for choosing exenterations would be expected, as opposed to ENB with less local regional recurrence rates. Third, reconstruction is essential for large defects resulting from total orbital floor resection involving 2 or more orbital walls to prevent displacement and dysfunction of the eye.66

If the eye is preserved, postoperative radiation is usually recommended. Current treatments are precise in XRT delivery and preserving orbital function. Nonetheless, patients should be counseled that despite surgical orbital preservation, impairment can occur from XRT, including optic atrophy, cataracts, dry eye, and ectropion.67

In the ideal cases, reconstruction preserves form and function. A free rectus flap or other distant tissue may be required to protect vital structures, or facial prosthetics may be used. Facial prosthesis can be offered to improve cosmetic results, but meticulous maintenance of the prosthesis by the team and patient is imperative.

Facial disfiguration is one of the most important patient concerns and can lead to considerable social and psychological stress. This outcome must be dealt with initially and on an ongoing basis.

More on Malignant Tumors of the Sinuses

Overview: Malignant Tumors of the Sinuses
Workup: Malignant Tumors of the Sinuses
Treatment: Malignant Tumors of the Sinuses
Follow-up: Malignant Tumors of the Sinuses
References
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References

  1. Robin PE, Powell DJ, Stansbie JM. Carcinoma of the nasal cavity and paranasal sinuses: incidence and presentation of different histological types. Clin Otolaryngol Allied Sci. Dec 1979;4(6):431-56. [Medline].

  2. Bridger GP, Mendelsohn MS, Baldwin M, Smee R. Paranasal sinus cancer. Aust N Z J Surg. Apr 1991;61(4):290-4. [Medline].

  3. Golabek W, Drop A, Golabek E, Morshed K. Site of origin of paranasal sinus malignancies [in Polish]. Pol Merkuriusz Lek. Sep 2005;19(111):413-4. [Medline].

  4. Larsson LG, Martensson G. Carcinoma of the paranasal sinuses and the nasal cavities; a clinical study of 379 cases treated at Radiumhemmet and the Otolaryngologic Department of Karolinska Sjukhuset, 1940-1950. Acta radiol. Aug 1954;42(2):149-72. [Medline].

  5. Bornholdt J, Hansen J, Steiniche T, et al. K-ras mutations in sinonasal cancers in relation to wood dust exposure. BMC Cancer. Feb 20 2008;8:53. [Medline].

  6. Klintenberg C, Olofsson J, Hellquist H, Sokjer H. Adenocarcinoma of the ethmoid sinuses. A review of 28 cases with special reference to wood dust exposure. Cancer. Aug 1 1984;54(3):482-8. [Medline].

  7. Luce D, Gerin M, Leclerc A, Morcet JF, Brugere J, Goldberg M. Sinonasal cancer and occupational exposure to formaldehyde and other substances. Int J Cancer. Jan 21 1993;53(2):224-31. [Medline].

  8. Katori H, Nozawa A, Tsukuda M. Markers of malignant transformation of sinonasal inverted papilloma. Eur J Surg Oncol. Oct 2005;31(8):905-11. [Medline].

  9. McKay SP, Gregoire L, Lonardo F, Reidy P, Mathog RH, Lancaster WD. Human papillomavirus (HPV) transcripts in malignant inverted papilloma are from integrated HPV DNA. Laryngoscope. Aug 2005;115(8):1428-31. [Medline].

  10. Ott G, Kalla J, Ott MM, Muller-Hermelink HK. The Epstein-Barr virus in malignant non-Hodgkin's lymphoma of the upper aerodigestive tract. Diagn Mol Pathol. Jun 1997;6(3):134-9. [Medline].

  11. Katori H, Nozawa A, Tsukuda M. Histopathological parameters of recurrence and malignant transformation in sinonasal inverted papilloma. Acta Otolaryngol. Feb 2006;126(2):214-8. [Medline].

  12. Waitz G, Wigand ME. Results of endoscopic sinus surgery for the treatment of inverted papillomas. Laryngoscope. Aug 1992;102(8):917-22. [Medline].

  13. Krouse JH. Endoscopic treatment of inverted papilloma: safety and efficacy. Am J Otolaryngol. Mar-Apr 2001;22(2):87-99. [Medline].

  14. Busquets JM, Hwang PH. Endoscopic resection of sinonasal inverted papilloma: a meta-analysis. Otolaryngol Head Neck Surg. Mar 2006;134(3):476-82. [Medline].

  15. Poetker DM, Toohill RJ, Loehrl TA, Smith TL. Endoscopic management of sinonasal tumors: a preliminary report. Am J Rhinol. May-Jun 2005;19(3):307-15. [Medline].

  16. Oikawa K, Furuta Y, Nakamaru Y, Oridate N, Fukuda S. Preoperative staging and surgical approaches for sinonasal inverted papilloma. Ann Otol Rhinol Laryngol. Sep 2007;116(9):674-80. [Medline].

  17. Cannady SB, Batra PS, Sautter NB, Roh HJ, Citardi MJ. New staging system for sinonasal inverted papilloma in the endoscopic era. Laryngoscope. Jul 2007;117(7):1283-7. [Medline].

  18. Tiwari R, Hardillo JA, Mehta D, et al. Squamous cell carcinoma of maxillary sinus. Head Neck. Mar 2000;22(2):164-9. [Medline].

  19. Batsakis JG, Rice DH, Solomon AR. The pathology of head and neck tumors: squamous and mucous-gland carcinomas of the nasal cavity, paranasal sinuses, and larynx, part 6. Head Neck Surg. Jul-Aug 1980;2(6):497-508. [Medline].

  20. Lavertu P, Roberts JK, Kraus DH, Levine HL, Wood BG, Medendorp SV. Squamous cell carcinoma of the paranasal sinuses: the Cleveland Clinic experience 1977-1986. Laryngoscope. Nov 1989;99(11):1130-6. [Medline].

  21. Lee CH, Hur DG, Roh HJ, et al. Survival rates of sinonasal squamous cell carcinoma with the new AJCC staging system. Arch Otolaryngol Head Neck Surg. Feb 2007;133(2):131-4. [Medline].

  22. Shipchandler TZ, Batra PS, Citardi MJ, Bolger WE, Lanza DC. Outcomes for endoscopic resection of sinonasal squamous cell carcinoma. Laryngoscope. Nov 2005;115(11):1983-7. [Medline].

  23. Weiss MD, deFries HO, Taxy JB, Braine H. Primary small cell carcinoma of the paranasal sinuses. Arch Otolaryngol. May 1983;109(5):341-3. [Medline].

  24. Huber PE, Debus J, Latz D, Zierhut D, Bischof M, Wannenmacher M. Radiotherapy for advanced adenoid cystic carcinoma: neutrons, photons or mixed beam?. Radiother Oncol. May 2001;59(2):161-7. [Medline].

  25. Douglas JG, Laramore GE, Austin-Seymour M, Koh WJ, Lindsley KL, Cho P. Neutron radiotherapy for adenoid cystic carcinoma of minor salivary glands. Int J Radiat Oncol Biol Phys. Aug 1 1996;36(1):87-93. [Medline].

  26. Laramore GE, Krall JM, Griffin TW, et al. Neutron versus photon irradiation for unresectable salivary gland tumors: final report of an RTOG-MRC randomized clinical trial. Radiation Therapy Oncology Group. Medical Research Council. Int J Radiat Oncol Biol Phys. Sep 30 1993;27(2):235-40. [Medline].

  27. Lupinetti AD, Roberts DB, Williams MD, et al. Sinonasal adenoid cystic carcinoma: the M. D. Anderson Cancer Center experience. Cancer. Dec 15 2007;110(12):2726-31. [Medline].

  28. Alessi DM, Trapp TK, Fu YS, Calcaterra TC. Nonsalivary sinonasal adenocarcinoma. Arch Otolaryngol Head Neck Surg. Sep 1988;114(9):996-9. [Medline].

  29. 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].

  30. Moran CA, Wenig BM, Mullick FG. Primary adenocarcinoma of the nasal cavity and paranasal sinuses. Ear Nose Throat J. Dec 1991;70(12):821-8. [Medline].

  31. Chang AE, Karnell LH, Menck HR. The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. The American College of Surgeons Commission on Cancer and the American Cancer Society. Cancer. Oct 15 1998;83(8):1664-78. [Medline].

  32. Medina JE, Ferlito A, Pellitteri PK, Shaha AR, Khafif A, Devaney KO. Current management of mucosal melanoma of the head and neck. J Surg Oncol. Jun 2003;83(2):116-22. [Medline].

  33. Manolidis S, Donald P. Malignant Mucousal Melanoma of the Head and Neck. Head and Neck. 1997;80(8):1373-1386. [Medline].

  34. Dauer EH, Lewis JE, Rohlinger AL, Weaver AL, Olsen KD. Sinonasal melanoma: a clinicopathologic review of 61 cases. Otolaryngol Head Neck Surg. Mar 2008;138(3):347-52. [Medline].

  35. Billings KR, Wang MB, Sercarz JA, Fu YS. Clinical and pathologic distinction between primary and metastatic mucosal melanoma of the head and neck. Otolaryngol Head Neck Surg. Jun 1995;112(6):700-6. [Medline].

  36. Rosenthal DI, Barker JL Jr, El-Naggar AK, et al. Sinonasal malignancies with neuroendocrine differentiation: patterns of failure according to histologic phenotype. Cancer. Dec 1 2004;101(11):2567-73. [Medline].

  37. Hyams VJ. Tumors of the upper respiratory tract and ear. In: Atlas of Tumor Pathology. 2nd series. Fascicle 25. Washington D.C: Armed Forces Institute of Pathology; 1988:240-248.

  38. Kameya T, Shimosato Y, Adachi I, Abe K, Ebihara S, Ono I. Neuroendocrine carcinoma of the paranasal sinus: a morphological and endocrinological study. Cancer. Jan 15 1980;45(2):330-9. [Medline].

  39. Broich G, Pagliari A, Ottaviani F. Esthesioneuroblastoma: a general review of the cases published since the discovery of the tumour in 1924. Anticancer Res. Jul-Aug 1997;17(4A):2683-706. [Medline].

  40. Dulguerov P, Allal AS, Calcaterra TC. Esthesioneuroblastoma: a meta-analysis and review. Lancet Oncol. Nov 2001;2(11):683-90. [Medline].

  41. 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].

  42. Diaz EM Jr, Johnigan RH 3rd, Pero C, et al. Olfactory neuroblastoma: the 22-year experience at one comprehensive cancer center. Head Neck. Feb 2005;27(2):138-49. [Medline].

  43. Loy AH, Reibel JF, Read PW, et al. Esthesioneuroblastoma: continued follow-up of a single institution's experience. Arch Otolaryngol Head Neck Surg. Feb 2006;132(2):134-8. [Medline].

  44. Levine PA, Gallagher R, Cantrell RW. Esthesioneuroblastoma: reflections of a 21-year experience. Laryngoscope. Oct 1999;109(10):1539-43. [Medline].

  45. Rischin D, Porceddu S, Peters L, Martin J, Corry J, Weih L. Promising results with chemoradiation in patients with sinonasal undifferentiated carcinoma. Head Neck. May 2004;26(5):435-41. [Medline].

  46. Chen A, Daly M, El-Sayed I, et al. Patterns of Failure After Combined-Modality Approaches Incorporating Radiotherapy for Sinonasal Undifferentiated Carcinoma of the Head and Neck. Oncology Bio Phys Inter J. Radiation. 2007;70(2):338-343.

  47. Frierson HF Jr, Mills SE, Fechner RE, Taxy JB, Levine PA. Sinonasal undifferentiated carcinoma. An aggressive neoplasm derived from schneiderian epithelium and distinct from olfactory neuroblastoma. Am J Surg Pathol. Nov 1986;10(11):771-9. [Medline].

  48. Gallo O, Graziani P, Fini-Storchi O. Undifferentiated carcinoma of the nose and paranasal sinuses. An immunohistochemical and clinical study. Ear Nose Throat J. Sep 1993;72(9):588-90, 593-5. [Medline].

  49. Uchida D, Shirato H, Onimaru R, et al. Long-term results of ethmoid squamous cell or undifferentiated carcinoma treated with radiotherapy with or without surgery. Cancer J. Mar-Apr 2005;11(2):152-6. [Medline].

  50. Medina JE, Dichtel W, Luna MA. Verrucous-squamous carcinomas of the oral cavity. A clinicopathologic study of 104 cases. Arch Otolaryngol. Jul 1984;110(7):437-40. [Medline].

  51. Kapadia SB, Barnes L, Deutsch M. Non-Hodgkin's lymphoma of the nose and paranasal sinuses: a study of 17 cases. Head Neck Surg. Jul-Aug 1981;3(6):490-9. [Medline].

  52. Abbondanzo SL, Wenig BM. Non-Hodgkin's lymphoma of the sinonasal tract. A clinicopathologic and immunophenotypic study of 120 cases. Cancer. Mar 15 1995;75(6):1281-91. [Medline].

  53. Petrella T, Delfau-Larue MH, Caillot D, et al. Nasopharyngeal lymphomas: further evidence for a natural killer cell origin. Hum Pathol. Aug 1996;27(8):827-33. [Medline].

  54. Kimura Y, Tanaka S, Furukawa M. Angiosarcoma of the nasal cavity. J Laryngol Otol. Apr 1992;106(4):368-9. [Medline].

  55. Nappi O, Wick MR. Sarcomatoid neoplasms of the respiratory tract. Semin Diagn Pathol. May 1993;10(2):137-47. [Medline].

  56. Aust MR, Olsen KD, Lewis JE, et al. Angiosarcomas of the head and neck: clinical and pathologic characteristics. Ann Otol Rhinol Laryngol. Nov 1997;106(11):943-51. [Medline].

  57. Yamasoba T, Kikuchi S, Sugasawa M, Higo R, Sasaki T. Occult follicular carcinoma metastasizing to the sinonasal tract. ORL J Otorhinolaryngol Relat Spec. Jul-Aug 1994;56(4):239-43. [Medline].

  58. Frigy AF. Metastatic hepatocellular carcinoma of the nasal cavity. Arch Otolaryngol. Sep 1984;110(9):624-7. [Medline].

  59. Cantù G, Bimbi G, Miceli R, et al. Lymph node metastases in malignant tumors of the paranasal sinuses: prognostic value and treatment. Arch Otolaryngol Head Neck Surg. Feb 2008;134(2):170-7. [Medline].

  60. Raghavan P, Phillips CD. Magnetic resonance imaging of sinonasal malignancies. Top Magn Reson Imaging. Aug 2007;18(4):259-67. [Medline].

  61. Yousem DM, Gad K, Tufano RP. Resectability issues with head and neck cancer. AJNR Am J Neuroradiol. Nov-Dec 2006;27(10):2024-36. [Medline].

  62. Schuster JJ, Phillips CD, Levine PA. MRI of olfactory neuroblastoma and appearance after craniofacial resection. AJNR Am J Neuroradiology. 1994;15:1169-1177.

  63. Shojaku H, Fujisaka M, Yasumura S, et al. Positron emission tomography for predicting malignancy of sinonasal inverted papilloma. Clin Nucl Med. Apr 2007;32(4):275-8. [Medline].

  64. Nasal cavity and paranasal sinuses. In: American Joint Committee on Cancer: AJCC Cancer Staging Manual. 6th ed. Springer; 2002:59-67.

  65. Shojaku H, Fujisaka M, Yasumura S, Ishida M, Tsubota M, Nishida H. Positron emission tomography for predicting malignancy of sinonasal inverted papilloma. Clin Nucl Med. Apr 2007;32(4):275-8. [Medline].

  66. Suarez C. Management of the Orbit in Maligant Sinonasal Tumors. Head and Neck. Head and Neck;242-250.

  67. Medina JE, Ferlito A, Pellitteri PK, et al. Current management of mucosal melanoma of the head and neck. J Surg Oncol. Jun 2003;83(2):116-22. [Medline].

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Further Reading

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Keywords

malignant tumors of the sinuses, sinus tumors, malignant sinus tumors, paranasal sinus malignancy, carcinoma of the sinus, sphenoid sinus, ethmoid sinus, ethmoid air cells, frontal sinus, maxillary sinus, sphenoid sinus, nasal cavity cancer, sinus carcinoma, sinus cancer, paranasal sinus cancer, sinus cancer, sinonasal malignancies

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Contributor Information and Disclosures

Author

Christopher Klem, MD, Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center
Christopher Klem, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, and American Society for Reconstructive Microsurgery
Disclosure: Nothing to disclose.

Coauthor(s)

Jared M Theler, MD, Resident Physician in Otolaryngology-Head and Neck Surgery, Department of Surgery, Tripler Army Medical Center
Jared M Theler, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Karen Hall Calhoun, MD, Professor, Department of Otolaryngology-Head and Neck Surgery, The Ohio State University
Karen Hall Calhoun, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association
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: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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