Cancers of the paranasal sinuses can be distinguished in three different regions.1 The maxillary sinus, ethmoid sinus, and sphenoid sinus all have the potential to host tumors. It is most common to see the tumors arise in the maxillary sinus, and less so in the ethmoid. It is rarely shown to occur in the sphenoid or frontal sinuses. Each year approximately 2,000 people are diagnosed with paranasal sinus cancer in the United States. Of these patients, 80% of them are over 45 years old with the average being 64. Studies have shown that men, especially those from Japan and South Africa have a higher possibility of having this disease.
Etiology:
While it isn't an extemely common cancer, there are some risk factors that can be associated with it.1
Workers exposed to mustard gas, isopropyl oils, volatile hydrocarbons, or metals such as nickel or chromium.
Chronic sinusitis
Tobacco use
Signs & Symptoms:
Paranasal sinus cancers are often found because of the symptoms they cause.2 Diagnosis in people without symptoms is rare and usually accidental (because of tests done to check other medical problems). Possible symptoms of these cancers include:
Nasal congestion and stuffiness that doesn't get better or even worsens Pain above or below the eyes Blockage of one side of the nose Post-nasal drip (nasal drainage in the back of the nose and throat) Nosebleeds Pus draining from the nose Decreased sense of smell Numbness or pain in parts of the face Loosening or numbness of the teeth Growth or mass of the face, nose, or palate Constant watery eyes Bulging of one eye Loss or change in vision Pain or pressure in one of the ears Trouble opening the mouth Lymph nodes in the neck getting larger (seen or felt as lumps under the skin)
These symptoms are often common for other conditions, but if cancer is present, the symptoms will get worse instead of better.
Diagnostic Procedures:
A list of possible ways to diagnose cancers of the paranasal sinuses:2
Physical exam
Nasal endoscope
X-ray to visualize air in the sinus cavities. If no air is present, the patient could be treated for an infection to see if the problem improves.
CT scan with and without contrast
MRI- better than CT to determine if fluid or tumor
Chest x-ray to determine if cancer has spread
Excisional (remove tumor) or incisional (removes only a portion of the tumor) biopsy
Endoscopic biopsy- an endoscope is used to reach the tumor
Open biopsy- for tumors deep within the sinus
Histology:
The most common histology for tumors of the paranasal sinuses is squamous cell, but other histologic types can occur such as lymphoma, esthesioneuroblastoma, sarcoma, and inverted papilloma.2
Lymph node drainage:
The lymphatic drainage route of the paranasal sinuses goes through the lateral and inferior collecting trunks to the submandibular, parotid, and jugulodigastric nodes and through the superoposterior trunk to retropharyngeal and jugular nodes.3
Metastatic spread:
The first place of metastatic spread from the paranasal sinuses is normally the nearby structures, mainly the surrounding bone.4 Depending on which sinus, a facial bone normally surrounds the sinus. They can also spread through the lymphatics, with the most common lymphatics involved being the submandibular and subdigastric. Paranasal sinus carcinomas can also metastasize to distant structures, with the most common being the lungs and also distant bones.
Grading:
Paranasal Sinus Grading5 Grade 1: low grade(well-differentiated)- cells looks very similar to normal cells Grade 2: intermediate(moderately differentiated)- cells look slightly like normal cells Grade 3: high grade(poorly differentiated)- cells look very abnormal and unlike normal cells.
Staging:
Maxillary sinus cancer staging6 Stage 0 (Carcinoma in Situ) Stage I – Cancer has formed in the mucous membranes of the maxillary sinus. Stage II – Cancer has spread to bone around the maxillary sinus, including the roof of the mouth and the nose, but not to bone at the back of the maxillary sinus or the base of the skull. Stage III - Cancer has spread to any of the following:
Bone at the back of the maxillary sinus.
under the skin.
The eye socket.
The base of the skull.
The ethmoid sinuses.
Stage IV – Cancer has spread to any of the following:
The back of the eye.
The brain.
The middle parts of the skull.
The nerves in the head that go to the brain.
The upper part of the throat behind the nose.
The base of the skull.
Ethmoid sinus cancer staging6 Stage I - Cancer has formed and is found in only one area (of either the nasal cavity or the ethmoid sinus) and may have spread into bone. Stage II – Cancer is found in two areas (of either the nasal cavity or the ethmoid sinus) that are near each other or has spread to an area next to the sinuses. Cancer may also have spread into bone. Stage III - Cancer has spread to any of the following:
The eye socket.
The maxillary sinus.
The roof of the mouth.
The bone between the eyes.
Stage IV - Cancer has spread to any of the following:
The front of the eye.
The skin of the nose or cheek.
Front parts of the skull.
The base of the skull.
The sphenoid or frontal sinuses.
Radiation side effects:
Sore mouth and throat
Pain on chewing and swallowing
Dry mouth
Taste changes
Eye problems
Changes in your sense of smell
Changes in your hearing
Changes to your thyroid gland
Hair loss
Difficulty opening your mouth7
Prognosis:
Like most types of cancer, the quicker a diagnosis is made, the better the prognosis. There are various studies and research on previous patients, which can help predict a persons outcome. However, every person is different and survival rates can be misleading. With that said, the 5 year survival rate is poor because of recurrent disease and invasion of the brain and skull. Survival is typically 20%-30% based on average time of diagnosis, but can be up to 75% for early stage lesions.1 Based on these rates, it would make sense to assume most people already have advanced disease at the time of diagnosis. Finally, Stage IV patients have a survival rate around 35%, and Stage I patients are around 65%.
Treatments:
The classic treatment technique would involve preoperative radiation therapy with doses around 6000 cGy delivered via external beam.1 Fields could consist of a wedged pair, lateral wedged fields, three or four fileds, and possibly Intensity Modulated Radiation Therapy (IMRT) depending on location. This region presents numerous critical, dose limiting structures such as the optic nerves, chiasm, eyes, lacrimal gland, pituitary, brainstem, which may require IMRT to allow for adequate dose to the tumor volume.
Reprinted from Radiation Oncology Management Decisions, 2013.2
The image above shows portals used to treat nasal cavity and paranasal sinuses disease.
A: In patients with extensive orbital invasion (palpable orbital mass, proptosis, blindness), all orbital contents are irradiated.2B: In patients with limited orbital invasion, the major lacrimal gland is shielded. This portal is used for limited lesions of the nasal cavity. C: Typical lateral portal for treatment of paranasal sinus and nasal cavity tumors. Field is angled 5 degrees posteriorly to avoid exit irradiation to the contralateral eye.
TD 5/5:
The normal tissue tolerance dose at 5% normal tissue complication probability (NTCP) within 5 years after radiotherapy.1 Muscles (adult): 6000 cGy Oral cavity: 6000 cGy Spinal cord: 4500 cGy Lens of eye: 500 cGy Brain: 6000 cGy Retina: 5500 cGy Cornea: 5000 cGy Ear: 5000 cGy Thyroid gland: 4500 cGy Pituitary gland: 4500 cGy
Images
Reprinted from Radiation Oncology Management Decisions, 2013.2
The image above shows the nasal cavity and surrounding structures.
References:
Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier;2010.
Chao KS. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Williams & Wilkins; 2011: 230-231.
Nasal congestion and stuffiness that doesn't get better or even worsens
Pain above or below the eyes
Blockage of one side of the nose
Post-nasal drip (nasal drainage in the back of the nose and throat)
Nosebleeds
Pus draining from the nose
Decreased sense of smell
Numbness or pain in parts of the face
Loosening or numbness of the teeth
Growth or mass of the face, nose, or palate
Constant watery eyes
Bulging of one eye
Loss or change in vision
Pain or pressure in one of the ears
Trouble opening the mouth
Lymph nodes in the neck getting larger (seen or felt as lumps under the skin)
These symptoms are often common for other conditions, but if cancer is present, the symptoms will get worse instead of better.
Grade 1: low grade(well-differentiated)- cells looks very similar to normal cells
Grade 2: intermediate(moderately differentiated)- cells look slightly like normal cells
Grade 3: high grade(poorly differentiated)- cells look very abnormal and unlike normal cells.
Stage 0 (Carcinoma in Situ)
Stage I – Cancer has formed in the mucous membranes of the maxillary sinus.
Stage II – Cancer has spread to bone around the maxillary sinus, including the roof of the mouth and the nose, but not to bone at the back of the maxillary sinus or the base of the skull.
Stage III - Cancer has spread to any of the following:
- Bone at the back of the maxillary sinus.
- under the skin.
- The eye socket.
- The base of the skull.
- The ethmoid sinuses.
Stage IV – Cancer has spread to any of the following:- The back of the eye.
- The brain.
- The middle parts of the skull.
- The nerves in the head that go to the brain.
- The upper part of the throat behind the nose.
- The base of the skull.
Ethmoid sinus cancer staging6Stage I - Cancer has formed and is found in only one area (of either the nasal cavity or the ethmoid sinus) and may have spread into bone.
Stage II – Cancer is found in two areas (of either the nasal cavity or the ethmoid sinus) that are near each other or has spread to an area next to the sinuses. Cancer may also have spread into bone.
Stage III - Cancer has spread to any of the following:
- The eye socket.
- The maxillary sinus.
- The roof of the mouth.
- The bone between the eyes.
Stage IV - Cancer has spread to any of the following:Reprinted from Radiation Oncology Management Decisions, 2013.2
The image above shows portals used to treat nasal cavity and paranasal sinuses disease.
A: In patients with extensive orbital invasion (palpable orbital mass, proptosis, blindness), all orbital contents are irradiated.2B: In patients with limited orbital invasion, the major lacrimal gland is shielded. This portal is used for limited lesions of the nasal cavity.
C: Typical lateral portal for treatment of paranasal sinus and nasal cavity tumors. Field is angled 5 degrees posteriorly to avoid exit irradiation to the contralateral eye.
Muscles (adult): 6000 cGy
Oral cavity: 6000 cGy
Spinal cord: 4500 cGy
Lens of eye: 500 cGy
Brain: 6000 cGy
Retina: 5500 cGy
Cornea: 5000 cGy
Ear: 5000 cGy
Thyroid gland: 4500 cGy
Pituitary gland: 4500 cGy
Reprinted from Radiation Oncology Management Decisions, 2013.2
The image above shows the nasal cavity and surrounding structures.
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