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Nasal cavity and paranasal sinus cancer

Nasal Cavity and Paranasal Sinus Cancer body diagram

The paranasal sinuses comprise of the frontal, ethmoidal, sphenoid and maxillary sinuses.

Facts and figures

Cancer of the nasal cavity and sinuses are very rare, only around 440 new cases are diagnosed each year in the UK, 40-50% arise in the nasal cavity, 30-40% arise in the maxillary sinuses and 10-15% arise in the ethmoid sinuses, tumours in the frontal or sphenoid sinuses are extremely rare. Much higher incidence in men. Age related, 80% of cases occurring in those aged 55+years.

Risk factors include smoking and exposure to HPV. Occupational exposure to wood dust, leather dust, formaldehyde, cloth fibres, chromium, nickel and mineral oils are also thought to increase the risk. Mostly squamous cell carcinomas, anaplastic and adenocarcinomas (approximately 60% squamous cell, 17% anaplastic and 10% adenocarcinomas others are a mix of rare tumour types).

Symptoms

Nose related:

  • Persistent blocked nose particularly on one side.
  • Nosebleeds.
  • Decreased sense of smell.
  • Pain/discomfort around the nose.
  • Discharge from the nose or draining into the throat.

Eye related:

    • Swelling around eye/both eyes.
    • Sight impairment/double vision.
    • Pain above or below the eye/both eyes.
    • Eye/both eyes watering.

Others:

    • Headaches.
    • Persistent pain or numbness in parts of the face.
    • Lumps on the face, nose or roof of the mouth.
    • Difficulty opening the mouth/unexplained loose teeth.
    • Ear pain or discomfort.
    • Swelling/lumps in the neck.

Diagnosis

Investigations may include:

  • Physical examination.
  • Blood tests.
  • CT scan.
  • PET-CT scan.
  • MRI scan.
  • Nasoendoscopy.
  • Panendoscopy- tissue samples may be taken for biopsy.
  • Fine needle aspiration (FNA) - a thin needle is used to collect cells from lumps/swellings for analysis.

Treatment

Depends on several factors:

  • The type of tumour
  • The size and position of the tumour
  • The stage of the cancer
  • General health

Surgery

Surgery alone is sometimes the choice of treatment for some of these tumours although some of them respond better to radiotherapy. Therefore, surgery is used as a common treatment and for some very early stage disease it may be possible to treat them with laser surgery. During surgery some neck nodes may be removed and if disease is found in the neck nodes then all of the nodes on one or both sides of the neck may be removed to reduce the risk of recurrence (neck dissection).

In some cases post-operative radiotherapy may be advised to reduce possible recurrence. Surgery for these tumours is complex and can result in significant facial disfigurement particularly if it is quite advanced at diagnosis.

Radiotherapy

Radiotherapy is the main treatment for some of these tumours and is effective in early stage cancers. Due to the complexities of surgery and the high risk of facial disfigurement, some patients are not fit for surgery or may request radiotherapy as an alternative to surgery. Radiotherapy may be given in combination with chemotherapy (chemoradiation), but the side effects can be quite severe, so patients need to be generally in good health to tolerate the treatment.

Radiotherapy can have unpleasant chronic side effects which includes a dry mouth (xerostomia- most common late side effect) due to the potential damage to the salivary glands where saliva is produced. However, trials have proved that in suitable cases where Intensity Modulated Radiotherapy (IMRT) has been used to treat head and neck cancers the incidence of xerostomia is significantly reduced. Image Guided Radiotherapy (IGRT) also enables the radiotherapy to be precisely delivered to the intended area which reduces potential radiation dose to healthy tissues and allows the radiography team to monitor any changes in the patients shape. This is important as head and neck patients often lose weight during treatment which can affect the aligning of the radiotherapy treatment.

In some cases, it may be necessary to make a new headshell and replan the patient’s radiotherapy treatment. It is important to achieve precise alignment for accuracy in delivering radiotherapy, therefore in most cases it is necessary for a ‘headshell’ to be produced. This is achieved by using a specialised thermoplastic material which can be heated in warm water and then is laid over the patient’s face to form an accurately fitting customised shell which can then be used for the planning CT scan and for all the radiotherapy treatments.

It is a painless procedure which is clearly explained by the radiographers prior to the procedure. Radiotherapy can be prescribed to relieve symptoms in advanced nasal cavity and paranasal sinus cancers. It may help to relieve difficulty in swallowing or breathing by shrinking the tumour but also as some nasal cavity and paranasal sinus cancers are close to the brain, they can grow and put pressure on the brain and radiotherapy treatment may be used in this situation to help relieve the pressure.

Chemotherapy

Chemotherapy may be used in combination with radiotherapy for some types of nasal and paranasal sinus tumours. Also, it can be used if the disease has spread to other parts of the body or recurred after surgery or radiotherapy and occasionally it is used to reduce the size of a tumour prior to surgery if there is no spread to other organs.

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