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

Cancer of the nasal cavity and paranasal sinuses occurs more often in men. Among the causes influencing the frequency 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 among the rest of the population.

The ethnicity of patients with malignant tumors of this localization is important. Ethnic groups representing the indigenous population of the eastern and southeastern regions of the country are characterized by a high proportion of diseases with malignant tumors of the nasal cavity and paranasal sinuses.

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Symptoms of Nasal Cavity and Sinus Cancer

In the early stages, the disease is asymptomatic. Therefore, for example, stage I-II maxillary sinus cancer is a finding during antrotomy for suspected polyposis of this sinus or chronic sinusitis. The first signs of the initial stages of nasal cavity cancer are difficulty breathing through the corresponding half of the nose and bloody discharge. In addition, during anterior rhinoscopy, it is easy to detect a tumor localized in the corresponding half of the nose.

In case of cancer of the ethmoid labyrinth cells, the first symptoms are a feeling of heaviness in the corresponding area and purulent-serous discharge from the nasal cavity. As the process spreads, deformation of the facial skeleton is noted. Thus, in case of cancer of the maxillary sinus, swelling appears in the area of its anterior wall, and in case of cancer of the ethmoid labyrinth cells, in the upper part of the nose with displacement of the eyeball. During this period, in case of cancer of all parts of the nasal cavity and paranasal sinuses, serous-purulent discharge appears, sometimes with an admixture of blood, pain of varying intensity may occur, which, if the tumor is localized in the posterior parts of the maxillary sinus and the pterygopalatine fossa is affected, is of a neuralgic nature. This type of pain also occurs in sarcomas of these localizations, even in limited processes. In widespread processes, when establishing a diagnosis is not difficult, symptoms such as diplopia, widening of the nasal root, intense headache, nosebleeds, and enlargement of the cervical lymph nodes may appear.

Determining the direction of growth of the maxillary sinus tumor is important both from the point of view of diagnostics and prognosis, as well as the choice of the method of surgical intervention. Its anatomical sections are determined according to the Ongren scheme by the frontal and sagittal planes, allowing the sinuses to be divided into 4 anatomical segments: upper-inner, upper-outer, lower-inner, and lower-outer.

Classification of cancer of the nasal cavity and paranasal sinuses

According to the International Classification of Malignant Tumors (6th edition, 2003), the cancer process is designated by 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 assess the primary tumor;
• T0 - primary tumor is not detected:
• Tis - preinvasive carcinoma (corcinoma in situ).

Maxillary sinus:

• T1 - the tumor is limited to the mucous membrane of the cavity without erosion or destruction of bone.
• T2 - tumor causing erosion or destruction of bone of the maxillary sinus and wings of the sphenoid bone (excluding the posterior wall), including extension to the hard palate and/or middle nasal meatus;
• T3 - the tumor extends into any of the following structures: the bony portion of the posterior wall of the maxillary sinus, subcutaneous tissues, skin of the cheek, inferior or medial walls of the orbit, pterygopalatine fossa, ethmoid cells:
• T4 - the tumor extends into any of the following structures: orbital apex, dura mater, brain, middle cranial fossa, cranial nerves (others, maxillary branch of the trigeminal nerve), nasopharynx, clivus of the cerebellum.

Nasal cavity and ethmoid cells:

• T1 - the tumor extends to one side of the nasal cavity or ethmoid cells with or without bone erosion;
• T2 - the tumor extends to both sides of the nasal cavity and adjacent areas within the nasal cavity and ethmoid cells with or without bone erosion;
• T3 - the tumor extends to the medial wall or floor of the orbit, maxillary sinus, palate, ethmoid plate;
• T4a - the tumor extends into any of the following structures: anterior orbital structures, skin of the nose or cheeks, minimally into the anterior cranial fossa, wings of the sphenoid bone, sphenoid or frontal sinuses;
• T4b - tumor invades any of the following structures: orbital apex, dura mater, brain, middle cranial fossa, cranial nerves (other than the maxillary branch of the trigeminal nerve), nasopharynx, clivus of the cerebellum,

N - regional lymph nodes:

• Nx - insufficient data to assess regional lymph nodes;
• N0 - no signs of metastatic lesions of the lymph nodes;
• N1 - metastases in one lymph node on the affected side up to 3.0 cm in greatest dimension;
• N2 - metastases in one lymph node on the affected side up to 6.0 cm in greatest dimension, or metastases in several lymph nodes on the affected side up to 6.0 cm in greatest dimension, or metastases in the lymph nodes of the neck on both sides or on the opposite side up to 6.0 cm in greatest dimension;
• N2a - metastases in one lymph node on the affected side up to 6.0 cm:
• N2b - metastases in several lymph nodes on the affected side up to 6.0 cm;
• N2c - metastases in the lymph nodes of the neck on both sides or on the opposite side up to 6.0 cm in greatest dimension;
• N3 - metastases in lymph nodes more than 6.0 cm in greatest dimension.

Note: Midline lymph nodes are considered to be nodes on the affected side.

M - distant metastases:

• Mx - insufficient data to determine distant metastases;
• M0 - no signs of distant metastases;
• M1 - there are distant metastases.

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Diagnosis of cancer of the nasal cavity and paranasal sinuses

At present, there is no doubt about the need for comprehensive diagnostics of malignant tumors of the nasal cavity and paranasal sinuses using, in addition to routine examination, fiber optics, CT and MRI, as well as other modern methods.

Examination of patients should begin with a thorough study of anamnestic data, allowing to clarify the nature of patients' complaints, timing and sequence of the onset of disease symptoms. Then one should proceed to examination and palpation of the facial skeleton and neck. Anterior and posterior rhinoscopy are performed, sometimes a digital examination of the nasopharynx.

At this stage, fibroscopy is performed both through the anterior nasal passages and through the nasopharynx. A flexible fibroscope with a complex optical system allows for a detailed magnification study of all sections of the specified organs, an assessment of the nature of the tumor lesion and the condition of the surrounding tissues. The small size of the device and remote control of the distal end of the fibroscope allow not only for examining all sections of the nasal cavity and paranasal sinuses, but also for taking targeted material for cytological and histological examination. The design features of the device allow for the use of color video recording, as well as photography and filming, which is important for obtaining objective documentation. A tumor biopsy can be performed using a fibroscope. The information content of the fibroscopy method is 93%.

Computer tomography, based on the principle of creating an X-ray image of organs and tissues using a computer, allows for a more accurate determination of the tumor's location, size, growth pattern, condition of surrounding tissues, and destruction boundaries. In terms of significance, this research method is equal to the discovery of X-rays, as evidenced by the awarding of the Nobel Prize in 1979 to its creators A.M. Cormak (USA) and G.H. Haunsfield (England). This method is based on obtaining a thin axial section similar to "Pirogov sections" of the body's organs and tissues when a fan-shaped beam of X-rays passes through it. When examining the nasal cavity and paranasal sinuses, tomography begins at the level of the base of the skull.

CT for tumors localized in the paranasal sinuses and nasal cavity. Allows to accurately determine the location and size of the tumor, the degree of invasion into the surrounding tissues, which is poorly accessible with other methods of instrumental examination. It gives a clear idea of the relationship of the tumor with the maxillary sinus, ethmoid labyrinth, sphenoid sinus, pterygopalatine and infratemporal fossae, to identify the destruction of the wings of the sphenoid bone and the walls of the orbit and tumor growth into the cranial cavity. CT data also serve to assess the effectiveness of treatment.

Magnetic resonance imaging.

The method is based on the possibility of recording signals of different frequencies emanating from the hydrogen nucleus in response to the action of radiofrequency pulses in a magnetic field. This provides a sufficiently strong magnetic resonance signal suitable for imaging. Obtaining a multiplanar image provides better spatial orientation and greater clarity than with CT.

MRI is good at detecting neoplasms, especially soft tissue, and allows one to assess the condition of adjacent tissues.

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

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Treatment of cancer of the nasal cavity and paranasal sinuses

Treatment methods for malignant tumors of the nasal cavity and paranasal sinuses, as well as indications for them, have undergone significant changes in recent years. 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. In widespread processes, the results of surgical treatment are unsatisfactory, and the survival rate does not exceed 10-15%. The introduction of radiation therapy using remote gamma installations into practice has improved the results somewhat, increasing the survival rate to 20-25%. However, radiation therapy as an independent treatment method turned out to be ineffective, and the five-year survival rate when used does not exceed 18%.

Currently, the combination method of treatment is generally accepted.

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

In recent years, chemotherapy has been used in conjunction with preoperative radiotherapy, using platinum and fluorouracil drugs. Drug treatment regimens vary widely, but for squamous cell carcinomas of the head and neck, and in particular, paranasal sinus tumors, the following are used:

• 1st, 2nd, 3rd days - fluorouracil at a rate of 500 mg/m2 ^of body surface, 500 mg intravenously, by jet stream;
• Day 4 - platinum preparations at a rate of 100 mg/m2 ^of body surface intravenously, drip over 2 hours with a water load of 0.9% sodium chloride solution.

To relieve nausea and vomiting, antiemetics are used, such as: ondansetron, granisetron, tropisetron.

Thus, two courses of chemotherapy are carried out with an interval of 3 weeks and immediately after the 2nd course, radiation therapy begins.

To potentiate radiation therapy during its implementation, platinum is used according to the following scheme: cisplatin 100 mg/m2 ^{intravenously} every week, drip by drip according to the standard method.

Surgery is performed 3 weeks after the end of radiation or chemoradiation treatment.

In case of nasal cancer, in the case of a limited process located in the area of the bottom of the nose and the nasal septum, it is possible to use intraoral access with dissection of the mucous membrane of the anterior parts of the vestibule of the mouth between the premolars (Rouget method).

The soft tissues are separated upward from the lower edge of the pyriform sinus and the mucous membrane of the nasal cavity is dissected. The cartilaginous part of the septum is dissected, which makes it possible to move the external nose and upper lip upward and expose the bottom of the nasal cavity. With this approach, it is possible to widely excise the neoplasm of the bottom of the nasal cavity and nasal septum within healthy tissues.

When the tumor is located in the lower sections of the lateral wall of the nasal cavity, the most convenient approach is the external Denker approach. A skin incision is made along the lateral surface of the nose from the level of the corner of the eye, enveloping the wing of the nose, usually with a dissection of the upper lip. An incision of the mucous membrane is made along the transitional fold of the vestibule of the oral cavity on the affected side, slightly going beyond the midline and separating the soft tissues to the level of the lower edge of the orbit. In this case, the anterior wall of the upper jaw and the edge of the pyriform opening are exposed along their entire length. The anterior and medial walls of the maxillary sinus are removed with excision of the lower, and if indicated, the middle nasal turbinates. The scope of the operation in the nasal cavity depends on the prevalence of the tumor.

In case of ethmoidal labyrinth cell cancer, Moore's approach is used. The facial tissue is incised along the medial edge of the orbit, the slope of the nose with the wing border and the cartilaginous part is moved to the side. Then the frontal process of the maxilla, the lacrimal and partially the nasal bones are removed. The ethmoidal labyrinth cells are excised and the sphenoid sinus is revised. If indicated, when it is necessary to expand the scope of the operation, this approach can be used to excise the lateral wall of the nasal cavity, open the maxillary sinus, and also to revise the frontal sinus.

Maxillary sinus.

Since malignant tumors of this localization make up 75-80% of all neoplasms of the nasal cavity and the course of the disease in the initial stages is asymptomatic, the scope of the operation is of an extended-combined nature and is possible to remove all neoplasms of this area.

The skin incision is made from the inner corner of the eye along the slope of the nose, then the wing of the nose is cut and continued through the upper lip along the philtrum. In the case of simultaneous exenteration of the orbit, the specified incision is supplemented by an upper one along the eyebrow line.

Electroresection of the jaw is performed by the method of staged bipolar coagulation of the tumor with subsequent tissue removal with nippers and an electric loop. Upon completion of the operation, the wound surface is coagulated with a monoactive electrode. For uniform coagulation of the bone structures of the upper jaw between two electrical incisions, it should be done through small gauze napkins measuring 1x1 cm, moistened with a 0.9% sodium chloride solution. If this is not done, only superficial charring of the tissues occurs.

During the electroresection process, to prevent overheating, it is necessary to periodically throw napkins soaked in a cold 0.9% sodium chloride solution onto the coagulated tissues.

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

In case of regional metastases, they are removed by means of fascial-case excision of the neck tissue or the Krail operation.

The dysfunction of chewing, swallowing, phonation and cosmetic defects that arise after an operation of such a volume must be restored. In order to correct cosmetic disorders, a three-stage complex maxillofacial prosthetics technique is used. A protective plate is installed on the surgical field. 2-3 weeks after the operation, a forming prosthesis is installed, 2-3 months later - a final prosthesis with an obturator, which does not allow the soft tissues of the infraorbital region and cheek to sink in. Staged prosthetics along with classes with a speech therapist significantly reduce defects in function and phonation.

Prognosis for cancer of the nasal cavity and paranasal sinuses

In cancer of the nasal cavity and paranasal sinuses, the prognosis is unfavorable. At the same time, a combined method with preoperative chemoradiation therapy and electroresection of tissues in this area during surgical treatment allows for a five-year cure in 77.5% of cases. With "bloody" resection, even in the case of combined treatment, the 5-year cure does not exceed 25-30%.