Malignant Tumors of the Sinuses Treatment & Management
- Author: Christopher Klem, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
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 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 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.
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 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 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.
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. 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 SCC, 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.
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.
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.
Flap reconstruction, instead of wearing a prosthesis during recovery, is an option for patients undergoing reconstruction for maxillectomy defects; however, it is associated with a longer recovery time, higher procedure costs, and increased risk of surgical complications. Additionally, the patient must be under the care of a highly experienced surgeon. The surgeon and reconstructive team should make individualized decisions after considering the extent of the maxillectomy defect and the need for radiation therapy.
Outcome and Prognosis
Survival rates for patients with maxillary sinus cancer average about 40% over 5 years. Early-stage tumors have a cure rate of up to 80%. Patients with unresectable tumors treated with radiation have a survival rate of less than 20%. Survival rates for ethmoid tumors have improved slightly because of advances in skull-base surgery.
Future and Controversies
Although intra-arterial chemotherapy was used in the past, it was only recently shown to be consistently effective. With the advent of thiosulfate, a neutralizer of cisplatin, physicians can now deliver large doses of intra-arterial chemotherapy more safely than before. High-dose cisplatin is administered by means of the arterial blood supply of the tumor. A simultaneous infusion of thiosulfate prevents the systemic effects of cisplatin.
Intra-arterial chemotherapy is used with radiation and had promising results in preserving organs and in managing bulky nodal disease.
Given the anatomy of the paranasal sinuses and their blood supply, intra-arterial chemotherapy may be an effective method of treating sinus malignancies.
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