Malignant tumors of the maxillary sinus: causes, symptoms, diagnosis, treatment

Tumors of the maxillary sinus - otorhinolaryngological diseases, which are both in the competence of maxillofacial surgeons (mainly), and with some clinical and anatomical variants, especially those relating to maxillary-ethmoidal microcircums, - to the competence of rhinologists.

In the overwhelming majority of cases (80-90%), these tumors are epitheliomas; 10-12% are sarcomas, usually occurring in children and young people. Most often, the cancer of the upper jaw originates from the posterior cells of the trellis labyrinth or the edge of the alveolar process of the upper jaw. In their structure, both epithelial and mesenchymal malignant tumors of the maxillary sinus are identical to those that arise in the nasal cavity.

[1], [2], [3], [4],

Symptoms of malignant tumors of the maxillary sinus

Symptoms of malignant tumors of the maxillary sinus are extremely diverse and depend on the stage and localization of the tumor. Distinguish the same stages as in malignant tumors of the nasal cavity.

The latent stage proceeds asymptomatically and most often goes unnoticed. Only in rare cases is it found out by chance in the examination of the patient about "polyposic etmoiditis", which is in fact the same "accompaniment" as in cancer of the nasal cavity.

The stage of tumor manifestation in which a tumor, reaching a certain size, can be detected in the upper nasal region of the nose or in the area of the lower wall of the maxillary sinus at the edge of the alveolar process or in the retromandibular region.

The stage of extrarritization of the tumor, characterized by the release of tumors beyond the maxillary sinus.

The famous French otorhinolaryngologist Sebilo describes three clinical and anatomical forms of cancer of the maxillary sinus. "Neoplasm of superstructure", in the terminology of the author, ie, tumors originating from the trellis labyrinth and penetrating into the maxillary sinus from above.

Symptoms of malignant tumors of the maxillary sinus are as follows: mucopurulent discharge of dirty gray with an admixture of blood, often fetid, often - nosebleeds, especially strong in the anterior artery anterior artery; progressive unilateral obstruction of the nasal passages, neuralgia of the first branch of the trigeminal nerve, anesthesia of the zones of its innervation, at the same time, palpation of these zones causes severe pain. With the anterior and posterior rhinoscopy, the same pattern is revealed, which was described above for tumors of the nasal cavity of ethmoid origin. Histological examination in many cases does not give positive results, so when biopsy or removal of "banal accompaniment polyps" histological examination should be repeated several times.

When puncturing the maxillary sinus with this form of cancer, any significant evidence in favor of its presence is most often not obtained, except that a "vacuum" is detected, or hemolyzed blood enters the syringe when it is sucked off. The addition of a secondary infection to the existing maxillary sinus tumor significantly complicates the diagnosis, since these patients are diagnosed with chronic or acute purulent inflammation of the sinus, and the true disease is detected only with surgical intervention.

Further development of this form of tumor leads to its growth into orbit, causing such symptoms as diplopia, exophthalmos, eyeball displacement laterally and downwards, ophthalmoplegia on the side of the lesion as a result of immobilization of the extraocular muscles with the tumor and damage to the corresponding oculomotor nerves, ophthalmodynia, optic neuritis, chemosis and often phlegmon orbit.

"Neoplasm of the mesostructure," ie, the tumor of the maxillary sinus "of its own origin." Such tumors in the latent period are practically not recognized because they pass in this period under the sign of a banal inflammatory process, which is always secondary. In the advanced stage, the tumor causes the same symptoms that were described above, but with this form, the predominant direction of exterritization is the facial region. The tumor through the front wall extends towards the canine fossa, the malar bone, and germinating through the upper wall into the orbit in exceptional cases can cause a picture.

The tumor can also spread into the nasal cavity, causing its obstruction, in the latticed labyrinth through the trellis plate, affecting the olfactory nerves, and further towards the sphenoid sinus. The spread of the tumor along the posterior wall downwards and laterally causes its penetration into the retroxillary region and in the KNI.

Germination of the tumor through the back wall of the maxillary sinus leads to the defeat of the anatomical formations located in the KNI, in particular the pterygoid muscles (trismus), the neural formations of the pterygoid node (Slader's syndrome). In the foreign literature, neoplasms of supra and mesostructure are called "tumors of rhinologists", meaning that this form of malignant neoplasms of the paranasal sinuses belongs to the competence of rhinosurgeons.

"Neoplasmic infrastructure" or tumors "dental type", or "cancer of the upper jaw of dentists." The starting point of tumor growth is the alveolar process of the upper jaw. These tumors are recognized much earlier than the forms described above, since one of the first complaints about which the patient refers to a doctor (dentist) is an intolerable toothache. The search for a "sick" tooth (deep caries, pulpitis, periodontitis), as a rule, does not yield any results, and removing the "suspicious tooth", repeatedly treated, does not relieve the pain that continues to bother the patient with increasing strength. Another symptom of this form of tumor is causeless loosening of the teeth, often treated as periodontal disease or periodontitis, but the removal of such teeth also does not relieve severe neuralgic pain. And only in this case the attending physician suspects the presence of a tumor of the alveolar process of the upper jaw. As a rule, when the teeth are removed, the roots of which have direct contact with the lower wall of the maxillary sinus, in the case of cancer of the alveolar process, perforations of this wall occur, through which the tumor tissue begins to prolapse in the coming days, which should eliminate the doubts in the diagnosis.

"Diffuse neoplasm"

This term, which determines the last stage of malignant tumors of the maxillary sinus, was introduced by the famous Romanian ENT oncologist V.Racoveanu (1964). Under the gene stage, the author implies a tumor condition in which it is impossible to determine the point of its outcome, and the tumor itself has grown into all the neighboring anatomical treatments, giving the facial region, according to the author's expression, "the kind of monster". Such forms refer to cases absolutely operable.

Evolution of malignant tumors of the maxillary sinus is determined by the anatomopathological structure of the tumor. Thus, lymphosarcomas and so-called soft sarcomas are characterized by extremely rapid growth, crushing invasion of surrounding tissues, early metastasis into the cranial cavity, and clinical manifestations of them - all the above-described violations of the functions of neighboring organs and fever. As a rule, they cause fatal complications earlier than metastasises to distant organs. Fibroblastic sarcomas, or chondro- and osteosarcomas (the so-called solid sarcomas), especially the infrastructure neoplasms, are markedly slower in development, do not ulcerate and do not disintegrate, so that these tumors can reach huge proportions. Unlike "soft" tumors, these tumors are resistant to radiation therapy and in some cases are amenable to surgical treatment.

Cancer of the upper jaw after exiting the anatomical limits of the sinus grows into the surrounding soft tissues, causes their decay and ulceration, and if the patient does not die by this time, it metastasizes into regional, pre-tracheal and cervical lymph nodes. At this stage, the prognosis is non-alternative, the patient dies after 1-2 years.

Complications: "cancer" cachexia, meningitis, hemorrhage, aspiration and metastatic bronchopulmonary lesions.

[5], [6], [7], [8], [9], [10]

Diagnosis of malignant tumors of the maxillary sinus

Diagnosis causes difficulties in the patent period. In subsequent stages, the presence of characteristic oncological and clinical signs in combination with X-ray or CT data does not cause difficulties. Of great importance is differential diagnosis, which must be carried out with the following nosological forms.

Banal sinusitis. From the clinical manifestations of this disease, the malignant tumor is characterized by the strongest, uncontrollable, neuralgic pains caused by the defeat of the first branch of the trigeminal nerve, and often ophthalmodynia; fetid grayish-bloody discharge, sometimes massive bleeding from the soup. Radiographically, tumors are characterized by the blurred contours of the maxillary sinus, significant shading of the sinus, and other phenomena indicative of the spread of the tumor to adjacent tissues.

The parodental cyst is characterized by a slow evolution, the absence of characteristic pains, invasion of surrounding tissues, typical for a tumor of discharge from the nose.

Benign tumors differ in the same signs as the parodental cysts.

Of the other diseases from which it is necessary to distinguish a malignant tumor of the maxillary sinus, it should be noted actinomycosis, dental epulitis, gum cancer, osteomyelitis.

The location of the tumor. Cancers of the superstructure are distinguished by the most severe prognosis due to difficulties and late diagnosis, the absence of the possibility of radical removal. The latter causes their recurrence in the latticed bone and orbit, germination through the trellis plate into the anterior cranial fossa, and through the orbit to the retrobulbar area and the middle cranial fossa. Tumors of meso- and especially infrastructures in this respect are characterized by a less pessimistic prediction, first, because of the possibility of earlier diagnosis, and secondly, because of the possibility of radical surgical removal of the tumor in the early stages of its development.

The prevalence of a tumor is one of the main criteria for the prediction, because it is based on the conclusion about operability or inoperability in this particular case.

[11], [12], [13], [14], [15], [16]

Treatment of malignant tumors of the maxillary sinus

Treatment of malignant tumors of the upper jaw is determined by the same criteria as the prognosis, i.e. If the prognosis is relatively favorable or at least encourages some minimal hope for recovery or at least prolongation of life, then surgical treatment is performed supplemented with radiotherapy.

In superstructural tumors, a partial resection of the upper jaw is performed, limited to removing its upper part, the lower and medial wall of the orbit, the fully latticed bone, retaining the trellis plate, as well as its own nasal bone on the side of the lesion, and using Moore, Otana or a combination thereof.

With mesostructural tumors, a total resection of the upper jaw is used. This literally mutilating and disfiguring operation is the only possible intervention that allows to completely remove the tumor of the upper jaw, however only if the tumor has not spread beyond this bone. As an operative method paralateronasal access according to the Mura is used with the extension of the incision downwards with the bend of the nose wing and the medial incision of the upper lip in combination with access via Otan. In this surgical intervention, the nasal bone is resected on the side of the lesion, the upper end of the ascending branch of the upper jaw is traversed, the lower wall of the orbit is cut, the alveolar process dissected at the posterior margin of the first molar, the hard palate resected, the wing of the maxillary sinostosis is dissected, and the whole block is removed with the upper jaw.

Later, after healing of the wound cavity, various variants of prosthesis of the upper jaw are used using removable prostheses. Often, the first and second types of surgery are compulsorily combined with enucleation of the affected eye.

Infrastructure tumors use a partial resection of the lower part of the upper jaw, the amount of surgical intervention is determined by the prevalence of the tumor.

The incision is made on the median plane of the upper lip, around the wing of the nose and is wound on the nasolabial fold, then the mucous membrane is cut along the transitional fold under the lip. After this, by removing soft tissues, the field of operative action for removal in the tumor block together with the part of the upper jaw is released. For this, a lateral wall of the upper jaw, a solid palate on the side of the tumor, and divide the wing of the maxillary sinostosis are resected in the upper part. The resulting block is removed, after which the final hemostasis is produced, the remaining soft tissues are diathermo-coagulated and a dressing is applied. When applying a dressing in the case of radiotherapy, radioactive elements are placed in the postoperative cavity.

Radiation therapy for malignant neoplasms of ENT organs is one of the main methods of treatment. Various types of ionizing radiation are used for its implementation, and in this connection they distinguish between x-ray therapy, gamma-therapy, beta therapy, electronic, neutron, proton, pimose therapy, alpha therapy, heavy ion therapy. Depending on the purpose of treatment, which is determined by the above forecast criteria, radiotherapy is divided into a radical one, whose goal is to achieve complete resorption and cure of the patient, palliative, aiming to slow the growth of the tumor and, if possible, prolong the patient's life, and symptomatic, directed on the elimination of certain painful symptoms - pain, compression syndrome, etc. There are also anti-relapse radiotherapy, which is used after a "radical" surgical removal of the tumor, when the corresponding radioactive nuclides are placed in the postoperative cavity. Radiation therapy is widely used in combination with surgical treatment and chemotherapy.

Radical radiation therapy is indicated with limited spread of the tumor; it provides for irradiation of the primary focus and zones of regional metastasis. Depending on the location of the tumor and its radiosensitivity, the type of radiation therapy, the method of irradiation, and the amount of SOD (60-75 Gy) are chosen.

Palliative radiotherapy is carried out by patients with a common tumor process, in which, as a rule, it is impossible to achieve complete and permanent cure. In these cases, only a partial regression of the tumor occurs, intoxication decreases, pain syndrome disappears, organ function is restored to a certain degree, and the patient's life is prolonged. To achieve these goals use smaller SOD - 40-55 Gy. Sometimes, with a high radiosensitivity of the tumor and a good response to irradiation, it is possible to switch from a palliative program to radical irradiation of the tumor.

Symptomatic radiation therapy is used to eliminate the most severe and threatening symptoms of a tumor disease that prevail in the clinical picture (compression of the spinal cord, obturation of the esophagus lumen, pain syndrome, etc.). Radiation therapy, temporarily eliminating these manifestations of the disease, improves the patient's condition.

At the heart of the therapeutic effect of ionizing radiation is the damage to the vital components of tumor cells, especially DNA, as a result of which these cells lose the ability to divide and die. Surrounding undamaged connective tissue elements provide resorption of damaged tumor cells and replacement of tumor tissue with scar tissue, so one of the main conditions for the successful implementation of radiation therapy is minimal damage to tissues surrounding the tumor, which is achieved by careful dosing of the irradiation.

Clinical practice is guided by the concept of a radiotherapeutic interval characterizing the difference in the radiosensitivity of the tumor and surrounding normal tissue. The wider this interval, the more favorable is the radiation treatment. Expansion of this interval is possible by selective enhancement of radiation damage to the tumor or preferential protection of surrounding tissues with the help of chemical radiomodifying agents - various chemical compounds (radioprotectors) introduced into the body before irradiation and reducing its radiosensitivity. Among the chemical radioprotectors are sulfur-containing compounds, for example cystamine, indolyl-kylamine derivatives, for example serotonin and mexamine. The damaging effect of ionizing radiation is greatly attenuated in an atmosphere with a reduced oxygen content, so that anti-radiation protection can be provided by inhalation of gas mixtures containing only 9-10% oxygen just before irradiation and during irradiation.

The use of radiation therapy makes it possible to obtain good results in many malignant tumors. Thus, the five-year survival of patients after radiation therapy for skin cancer of I-II stage reaches 97%, for laryngeal cancer of I-II stage - 85%, for lymphogranulomatosis I-II stage - 70%.

Radiation therapy after surgery for maxillary cancer is performed immediately after surgery by inserting into the wound cavity cobalt pearls or radium tubes at least 20, with "containers" containing radioactive substances placed around the perimeter of the cavity so that a uniform irradiation of the cavity The walls of the site, a special place of the expected outcome of the tumor. In this case, measures are taken to protect against the ionizing radiation of bone tissue, especially the trellis plate, and the eyeball by placing small plates of leaded rubber between them and the source of radiation. The filaments fixing radioactive attachments are taken out through the common nasal passage and fixed with an adhesive plaster on the face.

According to different authors, favorable results with such combined treatment are observed on average in 30% of cases. In other cases, there are relapses, mainly in the area of the trellis, eye socket, skull base, pterygopalous area, deep parts of the facial soft tissues, etc.

Complications of radiotherapy include severe necrosis of the bone tissue, lesions of orbital organs, secondary purulent complications in the massive decay of the tumor, etc.

What prognosis are the malignant tumors of the maxillary sinus?

Malignant tumors of the maxillary sinus have a varied prognosis. He plays an important role in determining the tactics of treatment and evaluating his intended result. A correctly constructed forecast is based on the following criteria.

Morphological structure of the tumor: lymphoblastoma, embryonic type sarcoma, observed most often in children, are characterized by extremely rapid development and in most cases end in the death of the patient. Other types of tumors with slower development with their early recognition, timely radical surgical and radiation treatment may result in recovery.