Peritoneum

What is the Nasal Cavity and Paranasal Sinuses?

To understand these cancers, it is important to know a little about the nasal cavity, the paranasal sinuses, and the type of cells present in these areas – which can develop cancer.

The nasal cavity is the region that runs from the top of the roof of the mouth (the palate, which separates the nose from the mouth) and descends to join the passage from the mouth to the throat. The sinuses are cavities (spaces) or small tunnels, called paranasal because they are around or near the nose. The nasal cavity opens into a network of sinuses – maxillary sinuses, frontal sinuses, sphenoid sinuses, and ethmoid sinuses – which are filled with air. When there is a cold or infection, the sinuses can become blocked and fill with mucus and pus.

The nasal cavity and paranasal sinuses are lined with a layer of mucus-producing tissue (mucosa). The mucosa has many types of cells, including squamous epithelial, glandular, nervous, infection-fighting cells, blood vessel cells, and other support cells. Other types of cells in the nasal cavity and paranasal sinuses, including bone and cartilage cells, can also become cancerous.

Types of cancer of the nasal cavity and paranasal sinuses

Any cell that makes up the mucosa can become cancer with its own characteristics, which means they cannot all be treated the same way. The main types of cancer of the nasal cavity and paranasal sinuses are:

• Squamous cell carcinoma – occurs when there is a change in squamous epithelial cells. It is the most common type of cancer in the nasal cavity and paranasal sinuses, constituting a little over half of the cancers in these areas;
• Adenocarcinoma, adenoid cystic carcinoma, and mucoepidermoid carcinoma – are formed when cells from the minor salivary glands begin to reproduce disorderly. These are also relatively common nasal and paranasal sinus cancers;
• Undifferentiated carcinoma – a type of cancer that can come from mucosal cells. It is a fast-growing cancer in which the cells appear so abnormal that it is difficult to tell which type of cell it started in;
• Melanoma – the cells that give color to the skin are called melanocytes, and melanoma is a type of cancer that begins in these cells. It can grow and spread quickly. Although they are cancers usually found in areas of the skin exposed to the sun, they can form in the lining of the nasal cavity and sinuses;
• Esthesioneuroblastoma – also called olfactory neuroblastoma, is a cancer that begins in the olfactory nerve (the nerve of the sense of smell). It usually starts in the roof of the nasal cavity and involves a structure called the cribriform plate – the bone between the eyes and above the ethmoid sinuses;
• Lymphoma – begins in the cells of the immune system (called lymphocytes) and can occur in the nasal cavity and paranasal sinuses. One type of lymphoma seen in this area is nasal type extranodal NK/T-cell lymphoma;
• Sarcoma – is a cancer of muscles, bones, cartilage, and fibrous cells that can start anywhere in the body, including the nasal cavity and paranasal sinuses. There are also benign tumors of the nasal cavity and paranasal sinuses that, although not cancer, can still cause problems;
• Nasal polyps – are abnormal growths inside the nasal cavity or paranasal sinuses. Most nasal polyps are benign (not cancer), caused by some type of chronic (long-lasting) inflammation in the nose. Small polyps that are not causing problems may not need treatment. Larger polyps, on the other hand, cause problems and may need to be treated with medication or surgery;
• Papillomas – are warts that can grow inside the nasal cavity or paranasal sinuses and destroy healthy tissue. Papillomas are not cancer, but sometimes a squamous cell carcinoma starts in a papilloma. Due to the risk of cancer, papillomas of the nasal cavity and paranasal sinuses are removed by surgery;
• Inverted papilloma – a type of papilloma classified as a benign tumor, but tends to act more like a cancer. It is often treated with the same type of surgery used for cancer.

Symptoms and signs of cancer of the nasal cavity and paranasal sinuses

The symptoms of cancer of the nasal cavity and paranasal sinuses are quite nonspecific, and suspicion is always raised when they persist for at least three weeks. The most common signs are:

• Nasal congestion that doesn’t improve;
• Pain above or below the eyes;
• Blockage of one side of the nose;
• Postnasal drip;
• Nasal bleeding;
• Purulent nasal discharge;
• Decreased sense of smell;
• Numbness or pain in parts of the face;
• Loosening or numbness of the teeth;
• Appearance of a lump on the face or neck;
• Bulging of an eye;
• Loss or alteration of vision;
• Ear pain or pressure;
• Difficulty opening the mouth.

Diagnosis of cancer of the nasal cavity and paranasal sinuses

Tumors of the nasal cavity and paranasal sinuses are diagnosed based on the symptoms they cause – a diagnosis in people without symptoms is very rare.

After the clinical examination or a radiological examination, if the doctor suspects cancer, a biopsy will be requested. Once the disease is confirmed, tests are performed to check the local and distant extent of the disease, through imaging tests. The main ones are:

• Computerized Tomography – very useful in identifying cancers of the nasal cavity and paranasal sinuses. CT scans can show if a tumor has destroyed the surrounding bone. If performed on the chest, it can also show if cancer has spread to the lungs;
• Magnetic Resonance Imaging – images are better than those of CT scans for observing cancers of the nasal cavities and paranasal sinuses and determining if a change is fluid or a tumor. They can also show if a tumor has spread to nearby soft tissues, such as the eye, brain, or blood vessels;
• PET Scan (positron emission tomography) – uses a form of radioactive sugar that is injected into the blood. Since cancer cells use glucose at a higher rate than normal cells, they absorb more radioactive sugar. A special scanner is then used to create images of the areas where radioactivity has accumulated.

To confirm the diagnosis, a biopsy is necessary. In this procedure, a small piece of tissue is removed to be examined under a microscope, and this is the only way to know for sure if the tumor is nasal cavity or paranasal sinus cancer.

If cancer is found, laboratory tests can also show what type of cancer it is and its aggressiveness.

Biopsies are often done in a doctor’s office or clinic, with local anesthesia. If the tumor is in a hard-to-reach location or can bleed a lot, the biopsy will be done in the operating room.

Deep-seated tumors may be reached by endoscopic biopsy. Long, thin surgical tools are passed through the endoscope to obtain a biopsy sample.

Finally, for tumors within the sinuses, the doctor may have to cut the skin near the nose and underlying bones to reach them, in a procedure called open (surgical) biopsy.

Treatment of nasal cavity and paranasal sinus cancer

The treatment depends on the type of cancer, where it is located, and how far it has spread. The most common types of treatment for nasal cavity and paranasal sinus cancer include surgery, radiation therapy, and chemotherapy.

If the cancer is detected at an early stage, surgery may successfully remove the entire tumor. If it is growing rapidly, several combined therapies may be necessary. Understand, below, the main ways to fight nasal cavity and paranasal sinus cancer.

• Surgery – the goal of surgery in these areas is to remove the entire tumor and a small amount of normal tissue around it, maintaining the appearance and function (such as breathing, speaking, chewing, and swallowing) as normal as possible. Reconstructing and/or repairing the area around the tumor is an important part of the surgical plan.

If the margins around the tumor, analyzed in the laboratory, show cancer cells, it is more likely that some cancer has been left behind. Often, this means more treatment, such as additional surgery or radiation.

• Endoscopic surgery – is more commonly used for small tumors. In this type of surgery, an endoscope (a thin, flexible tube that is inserted into the nose to reach the nasal cavity or sinus) is used to see and remove the tumor. This way, the surgeon does not need to cut skin and bone to open the entire cavity, which reduces damage to normal tissue. Generally, the recovery from this type of surgery takes less time.

For larger tumors, this type of surgery may be used to help try to control the cancer in people who are not healthy enough for a more invasive, larger operation. It is usually combined with radiation treatment.

• Lymph node removal – cancers of the nasal cavity or paranasal sinuses sometimes spread to the lymph nodes in the neck. Depending on the stage and location of the cancer, these lymph nodes may need to be removed in an operation called neck dissection.
• Radiation therapy – people with small tumors in the nasal cavity can often be cured with radiation alone. Patients who cannot undergo surgery due to health problems or because the tumor is too advanced to be removed may also benefit from radiation therapy – typically, their only possible treatment.

After surgery, radiation can be used to kill any remaining cancer cells. This is called adjuvant treatment. Radiation can also be used before surgery to shrink the tumor, making it easier to remove.

• Chemotherapy – Chemotherapy drugs can be administered intravenously or orally. They enter the bloodstream and reach all areas of the body, making this treatment useful for metastatic cancer that has spread to organs beyond the nasal cavity and paranasal sinuses.

Chemotherapy can be used before surgery to try to reduce the tumor and facilitate removal. It can also be useful in trying to save the eyeball if the cancer spreads to the region. Before surgery, chemotherapy quickly relieves symptoms caused by the tumor. After surgery, usually along with radiation therapy, it reduces the risk of cancer returning.

If surgery or radiation is not possible, chemotherapy is one form of palliative care to alleviate symptoms of the disease and provide comfort to the patient.

Prevention

Currently, there are no screening tests to diagnose nasal cavity and paranasal sinus cancer early, and there is no way to prevent it.