Malignant Tumors of the Sinuses Workup
- Author: Christopher Klem, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
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.
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.  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.  Esthesioneuroblastoma (ENB) on MRI often shows peritumoral cysts capping of the intracranial portion of the tumor, which is strongly suggestive of the diagnosis. 
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.  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.
Positron emission tomography is still in its infancy, and little has been studied regarding its use in sinonasal malignancies (SNM).
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.
The important histologic features are discussed in detail for the individual neoplasms in the Clinical section.
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.
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 
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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