Malignant neoplasm of the nose

According to modern data, malignant tumors of the nose are quite rare in otolaryngology (0.5% of all tumors), with squamous cell carcinoma accounting for 80% of cases, and there is also an estezioneuroblastoma (from the olfactory epithelium).

Malignant tumors of the nose are divided into tumors of the nose pyramid and nasal cavity.

[1], [2], [3]

Symptoms of malignant tumors of the nasal cavity

Symptoms of malignant tumors of the nasal cavity depend on the type of tumor, its location and stage of development. Evolution undergoes four periods: the latent period, the period of intranasal localization, the period of extraterritoriality, that is, the release of the tumor beyond the nasal cavity into neighboring anatomical formations (organs), and the period of metastatic involvement of regional lymph nodes and distant organs. It should be noted that metastasis of tumors, especially sarcomas, can begin with the second period.

Treatment: extensive excision is preferably a laser scalpel, chemotherapy, immunotherapy. With distant metastases, the prognosis is unfavorable.

Mesenchymal tumors (sarcomas) have a different structure depending on the source from which the tumor originated (fibrosarcoma, chondrosarcoma). These tumors are distinguished by early metastasis in the regional lymph nodes and distant organs even at small sizes.

Very rare tumors of the mesenchymal nature are gliocarcomas of the wing of the nose and the so-called disembriomas localized at the base of the nasal septum. Mesenchymal tumors are characterized by dense infiltrative growth, painlessness at the onset of the disease and absence of skin lesions.

Malignant neoplasm of the nose

Malignant tumors of the nose pyramid can come from the squamous squamous epithelium that makes up the skin of the outer nose, or from the mesenchymal tissues that make up the skeleton of the nose pyramid, which are connective tissue, cartilaginous and bony formations. Epithelial tumors are found mainly in adults, while mesenchymal tumors are found in all age groups.

Pathological anatomy

According to the histological structure, several types of malignant tumors of the nasal pyramid are distinguished.

Skin epitheliomas from the basal layer can be typical, metatynic, mixed, undifferentiated, basal cell, etc. These tumors called basalomas are more often observed in old people and arise as a result of malignancy of senile keratosis; manifest themselves in various clinical forms, such as squamous cell carcinoma of the skin, destructive of the basal cell structure. These forms of cancer of the nose pyramid are successfully treated with radiation therapy methods.

Epitheliomas from the integumentary epithelium have the form of epidermal cornified globular formations, characterized by rapid development, metastasis and recurrence after radiotherapy.

Cylinders arise from the cylindrical epithelium located at the edges of the vestibule of the nose.

Neoepithelioma develops from a pigment nevus (melanoblastoma) or from an emerging pigmentation spot on the skin. Significantly less often the first manifestations of melanoma can be changes in the color of the nevus, its ulceration or bleeding at the slightest trauma. Externally, the primary focus of skin melanoma can have the form of papilloma or ulcers. Non-carcinomas have a neuroepithelial nature and originate from the olfactory area, contain melanin. Most often, these tumors arise in the mucosa of the posterior cells of the latticed bone, less often in the septa of the nose.

Sarcomas

This class of malignant tumors of the internal nose is determined by the type of tissue from which the tumor originates and is divided into fibrosarcomas, chondrosarcomas and osteosarcomas.

Fibrosarcoma

Fibrosarcomas are formed by fibroblasts and include giant spindle-shaped cells, which is why this type of tumor is also called fusocellular sarcoma. The tumor has extremely malignant infiltrative growth and the ability to early hematogenous metastasis.

[4], [5], [6]

Chondrosarcomas

Chondrosarcomas originate from the cartilaginous tissue and are very rare in the nasal passages. These tumors, as well as fibrosarcomas, have a very pronounced malignancy, spread rapidly through hematogenous metastasis.

[7], [8], [9], [10]

Osteosarcoma

Osteosarcoma is characterized by high proliferation and infiltrative growth, and they can consist of osteoblasts or undifferentiated mesenchymal cells that can acquire fibrous (fibroid), cartilaginous (chondroid) or bone (osteoid) appearance. These tumors early metastasize by the hematogenous route, mainly into the lungs.

Lymphosarcomas

Lymphosarcomas are characterized by proliferation of lymphoid cells, rapid spread of per continuitatcm and lymphogenous metastasis. Most often this kind of sarcoma is localized on the middle nasal concha and the septum of the nose. The tumor is characterized by extremely high malignancy, rapid spread, metastasis and frequent relapses.

Diagnosis of malignant tumors of the nasal cavity

Diagnosis is based on a histological study of a distant tumor or biopsy, as well as on external signs of the tumor and its clinical course.

[11], [12], [13], [14], [15]

Malignant tumors of internal nose

Malignant tumors of the internal nose - diseases are quite rare. According to the combined foreign and domestic data, they constitute 0.008% of all malignant tumors and 6% of all malignant tumors of the upper respiratory tract. Most often they occur in males. Epitheliomas are more common in adults aged 50 years, sarcomas are found in all age groups, including in any childhood.

Pathological anatomy

Tumors of this localization are subdivided into epitheliomas (cancers) and sarcomas.

Epithelioma is a common name for various epithelial tumors. They can occur from multilayered cylindrical ciliated epithelium, from the epithelial lining of the glands of the mucous membrane of the inner nose. A variety of these epithelium are the so-called cylinders, the feature of which is their ability to encapsulate, which delimits them from surrounding tissues.

Symptoms of malignant tumors of the internal nose

The initial symptoms appear imperceptibly and gradually and are completely banal in character: mucous discharge from the nose, sometimes mucopurulent or bloody, but one-sided manifestation of these features is characteristic. Gradually, the discharge from the nose becomes purulent, dirty-gray with putrefactive odor, accompanied by frequent nasal bleeding. Simultaneously, obstruction of one half of the nose increases, manifested by unilateral disruption of nasal breathing and smell. During this period, both the objective kakosmia and the sense of the stuffiness of the ear on the side of defeat and subjective noise in it grow. Emerging severe craniofacial neuralgia and headaches of the frontal-occipital localization are constant companions of malignant tumors of the nasal cavity. With loose epithelial tumors or disintegrating sarcoma, sometimes during a strong nose or sneezing from the nose, tumor fragments can be allocated and nose bleeds can arise.

In the latent period, no characteristic oncologic traits are found in the nasal cavity, only in the middle nasal passage or in the olfactory region can there be banal both in appearance and in the structure of polyps ("accompanying polyps"), the occurrence of which VI. Voyachek explained the neurovascular disorders caused by the tumor. These polyps are characterized by the fact that when they are removed there is more severe bleeding, and their relapses occur much earlier with more abundant growth than with the removal of normal polyps. The presence of "support polyps" often leads to diagnostic errors, and their repeated removal contributes to faster growth of the tumor and speeds up the process of metastasis, which significantly complicates the prognosis.

On the septum of the nose, malignant neoplasm (more often - sarcoma) first manifests itself as a one-sided smooth swelling of red or yellowish color of varying density. Covering her mucous membrane for a long time remains intact. Tumors emanating from the anterior cells or located on the nasal concha (more often epitheliomas) quickly germinate into the mucosa, which ulcerates, which causes frequent occurrence of spontaneous unilateral nasal bleeding. Bleeding swelling fills one half of the nose, is covered with a dirty-gray coating, bloody purulent discharge, often its free fragments are observed. At this stage, the tumor is well visible in both anterior and posterior rhinoscopy.

The spread of the tumor into surrounding anatomical formations causes the corresponding symptoms, characteristic for the violation of both the functions of neighboring organs and their forms. Thus, the germination of a tumor in the orbit causes exophthalmos, in the anterior cranial fossa - shell symptoms, in the region of the branches of the trigeminal nerve - the neuralgia of this nerve. Simultaneously, especially with epitheliomas, there is an increase in submandibular and carotid lymph nodes, both metastatic and inflammatory. Otoscopy often determines the retraction of the tympanic membrane, the phenomenon of tubotitis and catarrhal otitis on the same side.

In this (third) period of the extraterritorial spread of the tumor, it can germinate in different directions. When spreading anteriorly, it often destroys the tympanic membrane and nasal bones, the ascending branches of the maxillary bone. In violation of the integrity of the septum of the nose, the tumor spreads to the opposite half of the nose. Usually at this stage there is a disintegration of the tumor and massive nasal bleeding from the destroyed vessels of the septum of the nose. This evolution of the tumor is most typical for sarcoma. When the tumor spreads downward, it destroys the hard and soft palate and prolapses into the oral cavity, and when germinating outside, especially with tumors emanating from the anterior cells of the latticed bone, the maxillary sinus, frontal sinus and orbit can be affected. With the defeat of the paranasal sinuses, secondary inflammation often occurs in them, which can simulate banal acute and chronic sinusitis, which often delays the establishment of a true diagnosis and dramatically complicates the treatment and prognosis. The invasion of the orbit, in addition to visual disturbances, causes an increasing compression of lacrimal passages, manifested by unilateral lacrimation, eyelid edema, retrobulbar neuritis, amaurosis, paresis and paralysis of the oculomotor muscles. Expressed exophthalm often leads to atrophy of the eyeball. The spread of the tumor upward leads to the destruction of the trellis plate and the occurrence of secondary meningitis and encephalitis. When the tumor grows posteriorly, it often affects the nasopharynx and auditory tube and can penetrate into the ear in a more harmful way through the tube channel, which causes a pronounced syndrome of conductive hearing loss, otalgia, and in case of defeat of the ear maze - and the corresponding labyrinth symptoms (dizziness, etc.). With this direction of tumor growth, it can spread into the sphenoid sinus, and hence into the middle cranial fossa, causing damage to the pituitary gland and retrobulbar neuritis. When the tumor spreads posteriorly, it is possible to damage the retro-maskillar region with the appearance of trism and severe pain due to the lesion of the pterygoid node. Neuralgic pain associated with the defeat of the sensitive nerves of the maxillofacial region is often accompanied by anesthesia of the corresponding skin areas.

Diagnosis of malignant tumors of the internal nose

Diagnosis of malignant tumors of the internal nose is difficult at the early stages of tumor development, especially if there are "support polyps". Suspicion of the oncological origin of these polyps should cause their one-sided appearance, rapid recurrence and magnificent growth after removal, their increased bleeding. However, the final diagnosis can be made only after a histological examination, and the polypous tissue itself, taken as a biopsy, as a rule, does not give a positive result. Therefore, it is necessary to take the material from the underlying, deeper parts of the mucosa.

Malignant tumors of the septum of the nose are differentiated from all benign tumors or specific granulomas of this region (bleeding polyp, adenoma, tuberculoma, syphiloma, rhinoscleroma, etc.). In rare cases, the glioma of the septum of the nose can be taken for the meningocele of the same area. The latter refers to congenital defects and is initially manifested by the expansion and swelling in the region of both the upper parts of the nose and the back of the nose. Tumors of the nasal cavity should also be differentiated from primary inflammatory and oncological diseases of the orbit.

[16], [17]

Treatment of malignant tumors of the nose

Modern treatment of malignant tumors of the nasal cavity, like the paranasal sinuses, involves a combined method, including radical tumor removal, radiation therapy and the use of special chemotherapeutic drugs for certain types of tumors.

With regard to epithelial tumors, radiation therapy, cryosurgery, excision with a laser scalpel are used. With connective tissue tumors (sarcomas), a wide excision of the tumor, the removal of regional (submandibular) lymph nodes, and radiation therapy are used. However, even the most radical treatment for sarcomas of the external nose can not prevent relapses and metastasis to distant organs (lungs, liver, etc.).

Surgical treatment of malignant tumors of the nose

The type of surgery and its volume are determined by the prevalence of the tumor and the clinical stage of the oncological process. Limited tumors of the septum of the nose and nasal concha are completely removed from the tissues to be treated with the endonasal route, followed by the use of radiotherapy. In a more pronounced process with the spread of the tumor into the deep sections of the nose, sublabial access is used along the Roughe in combination with the Denker operation.

When tumors of ethmoidal localization, paralateronasal access is used according to Sebilo or Moore. A vertical incision extending from the inner edge of the superciliary arbor and along the buccal-nasal sulcus enveloping the wing of the nose and ending at the entrance to the vestibule of the nose is exposed all over the edge of the pear-shaped aperture. Then, as far as possible, the surrounding tissues are uncovered with the exposure of the lacrimal sac, which is laterally displaced. After that, the chisel or scissors of Liston is divided along the median line by the nasal bones and the lateral flap of the corresponding side is moved away. Through the formed hole, the nasal cavity becomes highly visible, especially the area of its upper wall (the ethmoidal region). After this, an expanded extirpation of the tumor is performed with a partial removal of suspicious surrounding tissues. After this, the "containers" containing the radioactive elements (cobalt, radium) are placed in the operating cavity for the stipulated time, fixing them with gauze tampons.

With tumors of the bottom of the nasal cavity, a Ruzé incision is made with a sublabial separation of the nose pyramid and anterior pear-shaped opening, removing the quadrangular cartilage of the septum of the nose, after which the lower part of the nasal cavity becomes visible. The tumor is removed together with the underlying bone tissue. The resulting defect of the hard palate is closed after recovery by plastic means.

Radiotherapy

Radiotherapy can be used for inoperable tumors by introducing into the body of the corresponding radioactive elements. Particularly sensitive to radiation therapy of lymphoepithelioma and sarcoma.

Chemotherapy

Chemotherapy is used depending on the sensitivity of the tumor to certain anti-tumor drugs. In the arsenal of these drugs are drugs such as alkylating agents (dacarbazine, carmustine, lomustine, etc.), antimetabolites (hydroxycarbamide, proxyfen), immunomodulators (aldesleukin, interferon 0:26), and also in some cases, antitumor antibiotics (dactinomycin) and antineoplastic hormonal agents and hormone antagonists (tamoxifen, zitazonium). Supplementation of surgical and chemotherapeutic treatment can use antitumor agents of plant origin, including ala (vindesin, vincristine). Each appointment of chemotherapeutic agents in the treatment of cancer of the ENT organs is coordinated with the appropriate specialist after the establishment of the final morphological diagnosis.

[18], [19], [20]

What prognosis do malignant tumors of the nose have?

Usually untreated cases of tumors of the nasal cavity evolve within 2-3 years. At this time, extensive damage to surrounding tissues occurs with the attachment of secondary infection, metastasis to neighboring and distant organs, resulting in patients dying from secondary complications (meningoencephalitis, arrosive bleeding) or from "cancer" cachexia.

Malignant tumors of the nose have a different prognosis. It is determined by the type of tumor, the stage of its development, timeliness and quality of treatment. The prognosis is more serious with malodifferentiated mesenchymal tumors (sarcomas); in neglected cases, especially when regional lymph nodes are damaged and matastases are in the mediastinum and distant organs, is unfavorable.