Sino-nasal cancers are diverse group of cancers that involve nose and paranasal sinuses. These are rare with overall incidence of less than three percent among all the head and neck malignancies. The most common cause is exposure to wood dust followed by industrial fume, nickel-refining, leather tanning, chrome paints and snuffs (tobacco) usage. Recent studies have shown that outdoor air pollution can lead to sinonasal malignancies. Human papilloma virus (HPV) can lead to cancerous change of non-cancerous sinonasal tumors. The most common age group affected is sixth decade and these cancers are more common in males.
There are many types of sinonasal malignancies of which squamous cell carcinoma is the most common followed by adenocarcinoma. Rhabdomyosarcoma is the most common sinonasal cancer among children. Other rare types include adenoid cystic, sinonasal undifferentiated type, fibrosarcoma, hemangiopericytoma, extra-nodal lymphoma, Ewing’s sarcoma, etc.
The symptoms of these cancers are similar to those of common benign (non-cancerous) disorders like sinusitis leading to delay in diagnosis patients presenting at advanced stage of cancer. Usually patients present to us when the lesion has grown and extending to nearby structures like eye, brain, etc and causing complications leading to poor prognosis. The most common presentation is nasal block followed by pain over the cheek, bleeding from nose, swelling of cheek, growth over palate, double vision, cheek numbness, loose tooth, ill-fitting dentures and neck mass in decreased order of frequency.
The patient undergoes clinical examination of nose, mouth, eyes and neck along with nasal endoscopy. Contrast enhanced CT scan or MRI scan is essential to understand the location, extent of lesion along with involvement of nearby critical areas. Biopsy from the growth can tell us regarding the type of cancer. The treatment algorithm depends on the stage of the cancer and the prognostic factors like site and type of cancer.
The main modality of treatment in sinonasal carcinoma is surgery in early stage cancers. Advanced stage cancers need multimodality treatment with surgery followed by radiation alone or along with chemotherapy. Metastatic lesions warrant palliative therapy. Surgical therapy requires en-bloc resection of primary site along with management of eye and neck if involved.
Surgical approach and extent of resection depends on the site of the lesion and whether it involves the nearby critical structures. Surgery can be performed either by classic open approach or the novel endoscopic technique. With the advent of endoscopes, powered instruments and intra-operative navigation systems sinonasal cancers are currently treated by minimally invasive endoscopic techniques. Decision on using endoscope depends on type of cancer, location and extent of cancer. Open approaches require large incision on the face, extensive tissue dissection and unsightly scar. Endoscopic technique confers better visualization of critical structures, less complication rates, better cosmesis, early recovery and improved patient quality of life. However endoscopic techniques cannot be performed in case of involvement of eye, brain, major blood vessels and skin. Endoscopic approach should be practiced in centers with extensive experience with this technique.
The other important aspect in treating sinonasal malignancy is the reconstruction and rehabilitation. The reconstruction option depends on the extent of resection performed along with patient preference and cost factor. There is wide range of reconstructive options available like obturators, dentures or osseo-integrated implants, eye implants and prostheses, fasciocutaneous, pedicled or free flaps. Multimodal treatment along with well-supported rehabilitative management is warranted in cases of sinonasal cancers.
The five-year survival rates of these patients range from 90% in early stage to 45% among late stage patients. Clinician should have high index of suspicion when a patient presents with refractory nasal complaints. This can lead to early diagnosis and thereby improving the prognosis of these patients.