Malignant nasal tumors

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; esthesioneuroblastoma (from the olfactory epithelium) is also encountered.

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

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Symptoms of malignant tumors of the nasal cavity

Symptoms of malignant tumors of the nasal cavity depend on the type of tumor, its localization and stage of development. Evolution undergoes four periods: latent, the period of intranasal localization, the period of extraterritoriality, i.e. the tumor goes beyond the nasal cavity to neighboring anatomical structures (organs), and the period of metastatic lesions of regional lymph nodes and distant organs. It should be noted that metastasis of tumors, especially sarcomas, can begin in the second period.

Treatment: wide excision preferably with a laser scalpel, chemotherapy, immunotherapy. In case of distant metastases the prognosis is unfavorable.

Mesenchymal tumors (sarcomas) have different structures depending on the source from which the tumor arose (fibrosarcoma, chondrosarcoma). These tumors are characterized by early metastasis to regional lymph nodes and distant organs even with insignificant sizes.

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

Malignant tumors of the nasal pyramid

Malignant tumors of the nasal pyramid may originate from the squamous keratinizing epithelium that makes up the skin of the external nose, or from the mesenchymal tissues that make up the skeleton of the nasal pyramid, which are connective tissue, cartilage, and bone formations. Epithelial tumors are found mainly in adults, while mesenchymal tumors occur in all age groups.

Pathological anatomy

Based on the histological structure, there are several types of malignant tumors of the nasal pyramid.

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

Epitheliomas from the integumentary epithelium have the appearance of epidermal keratinized spherical formations, characterized by rapid development, metastasis and recurrence after radiation therapy.

Cylindromas arise from the columnar epithelium located along the edges of the nasal vestibule.

Nevoepitheliomas develop from a pigmented nevus (melanoblastoma) or from a pigmented spot on the skin. Much less often, the first manifestations of melanoma may be changes in the color of the nevus, its ulceration or bleeding with the slightest injury. Externally, the primary focus of skin melanoma may look like a papilloma or ulcer. Nevocarcinomas are neuroepithelial in nature and originate from the olfactory region, containing melanin. Most often, these tumors arise in the mucous membrane of the posterior cells of the ethmoid bone, less often - on the nasal septum.

Sarcomas

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

Fibrosarcomas

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

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Chondrosarcomas

Chondrosarcomas originate from cartilaginous tissue and are very rare in the nasal passages. These tumors, like fibrosarcomas, are characterized by a very pronounced malignancy and spread quickly by hematogenous metastasis.

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Osteosarcomas

Osteosarcomas are highly proliferative and infiltrative, and may consist of osteoblasts or undifferentiated mesenchymal cells that may take on a fibrous (fibroid), cartilaginous (chondroid), or bony (osteoid) appearance. These tumors metastasize early through the hematogenous route, primarily to the lungs.

Lymphosarcoma

Lymphosarcomas are characterized by proliferation of lymphoid cells, rapid per continuitatcm spread and lymphogenous metastasis. Most often, this type of sarcoma is localized on the middle nasal concha and nasal septum. 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 histological examination of the removed tumor or biopsy, as well as on the external signs of the tumor and its clinical course.

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Malignant tumors of the internal nose

Malignant tumors of the internal nose are quite rare diseases. According to consolidated foreign and domestic data, they make up 0.008% of all malignant tumors and 6% of all malignant tumors of the upper respiratory tract. They occur more often in males. Epitheliomas are observed more often in adults aged 50 years, sarcomas occur in all age groups, including any age of childhood.

Pathological anatomy

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

Epitheliomas are a general name for various epithelial tumors. They can originate from multilayered cylindrical ciliated epithelium, from the epithelial linings of the glands of the mucous membrane of the internal nose. A variety of these epitheliomas are the so-called cylindromas, a feature of which is their ability to encapsulate, which separates them from the surrounding tissues.

Symptoms of malignant tumors of the internal nose

Initial symptoms appear unnoticed and gradually and are quite banal: mucous discharge from the nose, sometimes mucopurulent or bloody, but typically unilateral manifestation of these signs. Gradually, the discharge from the nose becomes purulent, dirty gray with a putrid odor, accompanied by frequent nosebleeds. At the same time, obstruction of one half of the nose increases, manifested by unilateral disorders of nasal breathing and olfaction. During this period, objective cacosmia and a feeling of congestion in the ear on the affected side and subjective noise in it also increase. The resulting severe craniofacial neuralgia and headaches in the frontal-occipital localization are constant companions of malignant tumors of the nasal cavity. With loose epithelial tumors or disintegrating sarcoma, sometimes during strong nose blowing or sneezing, fragments of the tumor may be released from the nose and nosebleeds may occur.

In the latent period, no characteristic oncological signs are detected in the nasal cavity, only in the middle nasal passage or in the olfactory region can there be polyps that are banal both in appearance and structure ("accompanying polyps"), the occurrence of which V.I. Voyachek explained by neurovascular disorders caused by the tumor. These polyps are distinguished by the fact that when they are removed, more pronounced bleeding occurs, and their relapses occur much earlier with more abundant growth than when ordinary polyps are removed. The presence of "accompanying polyps" often leads to diagnostic errors, and their repeated removal contributes to more rapid tumor growth and accelerates the process of metastasis, which significantly worsens the prognosis.

On the nasal septum, a malignant neoplasm (usually sarcomas) first appears as a one-sided smooth swelling of red or yellowish color of varying density. The mucous membrane covering it remains intact for a long time. Tumors originating from the anterior cells or located on the nasal concha (usually epitheliomas) quickly grow into the mucous membrane, which ulcerates, which causes frequent spontaneous one-sided nosebleeds. The bleeding tumor fills one half of the nose, is covered with a dirty gray coating, bloody purulent discharge, and its free fragments are often observed. At this stage, the tumor is clearly visible both during anterior and posterior rhinoscopy.

The spread of the tumor to the surrounding anatomical structures causes corresponding symptoms characteristic of both the dysfunction of neighboring organs and their form. Thus, the growth of the tumor into the orbit causes exophthalmos, into the anterior cranial fossa - meningeal symptoms, in the area of the exits of the branches of the trigeminal nerve - neuralgia of this nerve. At the same time, especially with epitheliomas, an increase in the submandibular and carotid lymph nodes is observed, both metastatic and inflammatory in nature. Otoscopy often reveals retraction of the eardrum, symptoms of tubootitis and catarrhal otitis on the same side.

In this (third) period of extraterritorial spread of the tumor, it can grow in different directions. When spreading forward, it often destroys the eardrum and nasal bones, ascending branches of the maxillary bone. When the integrity of the nasal septum is compromised, the tumor spreads to the opposite half of the nose. Usually, at this stage, tumor disintegration and massive nosebleeds from the destroyed vessels of the nasal septum are observed. Such tumor evolution 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 growing outward, especially in tumors originating from the anterior cells of the ethmoid bone, the maxillary sinus, frontal sinus and orbit may be affected. When the paranasal sinuses are affected, secondary inflammatory phenomena most often occur in them, which can simulate banal acute and chronic sinusitis, which often delays the establishment of a true diagnosis and greatly complicates treatment and prognosis. Invasions into the orbit, in addition to visual impairment, cause increasing compression of the lacrimal ducts, manifested by unilateral lacrimation, eyelid edema, retrobulbar neuritis, amaurosis, paresis and paralysis of the oculomotor muscles. Severe exophthalmos often leads to atrophy of the eyeball. The spread of the tumor upward leads to the destruction of the cribriform plate and the occurrence of secondary meningitis and encephalitis. When the tumor grows backwards, it often affects the nasopharynx and auditory tube and can penetrate into the ear through the tubular canal, causing a pronounced syndrome of conductive hearing loss, otalgia, and, if the ear labyrinth is affected, the corresponding labyrinthine symptoms (dizziness, etc.). With the specified direction of tumor growth, it can spread to the sphenoid sinus, and from there to the middle cranial fossa, causing damage to the pituitary gland and retrobulbar neuritis. When the tumor spreads backwards, it is possible to affect the retromaxillary region with the occurrence of trismus and severe pain caused by damage to the pterygopalatine ganglion. Neuralgic pain associated with damage to the sensory 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 initial stages of tumor development, especially in the presence of "accompanying polyps". Suspicion of the oncological origin of these polyps should be caused by their unilateral appearance, rapid recurrence and lush growth after removal, their increased bleeding. However, the final diagnosis can only be made after 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 material from underlying, deeper areas of the mucous membrane.

Malignant tumors of the nasal septum are differentiated from all benign tumors or specific granulomas of this area (bleeding polyp, adenoma, tuberculoma, syphiloma, rhinoscleroma, etc.). In rare cases, glioma of the nasal septum may be mistaken for meningocele of the same area. The latter is a congenital defect and initially manifests itself as expansion and swelling in the area of both the upper parts of the nose and the bridge of the nose. Tumors of the nasal cavity should also be differentiated from primary inflammatory and oncological diseases of the orbit.

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Treatment of malignant tumors of the nose

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

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

Surgical treatment of malignant tumors of the nose

The type of surgical intervention and its scope are determined by the extent of the tumor and the clinical stage of the oncological process. Limited tumors of the nasal septum and nasal conchae are completely removed with the underlying tissues by the endonasal route with subsequent use of radiation therapy. In a more pronounced process with tumor spread to the deep parts of the nose, the sublabial approach according to Rouget is used in combination with the operation according to Denker.

For tumors of the ethmoidal localization, the paralateronasal approach according to Sebilo or Moore is used. The edge of the pyriform opening is exposed along its entire length by a vertical incision going from the inner edge of the superciliary arch and along the buccal-nasal groove, enveloping the wing of the nose and ending at the entrance to the vestibule of the nose. Then, the surrounding tissues are separated as widely as possible, exposing the lacrimal sac, which is moved laterally. After this, the nasal bones are separated along the midline with a chisel or Liston scissors, and the resulting flap of the corresponding side is moved laterally. The nasal cavity, especially the area of its upper wall (ethmoidal region), becomes clearly visible through the resulting opening. After this, an extended extirpation of the tumor is performed with partial removal of suspicious surrounding tissues. After this, “containers” containing radioactive elements (cobalt, radium) are placed in the operating cavity for the prescribed time, securing them with gauze swabs.

In case of tumors of the nasal cavity floor, a Rouget incision is made with sublabial separation of the nasal pyramid and anterior sections of the pyriform aperture, removal of the quadrangular cartilage of the nasal septum, 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 surgery.

Radiotherapy

Radiotherapy can be used for inoperable tumors by introducing appropriate radioactive elements into their thickness. Lymphoepitheliomas and sarcomas are particularly sensitive to radiotherapy.

Chemotherapy

Chemotherapy is used depending on the sensitivity of the tumor to certain antitumor drugs. The arsenal of these drugs includes such drugs as alkylating agents (dacarbazine, carmustine, lomustine, etc.), antimetabolites (hydroxycarbamide, proxyfen), immunomodulators (aldesleukin, interferon 0:26), and in some cases antitumor antibiotics (dactinomycin) and antitumor hormonal agents and hormone antagonists (tamoxifen, zitazonium). Surgical and chemotherapeutic treatment can be supplemented by the use of antitumor agents of plant origin, including ala (vindesine, vincristine). Each prescription of chemotherapeutic agents for the treatment of oncological diseases of the ENT organs is agreed upon with the appropriate specialist after the final morphological diagnosis has been established.

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What is the prognosis for malignant tumors of the nose?

Usually untreated cases of nasal cavity tumors evolve over 2-3 years. During this time, extensive lesions of surrounding tissues occur with the addition of secondary infection, metastasis to neighboring and distant organs, as a result of which patients die either from secondary complications (meningoencephalitis, erosive bleeding) or from "cancer" cachexia.

Malignant tumors of the nose have different prognosis. It is determined by the type of tumor, the stage of its development, the timeliness and quality of treatment. The prognosis is more serious in poorly differentiated mesenchymal tumors (sarcomas); in advanced cases, especially with damage to regional lymph nodes and metastases in the mediastinum and distant organs, it is unfavorable.