Neoplasms of the Nose and Paranasal Sinuses

Malignant tumors of the sinonasal tract constitute about 3% of tumors arising in the
upper respiratory tract, and the incidence in males is twice the incidence in females.
Exposure to industrial fumes, wood dust, nickel-refining processes, and leather
tanning have been implicated in the carcinogenesis of certain types of sinonasal
malignant tumors. ther industrial exposures associated with an increased incidence
of sinonasal cancer include mineral oils, chromium and chromium compounds,
isopropyl oils, lac!uer paint, soldering and welding, and radium dial painting. " recent
report demonstrates a higher incidence of nasal cancers in cigarette smokers.
#!uamous cell carcinoma is the most common tumor of the sinonasal tract. $t is most
commonly reported in white men in their fifth to sixth decade. %he prognosis is
related to the extent of the tumor and the site of origin. "denocarcinomas make up
&% to '% of all sinonasal tumors. %hey originate most commonly in the ethmoid
sinuses and nasal cavity and are associated with exposure to hardwood dust.
"denoid cystic carcinomas ("))s* of the sinonasal tract compose +&% to ,-% of all
the adenoid cystic carcinomas arising in the head and neck. %hey are characteri.ed
by early spread to neurovascular structures, submucosal spread, and advanced
stage at the time of diagnosis. "lthough ,-% of all melanomas originate in the head
and neck, less than +% arise from the sinonasal tract. %hey are most commonly
found in the nasal cavity, followed by the maxillary sinus, ethmoid sinus, and frontal
sinus, in descending order.
/ibroosseous lesions, including osteomas, fibromas, and chordomas, are the most
common benign tumors of the sinonasal tract.
%umors of the sinonasal tract commonly appear with symptoms identical to those
caused by inflammatory sinus disease, such as nasal airway obstruction, epistaxis,
headache, facial pain, and nasal discharge, and are fre!uently asymptomatic in 0%
to +,% of patients, contributing to a delay in the diagnosis and advanced stage of
disease. 1egional and distant metastases are infre!uent despite the advanced stage
of the primary tumor. %he incidence of cervical metastases on initial presentation
varies from+% to ,2%, with most large series reporting less than +-%. $n only +3% of
patients with malignancies of the paranasal sinuses do cervical metastases develop
after treatment of the primary site. %he presence of distant metastasis on initial
presentation is even less common.
%he physical examination should be thorough, with emphasis on the sinonasal
region, orbit, and cranial nerves. "lthough not pathonogmonic, numbness or
hypesthesia of the infraorbital nerve strongly suggests malignant invasion. ther
findings such as proptosis4 chemosis4 extraocular muscle impairment4 mass effect in
the cheek, gingiva or gingivobuccal sulcus (e.g., ill-fitting dentures*4 and loose
dentition also suggest the presence of a sinonasal tumor. 1adiologic imaging is
essential for staging. 5lain films may demonstrate bone destruction4 however, a
significant number will be interpreted as normal. %he computed tomography ()%*
scan is more accurate. M1$ differentiates ad6acent tumor from soft tissue,
differentiates secretions in an obstructed sinus from a space-occupying lesion,
demonstrates perineural spread, has less artifact effect with dental fillings, and does
not involve exposure to ioni.ing radiation. M1$, however, is more expensive than )%
scan, more prone to motion artifact, and less tolerated because of claustrophobia.
" )% scan of the chest and abdomen is recommended for patients with tumors that
metastasi.e hematogenously, such as sarcoma, melanoma, and adenoid cystic
carcinoma. Metastatic evaluation is important if an extensive resection is considered.
%issue sampling may be performed by using endoscopic sinus surgery instruments
or through open transcutaneous or transoral procedures.
"n understanding of the variable natural history of tumors of the sinonasal tract is
crucial to patient counseling and treatment planning. " wide variety of histologies
may be encountered, although s!uamous cell carcinoma is most common. #urgical
resection is usually recommended with curative intent. 5alliative excision may be
considered to alleviate intractable pain, to provide rapid decompression of vital
structures, or to debulk a massive lesion, thus freeing the patient from social
embarrassment. #urgery as a single treatment modality for malignant tumors of the
sinonasal tract has yielded 3-year survival rates from +0% to '2%.. 1ehabilitation
after surgical resection may be achieved with a dental prosthesis or reconstructive
flaps. 1adiation may be used as a single modality, as an ad6unct to surgery, or as
palliative therapy. . %he response of sinonasal tract tumors to radiation therapy varies
with the stage and histology of the tumor. 5atients with tumor involvement of the skull
base, either in the infratemporal fossa or at the fovea ethmoidalis and cribriform
plate, should be considered for craniofacial resection. )omplications, such as )#/
leak, meningitis, intracranial abscess, and tension pneumocephalus, although
uncom-mon, are potentially devastating and must be addressed.
%7M1# / %8E #$99"#": %1")%
Epithelial
Benign
Exophytic papilloma
$nverted papilloma
)olumnar papilloma
"denoma
Malignant
#!uamous cell carcinoma
%ransitional cell carcinoma
"denocarcinoma
"denoid cystic carcinoma
Melanoma
lfactory neuroblastoma
7ndifferentiated carcinoma
Nonepithelial
Benign
/ibroma
)hondroma
steoma
9eurilemmoma
9eurofibroma
8emangioma
Malignant
#oft-tissue sarcoma
1habdomyosarcoma
:eiomyosarcoma
/ibrosarcoma
:iposarcoma
"ngiosarcoma
Myxosarcoma
8emangiopericytoma
)onnective tissue sarcoma
)hondrosarcoma
steosarcoma
Lymphoreticular
tumors

:ymphoma
5lasmacytoma
;iant cell tumor
Metastatic carcinoma
M"<$::"1= #$97# %9M #%";$9; /1 51$M"1= %7M1 (%*
%< 5rimary tumor cannot be assessed
%- 9o evidence of primary tumor
%is )arcinoma in situ
%+ %umor limited to maxillary sinus mucosa with no erosion or destruction of bone
%, %umor causing bone erosion or destruction including extension into the hard
palate and>or middle nasal meatus, except extension to posterior wall of maxillary
sinus and pterygoid plates
%3 %umor invades any of the following? bone of the posterior wall of the maxillary
sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa,
ethmoid sinuses
%&a %umor invades anterior orbital contents, skin of cheek, pterygoid plates,
infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
%&b %umor invades any of the following? orbital apex, dura, brain, middle cranial
fossa, cranial nerves other than maxillary division of trigeminal nerve (@
,
*,
nasopharynx, or clivus