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Malignant Tumors of the Sinuses Workup

  • Author: Christopher Klem, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Mar 31, 2015
 

Laboratory Studies

As with other head and neck cancers, liver enzymes are usually obtained to assess for distant disease in addition to a chest radiograph or CT scan to evaluate for pulmonary metastasis.

In the case of a nasal cavity or paranasal sinus mass or erosion, an antineutrophil cytoplasmic antibody (ANCA) test for possible Wegener granulomatosis should be considered. This condition often mimics a neoplasm.

Consultation with multiple specialties should be considered because these tumors involve complex structures throughout the face and skull base. Consult neurosurgery as needed for skull base involvement and possible intracranial extension. Consult ophthalmology to document visual acuity, evaluation of any extra ocular motility disturbances, and proptosis. In addition, after surgery the ophthalmologist may be called upon to assist with treatment of epiphora or dry eye syndrome. Consult a dentist to evaluate for dental extraction in preparation for radiotherapy. Consult a prosthodontist if maxillectomy is expected, and consult speech pathology as needed.

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Imaging Studies

Imaging studies depend on the differential diagnosis. Plain radiography, CT scanning, and MRI all provide information. Each has its own advantages and limitations. With the ubiquitous nature of the acute and chronic inflammation disease in the sinonasal cavity and the complex anatomy of the sinonasal tract, these tumors are often difficult to diagnose and treat.

  • Magnetic resonance imaging (MRI) is vital in the establishing the presence or absence of factors that determine resectability such as orbital invasion, perineural spread, skull base invasion, intracranial extension, and invasion of the masticator and parapharyngeal spaces by tumor. [66] One of MRI’s greatest uses is in helping to demonstrate the distinction tumor and retaining secretions in the multiple sinus cavities.
  • Special emphasis should be placed on MRI evaluation of perineural invasion in adenoid cystic carcinoma because these can track down the nerve in over 60% of cases. [67] Esthesioneuroblastoma (ENB) on MRI often shows peritumoral cysts capping of the intracranial portion of the tumor, which is strongly suggestive of the diagnosis. [68]
  • CT scan has a higher accuracy at determining both bony remodeling and erosion of the skull base and sinuses. Osteolysis can often be observed with SCC, metastatic disease, sarcoma, and SNUC. Boney remodeling is more often seen with salivary gland tumors, large cell lymphoma, melanoma, and ENB. In addition, chronic or acute inflammatory sinus disease may also cause boney remodeling. [66] Finally, CT scanning is slightly more accurate than MRI in demonstration of orbital invasion due to its ability to evaluate both the bony orbital wall and adjacent fat.

The authors’ opinion is that both CT scanning and MRI should be performed prior to surgical intervention to help assist in preliminary staging, surgical planning, and defining respectability in close consultation with the neuroradiologist. In addition, as most landmarks and normal anatomy after surgery are disrupted, recurrence is difficult to identify on imaging. Therefore, postoperative baseline imaging is recommended for comparison tumor surveillance. Apparent Diffusion Coefficient (ADC) mapping shows potential as an additional MRI tool to effectively differentiate benign/inflammatory lesions from malignant tumors in the sinonasal area.[69]

Positron emission tomography is still in its infancy, and little has been studied regarding its use in sinonasal malignancies (SNM).[70]

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Diagnostic Procedures

See the list below:

  • Biopsy is the only 100% accurate means of obtaining a tissue diagnosis.
  • Remember that the turbinates and the possibility of a juvenile angiofibroma may both lead to extensive bleeding. In addition, patients with midline nasal masses may include intranasal dermoids, gliomas, and meningoencephalocele with direct communication with the anterior cranial fossa. Should the surgeon suspect these neoplasms, proper imaging and other tests should be performed before biopsy.
  • A biopsy should be performed on highly suspicious vascular tumors in the OR under controlled conditions where bleeding can be more safely controlled.
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Histologic Findings

The important histologic features are discussed in detail for the individual neoplasms in the Clinical section.

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Staging

Staging of nasal cavity and paranasal sinus carcinomas is not as well established as for other head and neck tumors. Two generally accepted staging systems are currently in use. The Kadish staging system is used specifically for Esthesioneuroblastoma because this often involves the skull base and intracranial extension. For cancer of the maxillary sinus, the nasal cavity, and the ethmoid sinus, the American Joint Committee on Cancer (AJCC) has designated staging by TNM classification. No broadly accepted staging systems for frontal and sphenoid sinus cancer currently exist.[71]

Maxillary sinus

Primary tumor (T)

  • T1 - Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone
  • T2 - Tumor causing bone erosion or destruction including extension into the hard palate and/or the middle of the nasal meatus, except extension to the posterior wall of maxillary sinus and pterygoid plates
  • T3 - Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses
  • T4a - Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
  • T4b - Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus

Nasal cavity and ethmoid sinus

Primary tumor (T)

  • T1 - Tumor restricted to any one subsite, with or without bony invasion
  • T2 - Tumor invading 2 subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion
  • T3 - Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate
  • T4a - Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses
  • T4b - Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than (V2), nasopharynx, or clivus

Regional lymph nodes (N)

See the list below:

  • N1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
  • N2 - Metastasis in a single ipsilateral lymph node, more than 3 cm but 6 cm or less in greatest dimension; or in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension; or in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension
  • N2a - Metastasis in a single ipsilateral lymph node more than 3 cm but 6 cm or less in greatest dimension
  • N2b - Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension
  • N2c - Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension
  • N3 - Metastasis in a lymph node more than 6 cm in greatest dimension

Kadish Staging for esthesioneuroblastoma [72]

  • Stage A: The tumor is limited to the nasal fossa.
  • Stage B: The tumor extends to the paranasal sinuses.
  • Stage C: The tumor extends beyond the paranasal sinuses.
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Contributor Information and Disclosures
Author

Christopher Klem, MD Attending Surgeon, Chief, Head and Neck Oncologic Surgery, Microvascular Reconstructive Surgery, Assistant Chief, Otolaryngology–Head and Neck Surgery Service, 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, 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, Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

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, Nebraska Medical Association

Disclosure: Nothing to disclose.

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