Cancer of the nasal cavity and paranasal sinuses: causes, symptoms, diagnosis, treatment

Cancer of the nasal cavity and paranasal sinuses is more common in men. Among the factors that affect the incidence of cancer in this area, professional factors also play a role. The incidence of cancer of the nasal cavity and paranasal sinuses is especially high among cabinetmakers. Among the latter, the risk of death is 6.6 times higher than that of the rest of the population.

Ethnicity of patients with malignant tumors of this localization is important. For ethnic groups representing the indigenous population of the eastern and south-eastern regions of the country, a high proportion of malignant tumors of the nasal cavity and paranasal sinuses is characteristic.

[1], [2]

Symptoms of cancer of the nasal cavity and paranasal sinuses

In the early stages of the disease is asymptomatic. Therefore, for example, the cancer of the maxillary sinus of stages I-II is a finding when performing a maxillary sinus after the alleged polyposis of this sinus or chronic sinusitis. The first signs of the initial stages of cancer of the nasal cavity are difficulty in breathing through the corresponding half of the nose and spotting. In addition, with anterior rhinoscopy, it is not difficult to detect a tumor localized in the corresponding half of the nose.

In cancer cells of the latticed maze, the first symptoms are a feeling of heaviness in the corresponding zone and a purulent-serous discharge from the nasal cavity. As the process spreads, deformation of the facial skeleton is noted. Thus, with cancer of the maxillary sinus appears swelling in the area of its anterior wall, and with cancer from cells of the latticed labyrinth at the top of the nose with an eyeball shift. During this period, with cancer of all parts of the nasal cavity and paranasal sinuses, a serous-purulent discharge appears, sometimes with an admixture of blood, and pain may occur of varying intensity, which, when the tumor is localized in the posterior sections of the maxillary sinus and the pterygopalatine fossa is neuralgic. This kind of pain can also occur with sarcomas of these localizations, even under limited processes. In common processes, when the diagnosis is not difficult, symptoms such as diplopia, enlargement of the nasal root, intense headache, nosebleeds, and enlargement of the cervical lymph nodes may appear.

Important, both from the point of view of diagnosis, and the forecast, as well as the choice of the method of surgical intervention, is to determine the direction of growth of the tumor of the maxillary sinus. Its anatomical divisions are determined according to the Ongren pattern by the frontal and sagittal planes, which allow dividing the sinuses into 4 anatomical segments: the upper-inner, the upper-outer, the lower-inner and the lower-external.

Classification of cancer of the nasal cavity and paranasal sinuses

According to the International Classification of Malignant Tumors (6th and building, 2003), the cancer process is denoted by the symbols: T - primary tumor, N - regional metastases, M - distant metastases.

TNM clinical classification of malignant tumors of the nose and paranasal sinuses.

• T - primary tumor:
• Tx - insufficient data to estimate the primary tumor;
• T0 - primary tumor is not detected:
• Tis - preinvasive carcinoma (corcinoma in situ).

Maxillary sinus:

• T1 - the tumor is confined to the mucous membrane of the cavity without erosion or bone destruction.
• T2 - a tumor that causes erosion or destruction of the bones of the maxillary sinus and wings of the sphenoid bone (with the exception of the posterior wall), including spreading to the hard palate and / or the middle nasal passage;
• T3 - the tumor extends to any of the following structures: the bony part of the posterior wall of the maxillary sinus, subcutaneous tissues, the cheek skin, the lower or medial walls of the orbit, the pterygopalatine fossa, the cells of the latticed horse:
• T4 - the tumor extends to any of their following structures: the apex of the orbit, the dura mater, the brain, the middle cranial fossa, the cranial nerves (the other, the maxillary branch of the trigeminal black), the nasopharynx, the cerebellum rami.

The nasal cavity and the cell of the latticed bone:

• T1 - the tumor extends to one side of the nasal cavity or cells of the latticed bone with or without bone erosion;
• T2 - the tumor extends to the two sides of the nasal cavity and adjacent areas within the nasal cavity and the cell of the latticed bone with or without bone erosion;
• ТЗ - the tumor extends to the media bald wall or bottom of the orbit, maxillary sinus, palate, trellis plate;
• T4a - the tumor extends to any of the following structures: the anterior structures of the orbit, the skin of the nose or cheeks, minimally to the anterior cranial fossa, the wings of the sphenoid bone, the wedge or frontal sinuses;
• T4b - the tumor extends to any of the following structures: the apex of the orbit, the solid medulla, the brain, the middle cranial fossa, the cranial nerves (other than the maxillary branch of the trigeminal nerve), the nasopharynx, the cerebellum slant,

N - regional lymph nodes:

• Nx - insufficient data to evaluate regional lymph nodes;
• N0 - no signs of metastatic lymph node involvement;
• N1 - metastases in one lymph node on the affected side to 3.0 cm in the largest dimension;
• N2 - metastases in one lymph node on the affected side to 6.0 cm in the largest measurement, or metastases in several lymph nodes on the side of the lesion to 6.0 cm in the largest measurement, or metastases in the lymph nodes of the neck on either side or on the opposite side up to 6.0 cm in the largest dimension;
• N2a - metastases in one lymph node on the affected side to 6.0 cm:
• N2b - metastases in several lymph nodes on the affected side to 6.0 cm;
• N2c - metastases in the lymph nodes of the neck from either side or from the opposite side to 6.0 cm in the largest dimension;
• N3 - metastases in lymph nodes more than 6.0 cm in the largest dimension.

Note: the lymph nodes of the median line are regarded as nodes on the side of the lesion.

M - distant metastases:

• Mx - insufficient data for the definition of distant metastases;
• M0 - no signs of distant metastases;
• M1 - there are distant metastases.

[3], [4], [5], [6], [7],

Diagnosis of cancer of the nasal cavity and paranasal sinuses

At the moment, there is no doubt about the need for comprehensive diagnosis of malignant tumors of the nasal cavity and paranasal sinuses using, besides routine research, fiber optics, KT and MRI, as well as other modern methods.

The examination of patients should begin with a careful study of anamnestic data, which allows to clarify the nature of patient complaints, the timing and sequence of the onset of symptoms of the disease. Then you should start to examine and palpate the facial skeleton and neck. The anterior and posterior rhinoscopies are performed, sometimes finger examination of the nasopharynx.

At this stage, fibroscopy is performed, both through the forward nasal passages, and through the nasopharynx. Flexible fibroscope, which has a complex optical system, allows to study in detail all the departments of these organs in detail, to evaluate the nature of the tumor lesion and the condition of surrounding tissues. The small size of the device, remote control of the distal end of the fibroscope allow not only to examine all parts of the nasal cavity and paranasal sinuses, but also to take the material for cytological and histological examination. The design features of the device allow the use of color video recording, as well as photo and filming, which is important for obtaining objective documentation. With the help of a fibroscope, it is possible to perform a biopsy of the tumor. Informativeness of the method of fibroscopy is 93%.

Computer tomography, based on the principle of creating an X-ray image of organs and tissues with the help of a computer, allows you to more accurately determine the tumor's location, its size, shape of growth, the state of surrounding tissues and the boundaries of destruction. In importance, this method of research is equated to the discovery of x-rays, as evidenced by the award of the 1979 Nobel Prize to its creators, A.M. Cormak (USA) and GH Haunsfield (England). This method is based on obtaining a thin axial cut like "pirogov slices" of organs and tissues of the organism when a fan-shaped beam of X-rays passes through it. When examining the nasal cavity, the paranasal sinuses begin at the level of the skull base.

KT for tumors localized in the paranasal sinuses and the nasal cavity. It allows to accurately determine the localization and size of the tumor, the degree of invasion into surrounding tissues, which is not widely available with other methods of instrumental research. She gives a clear idea of the relationship between a tumor with the maxillary sinus, a latticed labyrinth, a sphenoid sinus, a pterygoid and palpable fossa, to reveal the destruction of the wings of the sphenoid bone and the walls of the orbit and the growth of the tumor into the cavity of the skull. KT data also serve to evaluate the effectiveness of treatment.

Magnetic resonance imaging.

The method is based on the possibility of recording different-frequency signals emanating from the hydrogen nucleus in response to the action of radio-frequency pulses in a magnetic field. This provides a sufficiently strong magnetic resonance signal, suitable for imaging. Obtaining a multi-plane image provides a better spatial orientation and greater visibility than with KT.

MRI reveals neoplasm, especially soft tissue, and allows to assess the condition of neighboring tissues.

Morphological verification of the tumor takes a very significant place, since without an accurate diagnosis it is impossible to choose an adequate method of baking.

[8], [9],

Treatment of cancer of the nasal cavity and paranasal sinuses

Methods of treatment of malignant tumors of the nasal cavity and paranasal sinuses, as well as indications to them in recent years have undergone significant changes. Surgical removal of tumors, which began to be used as a separate type of treatment more than 100 years ago, gives satisfactory results only with limited lesions. With the widespread processes, the results of surgical treatment are unsatisfactory, and the survival rate does not exceed 10-15%. The introduction of radiotherapy with the use of remote gamma-ray devices allowed to improve the results somewhat, to increase the survival rate to 20-25%. However, radiation therapy, as an independent treatment method, proved to be ineffective, and the five-year survival rate does not exceed 18% when it is used.

Currently, the combined method of treatment is universally recognized.

At the first stage, preoperative radiotherapy is performed. In malignant tumors of the maxillary sinuses, the anterior and lateral margins are usually used. Irradiation is carried out daily 5 times a week with a single dose of 2 Gy. The total dose from two fields is 40-45 Gy. It should immediately be emphasized that an increase in the preoperative dose of up to 55-60 Gy allows increasing the five-year survival rate by 15-20%.

To improve the long-term results, in recent years, together with preoperative radiation therapy, chemotherapy has been used, using platinum and fluorouracil. Schemes of drug treatment are quite diverse, but for squamous cell carcinomas of the head and neck and, in particular, tumors of the paranasal sinuses, the following are used:

• 1 st, 2 nd, 3 rd days - fluorouracil from the calculation of 500 mg / m ² body surface for 500 mg intravenously, jet;
• The 4th day - preparations of platinum from the calculation of 100 mg / m ^{2 of} the body surface intravenously, drip for 2 hours with an aqueous load of 0.9% sodium chloride solution.

To remove nausea, vomiting uses antiemetics, such as: ondansetron, granisetron, troposetron.

Thus, two courses of chemotherapy are carried out with an interval of 3 weeks and immediately after the second course they start radiation therapy.

To potentiate radiotherapy against the background of its implementation, platinum is used according to the scheme: every week cisplatin is 100 mg / m ² intravenously, drip by a standard procedure.

After 3 weeks after the end of radiation or chemoradiotherapy, surgical intervention is performed.

In case of nose cancer in case of a limited process located in the area of the bottom of the nose and nasal septum, intraoral access with a dissection of the mucous membrane of the anterior parts of the mouth between small molars (Rouget's method) can be used.

Soft tissues are cut off from the lower edge of the pear-shaped sinus and dissect the mucosa of the nasal cavity. The cartilaginous part of the septum is dissected, which makes it possible to withdraw the outer nose and upper lip to the top and expose the bottom of the nasal cavity. With this access, it is possible to widely excise a new formation of the bottom of the nasal cavity and nasal septum within the limits of healthy tissues.

When the tumor is located in the lower parts of the lateral wall of the nasal cavity, the most convenient external access is of the Denker type. On the lateral surface of the nose from the eye angle level, a skin incision is made, enveloping the wing of the nose, usually with a dissection of the upper lip. The incision of the mucous membrane is carried out along the transitional fold of the vestibule of the oral cavity on the side of the lesion, somewhat by going beyond the middle line and separating the soft tissues to the level of the lower edge of the orbit. At the same time, the entire front wall of the upper jaw and the edge of the pear-shaped opening are exposed. The removal of the anterior and medial walls of the maxillary sinus with excision of the lower one, and with indications - of the middle nasal concha is performed. The amount of operation in the nasal cavity depends on the prevalence of the tumor.

With the cancer cells of the trellis labyrinth use access according to Moore. The cut of the facial tissues is made along the medial edge of the orbit, the slope of the nose with the fringing of its wing and the cartilage diverting to the side. Then remove the frontal process of the upper jaw, the tear and partially nasal bones. Excise the cells of the trellis labyrinth and perform revision of the sphenoid sinus. At indications when it is necessary to expand the volume of the operation, with this access it is possible to excise the lateral wall of the nasal cavity, to open the maxillary sinus, and also to audit the frontal sinus.

The maxillary sinus.

Since malignant tumors of this localization constitute 75-80% of all neoplasms of the nasal cavity and the course of the disease and the initial stages are asymptomatic, the volume of the operation is of an extended-combined nature and is possible to remove all tumors of this zone.

Cut the skin from the inner corner of the eye along the slope of the nose, then cut the wing of the nose and continue through the upper lip along the filter. In the case of simultaneous exenteration of the orbit, this incision is complemented by the upper line along the line of the eyebrow.

Electroectomy of the jaw is performed by the method of step-by-step bipolar coagulation of the tumor with subsequent removal of the tissues by nippers and electric loops. Upon completion of the operation, the wound surface is coagulated with a monoactive electrode. For uniform coagulation of the maxillary bone structures between two electro-cuts, it should be made through small gauze napkins measuring 1x1 cm, moistened with 0.9% sodium chloride solution. If this is not done, then only surface charring of the tissues occurs.

In the process of electroresection, to prevent overheating, it is necessary to occasionally roll up napkins moistened with a cold 0.9% solution of sodium chloride on coagulated tissues.

The postoperative cavity is filled with a gauze tampon with the addition of a small amount of iodoform. The defect of the hard palate and the alveolar process is covered with a protective plate, made in advance, taking into account the volume of surgical intervention. Stitches on the skin are applied with a traumatic needle with a polyamide thread. And in most cases, a bandage on the face should not be imposed. After treatment with a 1% solution of a brilliant green line, the seam is left open.

With regional metastases, they are removed in the volume of fascicle-neck excision of the neck tissue or Krajl's operation.

Violation of the function of chewing, swallowing, phonation and cosmetic defects that occur after surgery of this volume, it is necessary to restore the technique of a three-stage complex maxillofacial prosthesis in order to correct cosmetic disorders. The protective plate is placed on the operating field. 2-3 weeks after the operation, the forming prosthesis is put, after 2-3 months - the final prosthesis with the obturator, which does not allow the occlusion of the soft tissues of the infraorbital region and cheek. Step-by-step prosthetics, along with the exercises of a speech therapist, significantly reduce defects in function and background.

Prognosis for cancer of the nasal cavity and paranasal sinuses

With cancer of the nasal cavity and paranasal sinuses, the forecast is unfavorable. At the same time, the combined method with preoperative chemoradiotherapy and electroresection of this zone in the process of surgical treatment makes it possible to obtain a five-year cure in 77.5% of cases. With a "bloody" resection, even in the case of combined treatment, a 5-year cure does not exceed 25-30%.