Background

Sinonasal malignant neoplasms are rare tumors that constitute about 3% of tumors in the upper respiratory tract. Only a fraction arises at the nasal cavity.[1] Due to the contiguity of the nasal cavities with the paranasal sinuses, identifying the specific site of origin of large sinonasal tumors is often difficult. Henceforth, malignant tumors of the nasal cavities are often grouped with those in the paranasal sinuses. Their proximity to vital structures such as the brain, optic nerves, and internal carotid artery pose significant challenges for their treatment and may be the source of significant morbidity to the patients. Malignant tumors of the sinonasal tract are derived from diverse histologic elements within the nasal cavity. They include the following:

Epithelial Squamous cell carcinoma Transitional cell carcinoma Adenocarcinoma Adenoid cystic carcinoma Melanoma Olfactory neuroblastoma Undifferentiated carcinoma Nonepithelial Soft-tissue sarcoma Rhabdomyosarcoma Leiomyosarcoma Fibrosarcoma Liposarcoma Angiosarcoma Myxosarcoma Hemangiopericytoma Connective tissue sarcoma Chondrosarcoma Osteosarcoma Synovial sarcoma Lymphoreticular tumors Lymphoma Plasmacytoma Giant cell tumor Metastatic carcinoma Epidemiology Frequency

The annual incidence of nasal tumors in the United States is estimated to be less than 1 in 100,000 people per year. These tumors occur most commonly in whites, and the incidence in males is twice that of females.[2] Epithelial tumors most commonly present in the fifth and sixth decades of age.

Although tumors of the nasal cavities are equally divided between benign and malignant types, most tumors of the paranasal sinuses are malignant. Approximately 55% of sinonasal tumors originate from the maxillary sinuses, 35% from the nasal cavities, 9% from the ethmoid sinuses, and the remainder from the frontal and sphenoid sinuses. Squamous cell carcinoma is the most common malignant histologic type (approximately 70-80%) followed by adenoid cystic carcinoma and adenocarcinoma (approximately 10% each).[3]

Etiology

Exposures to industrial fumes, wood dust, nickel refining, and leather tanning have all been implicated in the carcinogenesis of various types of sinonasal malignant tumors. In particular, wood dust and leather tanning exposures are well associated with increased risk for adenocarcinoma.[4] Other etiologic agents have been reported including mineral oils, chromium and chromium compounds, isopropyl oils, lacquer paint, soldering and welding, and radium dial painting. Tobacco smoking is not considered to be a significant etiologic factor; however, recent studies demonstrated a higher incidence of nasal cancers in cigarette smokers.[2, 5]

Presentation

Tumors of the sinonasal tract commonly present with symptoms that are identical to those caused by inflammatory sinus disease, such as nasal obstruction, nasal discharge, epistaxis, headache, facial pain, and nasal discharge. Tumors of nasal cavities, however, tend to be diagnosed earlier than those of the paranasal sinuses because of the earlier presentation of obstructive symptoms and epistaxis.

To further complicate this issue, 9-12% of patients are frequently asymptomatic.[6] These factors contribute to a delay in diagnoses, and, hence, an advanced stage of disease at the time of diagnosis. Patients with unilateral sinonasal symptoms or those that are associated with unilateral facial swelling, diplopia or blurred vision, unilateral proptosis, and cranial neuropathies should raise a high index of suspicion for sinonasal cancer and warrant urgent evaluation.

Regional and distant metastases are infrequent even in the presence of advanced stage tumors. The incidence of cervical metastases on initial presentation varies from 1-26%, with most large series reporting less than 10%. Distant metastasis on initial presentation is even less common, with most series presenting an incidence of less than 7%.[1] The presence of regional or distant metastases is a poor prognostic sign.

A thorough head and neck examination, cranial nerve assessment, and a nasal endoscopy should be performed in all patients. Physical examination may reveal proptosis, extraocular muscle impairment, mass effect of the cheek, gingival or gingivobuccal sulcus, (eg, ill-fitting dentures) and loose dentition. Numbness or hyperesthesia of the infraorbital (V2) branch of the maxillary nerve strongly suggests malignant invasion (as in the images below).

A nasal cavity tumor has eroded through the hard palate and is causing difficulty with fitting a denture.

A nasal tumor that has eroded through the nasal bone and causing deformity of the nasal bridge.

Relevant Anatomy

By examining the close relationships of the nasal cavities to the oral cavity, paranasal sinuses, orbit, nasopharynx, pterygomaxillary fissure and pterygopalatine fossa, infratemporal fossa, skull base, and intracranial fossa, one can better understand the myriad signs and symptoms caused by sinonasal tumors.

Local tumor invasion can breach the boundaries of the nasal cavity invading and destroying structures and/or following preformed pathways. The paired nasal cavities are separated by the nasal septum. Their lateral walls comprise the medial wall of the maxillary sinus and the inferior, middle, and superior turbinates. Lateral extension of tumor can infiltrate the maxillary sinus, ethmoid air cells, or even the orbit (through the lamina papyracea). Eventually, orbital involvement manifests as ocular pain, fullness of the eyelid, unilateral epiphora, diplopia, extraocular muscle limitation/diplopia, or proptosis. The floor of the nasal cavity corresponds to the hard palate of the oral cavity; thus, caudal extension of the tumor can present as palatal fullness, pain, and ulceration.

The roof of the nasal cavities is formed by the cribriform plate, which separates the dura of the anterior cranial fossa from the nasal cavity. The cribriform plate, as implied by its name, has multiple openings to accommodate the passage of olfactory filaments. Tumor can spread to the anterior cranial fossa using these openings or by perineural spread. Violation of this barrier during surgery is likely to produce a cerebrospinal fluid (CSF) leak, increasing the risk for meningitis and intracranial abscess. The nasal cavities open externally via the nares and communicate posteriorly with the nasopharynx via the choanae. The eustachian tubes open into the nasopharynx just behind the infero-lateral aspect of the choanae. Tumor extension into the nasopharynx may cause eustachian tube obstruction and secondary serous otitis media that manifests as hearing loss.

Except in the nasal vestibule, the nasal cavity is lined with pseudostratified columnar ciliated epithelium. The nasal vestibule, which corresponds to the ala of the nose, is lined with squamous epithelium containing vibrissae and sweat and sebaceous glands. A small part of the superior portion of the nasal cavity (bound by the superior turbinate laterally and the nasal septum medially) is lined by olfactory epithelium.

The pterygopalatine and infratemporal fossae are important anatomical considerations, as they are densely populated by the mastication muscles, various sensory and motor nerves, and by the blood vessels that supply the nasal cavity, oral cavity, maxillary teeth, pharynx, and ICAs. Tumor extension into these areas can cause a myriad of symptoms, such as the following:

1. Trismus (involvement of the pterygoid muscles or motor branches of the mandibular division of the trigeminal nerve)

2. Facial hypesthesia (involvement of the infraorbital nerve or other sensory branches from the maxillary and mandibular divisions of the trigeminal nerve)

3. Pain in the maxillary dentition (involvement of the anterior, middle, or posterior superior alveolar nerve branches of the maxillary division of the trigeminal nerve)

4. Severe epistaxis (involvement of the terminal branches of the internal maxillary artery)

The pterygopalatine and infratemporal fossae are also potential routes for intracranial tumor spread, via direct extension or hematogenous spread.

Sinus Anatomy & Function

The sinuses are air filled cavities located in the face and around the nose. The sinuses are named according to the bone in which they are located.

grosssinus

There are four paired sinus cavities. The maxillary sinuses are located in each cheek bone. The ethmoid sinuses are located between the eyes. The frontal sinuses are in the forehead above the eyes. The sphenoid sinuses are in the back of the head, located behind the ethmoid. They drain into the nose via specific openings called ostia. The goal of Functional Endoscopic Sinus Surgery is to maximize the size of these ostia.

Children have maxillary and ethmoid sinuses, however, the sphenoid and frontal sinuses develop during the teenage years.

Sinuses serve many functions. They first filter and humidify the air we breath. In evolutionary terms, they lighten the weight of the head. They also protect our vitals structures in trauma situations functioning as crumple zones.

The nasal septum divides the nose into two separate nasal cavities. The side of the nose contains three structures called turbinates. The turbinates are named for their location in the nose, inferior (lower), middle and superior (upper). Inferior turbinate enlargement will result in patients

complaining of nasal obstruction. The main function of turbinates is to provide humidification and provide mucus production for the nose.

The nose and sinuses are covered with a complex lining that is lined with millions of cilia. The lining secretes mucus which functions to keep the nose moist and has properties to capture and eliminate allergens and certain viruses/bacteria. The cilia sweep mucus in a choreographed fashion to eliminate irritants in the nose and sinuses. When the cilia are damaged, patients develop chronic sinusitis. Cilia are damaged by viruses, tobacco, genetic illnesses (cystic fibrosis), allergens, bacteria and certain chemicals. Ciliary damage is a difficult and complicated problem to manage.

cilia 3500X

Electron micrograph of sinus mucosa demonstrating hair-like cilia projections

Paranasal Sinuses - MRILaurie Loevner and Jennifer Bradshaw

Radiology department of the University of Pennsylvania, USA and the radiology department the Medical Centre Alkmaar, the Netherlands

Role of CT and MRIo Signal characteristics of secretionso Pseudo-pneumatized sinuso Enhancement Complications of Sinusitiso Brain abscesso Mucoceleo Orbital Cellulitis and Abscesso Complication of FESS Tumor and tumorlike lesionso Encephaloceleo Mucoceleo Inverted papillomao Malignant tumors of the sinonasal tracto Meningiomao Keratocysto Silent sinus Fibro-osseous Lesionso Fibrous dysplasiao Osteitiso Osteoma Monitoring response to therapy

Publicationdate February 25, 2009

This article is based on a presentation given by Laurie Loevner and adapted for the Radiology Assistant by Jennifer Bradshaw.This review focusses on the complimentary roles that CT and MR play in the assessment of:

Complicated sino-nasal infections Sino-nasal and skull base lesions Fibro-osseous lesions

Role of CT and MRI

CT is of value for determining anatomic landmarks and variants.This information is of vital importance to the ENT-surgeon. In addition, we need it to identify erosive processes and acquired developmental deficiencies of the bone. CT is also excellent for determining whether there is intraorbital extension of sino-nasal disease in the ventral 2/3 of the orbit. When pathology approaches the orbital apex, an MRI study is necessary to assess spread to the cavernous sinus and intracranial compartment.CT is performed without contrast medium. If additional imaging is necessary, orbital MRI is the next step.

The real value of unenhanced CT is the following: if you see an opacified sinus with hyperdense contents, it is usually a sign of benign disease. Tumor is not hyper-dense. 

The hyperdensity is due to one or a combination of the following:

inspissated secretions fungus blood

On the left you see a case that was initially interpreted as a tumor. There is hyperdense material in the posterior right ethmoid, the bilateral spheno-ethmoidal recesses, the sphenoid sinus and there is involvement of the clivus. The hyperdensity is a good prognostic sign, indicating a benign process. This is an example of allergic fungal sinusitis.Usually it is more anteriorly located.

On the left another, more characteristic, example of allergic fungal sinusitis.There is bilateral opacification of the nasal cavities, usually a sign of an inflammatory process or polyps. Note the concentric lamellated appearance of alternating hyper- and hypodensity in the maxillary sinusses. 

The hyperdensity is due to inspissated secretions and fungal elements.The hypodensity reflects cysts, mucosal disease, and granulation tissue.In the ethmoidal region some of the hyper-density reflects periostitis and neo-osteogenesis along the septae.

Signal characteristics of secretions

MRI is extremely helpful in complicated sinonasal disease.MRI can discern secretions and mucosa from masses. When you understand the signal characteristics, you are readily able to distinguish soft tissues masses from inspissated secretions. The signal intensity of secretions can vary and mainly depends on the ratio of water to protein and the viscosity. Different protein contents result in different signal intensities on T1 and T2W-images (figure).Fungus usually has a high protein content of more than 28% and can mimic an aerated sinus because it is low on T1- and T2WI. You need CT to make the distinction!

MRI is also useful for determining invasion of the skull base.Involvement of the skull base is seen as replacement of the high signal of the fatty marrow on T1WI by hypointense signal of the tumor.

Also look for foraminal extension, whether by perineural spread or direct invasion of the tumor. MRI is also the study of choice for detecting intracranial extension of sinonasal disease.

Pseudo-pneumatized sinus

Role of CT and MR (2)On the left a T2W-image in an immuno-compromised patient with fever.Initially a MRI was performed to rule out sinusitis. Notice the low signal intensity of the left sphenoid sinus, which also had a low signal intensity on the T1W-image (not shown).Continue with the CT.

The CT clearly shows the opacified sinus, which is slightly hyperdense. The signal characteristics on MRI and the attentuation on CT are a result of the high protein content of fungus.This is a good example of the pitfall of the 'pseudo-pneumatizedsinus' . This is an example of an Actinomyes infection. So, when invasive fungal infection is suspected, start with a CT, then move on to MRI to rule out spread to the eye, cavernous sinus and intracranial compartment!

Enhancement

In general bright signal on T2 is a sign of benign disease, since fluid and mucosal disease usually have a high water content. 

Secretions do not have solid enhancement. If you have an enhancing mass, you must rule out tumor.

On the left an example of infectious sinonasal disease.On the pre-contrast scan you see relatively high signal content of the maxillary sinusses due to

proteineous material. After the administration of i.v. contrast there is only enhancement of the circumferential mucosa and no solid enhancement.

Role of CT and MR (3)In complicated cases both CT and MR are needed to demonstrate the extention of the disease. On the left CT-images of a patient post-lung transplant with fever and multiple rapidly progressing cranial nerve palsies. We will show you CT- and MR-images of this patient. The diagnosis lymphoma was made through biopsy. 

First study the images to study the extentionod the disease.Then continue reading.

On the CT-images the findings are:

Soft tissue mass in the maxillary sinus (red arrow).

Destruction of the sinus wall (yellow arrow).

Remodelling and destruction of the pterygoid bone (blue arrow).

Large soft tissue mass in the masticator space (asterisk).

The image on the right is more cranial. There is opacification of the sphenoid sinus with destruction of and osteopenia of the sphenoid bone.CT nicely demonstrates the bone destruction and some of the soft tissue involvement.Continue with the MR-images.

On the left the corresponding MRI.  First study the images, then continue reading.

The findings are:

Fluid in the right sphenoid sinus (red arrow). Hypointense tissue in the left sphenoid sinus (yellow arrows). Tracking along the dural margin of the middle cranial fossa (blue arrows). Extension into the left zygomatic-masticator space (large yellow arrow). Following contrast, there is no solid enhancement of the tissue in the sphenoid space.

Continue with the coronal images.

Coronal images of the same patient: T1 pre-and post-contrast. Normal aspect of the right Meckel's cave, tissue in the left Meckel's cave extending into the cavernous sinus (blue arrow). The red arrow points to the dural margin of the cavernous sinus: there is enhancement on both sides of the dura. The disease wraps around the temporal lobe (green arrow) and extents downward in the foramen ovale (yellow arrow) and into the masticator space. The asterix indicates normal non-enhancing tissue in the masticator space.This patient had a lymphoma. Nine out of ten times an immunocompromised patient will have a fungal infection, in one out of ten it will be a lymphoma. CT and MR have a complimentary role in this case, but finally a biopsy is called for to differentiate between these two diagnoses, because of different treatment.

Role of CT and MR (4)On the left images of a 64-yrs-old, immuno-competent patient, who had a follow-up scan for left-sided vestibular neuroma. On the image on the left hypointense tissue is seen in the pterygo-palatine fossa and videan canal (yellow arrow). On the image on the right, which is more cranial, there is hypointense tissue in the pterygo-maxillary fissure and pterygo-palatine fossa. Continue with the contrast-enhanced T1W-image.

There is solid enhancement of the abnormality. The differential diagnosis again consists of 2 catagories: neoplasm and chronic invasive fungal infection. In an immuno-competent patient, a neoplasm is much more likely. Continue with the CT-images.

This is the corresponding CT, performed not to make the diagnosis, but to assess the condition of the adjacent bony structures, especially the sphenoid sinus. Also, it serves to guide the endoscopist for intraoperative biospy. There is extensive destruction of the skull base.

The coronal image illustrates a normal foramen rotundum on the left (yellow arrow), which on the right has been obliterated by soft tissue. There is extensive bone destruction, and a possible area for biopsy is indicated by the blue arrow. At biopsy the diagnosis of a spindle cell carcinoma was made.

Complications of Sinusitis

When assessing the complications of sinusitis, CT is excellent for imaging of subperiostial abscesses or orbital extension into the ventral 2/3 of the orbit. MRI is necessary for assessing intracranial complications, such as brain or epidural abscesses, subdural empyema or sinus thrombosis.

Brain abscess

On the left images of a patient was initially diagnosed with a glioblastoma multiforme. There are abnormalities in both frontal lobes.Notice however the abnormal tissue in the frontal sinus (yellow arrow), subperiosteal abscess (red arrow) and the fluid-fluid level (green arrow) in the large intracranial lesion which has ring enhancement. 

All abnormalities are continuous meaning there is frontal bony destruction. The restricted diffusion also supports the diagnosis of brain abscess.This is a subperiosteal abscess and osteomyelitis of the frontal bone, usually with a soft tender swelling of the forehead.This is also called Pott's puffy tumor after Sir Pott, an English surgeon who first described this entity.

Brain abscess (2)On the left images of another patient, who had recently been treated for sinusitis and now presented with a seizure. The CT shows an abnormality in the left temporal lobe with shaggy thick rim enhancement, and a large amount of vasogenic edema. This is also a brain abscess, most probably due to reflux of bacteria into cranial veins and the venous plexus around the cavernous sinus.

Mucocele

On the left images of a patient with acute sinusitis and ethmoid air cell disease.He presented with blurred vision. First study the images, then continue reading.

Notice the fluid in the left anterior clinoid process. The optic nerve runs medial to it.Continue with the coronal images. 

The coronal T2WI shows expansion of the clinoid process. The T1WI shows loss of normal fat compared with the right side, and extension into the orbital apex (red arrow). This is a mucocele of the anterior clinoid with secondary involvement of the optic nerve.

Orbital Cellulitis and Abscess

Left is an axial T1WI, right is a coronal T2WI. There is an abnormality on the left side, but to a lesser degree also on the right. Try to determine which structures are involved. The yellow arrows point to the naso-lacrimal ducts. The naso-lacrimal sac connects with the duct, which then drains into the inferior meatus. On the left there is peri-orbital pre-septal soft tissue swelling. On the coronal image there is bilateral high signal at the junction of the nasolacrimal duct and sac, indicative of a fluid collection. On the left side there is also edema of the surrounding tissue.

Post-contrast T1WI, axial and coronal. Lateral to the naso-lacrimal ducts on both sides, there are the fluid collections which now show peripheral enhancement.

The additional images (T2WI) show mucosal disease of the right maxillary sinus and a fluid level in the left maxillary sinus, in addition to extensive ethmoidal and sphenoidal sinus disease. This patient had acute sinusitis which was complicated by orbital cellulitis and dacrocystitis with abscesses. Developmental or inflammatory narrowing of the naso-lacrimal duct is a risk factor for developing dacrocystitis.

See the article on Orbital Pathology by David Youssem for more information about orbital and periorbital cellulitis

Complication of FESS

A rare complication of FESS is seen on the images on the left. The Hounsfields Units of the tiny abnormalities that the asterisk points to were around -120.

First study the axial images. Then continue with the coronal images.

There is a bone defect at the fovea ethmoidalis (red arrow). Also there are post-operative changes indicating that the patient had undergone FESS. The intracranial air is a complication of FESS.

With this complication, usually the patient goes home feeling fine, and then shows up approximately two weeks later with CSF leak and meningitis, due to the defect in the bone and dura. Tension pneumocephalus occurs when air in the head acts like a mass: there is a bony defect which lets air in but not out (valve-like function). Every time the patient sneezes, air is forced through the defect into the intra-cranial space, and remains trapped there. At a certain moment the amount of air is sufficient to cause mass effect on the surrounding intra-cranial structures.

Tumor and tumorlike lesions

Role of CT and MRWhen it comes to imaging of neoplasms of the paranasal sinuses, CT and MRI play complementary roles. It is not about the histology but about answering the question 'is it tumor or not?' and then determining the extent of the disease, for example intracranial or orbital extension. Use MRI to differentiate inspissated secretions from neoplasms. Scanning down to the hyoid bone allows for examination of the levels I and II lymph nodes: about 10% of paranasal neoplasms have nodal metastases at presentation.

Encephalocele

Coronal T2WI of the patient on the left show an abnormal structure in the right nasal cavity. When you've decided what it is, then stop to think about whether the abnormality is developmental or acquired. This patient has an encephalocele. There are two findings on the images that let you know that this is developmental. First of all, notice the smaller encephalocele on the left side (green arrow). Acquired encephaloceles are more often than not unilateral. The second clue is the cortical dysplasia (yellow arrow) as part of a migrational abnormality. Acquired encephaloceles (ie after surgery) tend to lead to dead gliotic brain, which would have a high signal intensity on T2WI. The strange looking structure in the left image (red arrow) is surgical packing, placed there after the involuntary encounter with brain tissue.

The blue arrow points to the sphenoid sinus which is hyperintense, due to mucoid impaction as a result of obstruction by the encephalocele.

Mucocele

Mucoceles are benign, locally expansile paranasal sinus masses most commonly found in the frontal sinus.Secondary to obstruction of the sinus ostia, there is accumulation of fluid within a mucoperiosteal lined cavity, resulting in erosion and remodelling of the surrounding bone.The most common causes of mucoceles are chronic infection, allergic sinonasal disease, trauma and previous surgery.The most common location of a mucocele is the fronto-ethmoidal sinus, followed by the sphenoid sinus. The least common location is the maxillary sinus.

On the left a patient with an uncommon cause of a mucocele.Notice the obstructing solid mass at the frontal ethmoidal junction (yellow arrows).

Pre- and post-contrast MRI of the same patient. The mucocele shows high signal intensity on T1W (benign finding).The mass in the ethmoidal region is hypointense and solidly enhancing. 

Mucocele (2)The case on the left shows two classic complications of frontal facial trauma. The bilateral nasal fractures are the clue to a traumatic etiology. Looking at the CT scan on the far left you will notice a convex soft tissue mass in the frontal sinus. The corresponding MRI shows a round hyperintense structure in the same location. 

Study the images on the left and then continue reading.

Now look again carefully at the far left CT. Did you notice the bony defect on the left side, at the lateral border of the ethmoid air space (yellow arrow)? The MRI shows that there is brain tissue at the site of the defect. This patient had both a mucocele and an acquired encephalocele. The two most common causes of mucoceles are trauma and chronic inflammation due to blockage of the ostia.

Mucocele (3)This companion case nicely demonstrates bilateral mucoceles. This patient has chronic sinusitis with sino-nasal opacification, mucoid impaction in the maxillary sinusses and huge bilateral mucoceles. The CT shows hyperdensity and the MRI shows hyperintensity on T2WI, both of which you will remember are benign signs in sino-nasal disease, indicating a proteinaceous substance. There is smooth bone remodelling and elevation of the frontal sinusses, and although it looks as if there is bony destruction at the orbital boundary of the frontal sinus, usually the surgeon will still see a fine line of bone in place.

Inverted papilloma

Inverted papilloma is characterized by inversion of the neoplastic epithelium into the underlying stroma.It presents as a unilateral nasal polyp arising from the lateral nasal wall, usually in the region of the middle meatus and middle turbinate.Extension into the maxillary and ethmoid sinuses is common.

It causes non-specific symptoms like nasal congestion or epistaxis.Biopsy is necessary to make the diagnosis and because more than 10% of inverted papillomas harbor a squamous cell carcinoma.

When you want to differentiate inspissated secretions from neoplasms it is important to have pre- and post-contrast images. If you were to just look at the post-contrast study on the right, you might be tempted to think that there was solid enhancement of the mass in the nasal cavity (asterisk) as well as in the ethmoidal and maxillary sinus on the right. Looking at the pre-contrast study, however, you will notice that the contents of the ethmoidal and maxillary sinuses are hyperintense as opposed to the mass in the nasal cavity (the middle meatal region), because the sinuses are filled with inspissated secretions. This solidly enhancing mass is a tumor until proven otherwise. The imaging findings are non-specific and the differential diagnosis includes a polyp or a carcinoma.Biopsy revealed an inverted papilloma.

Inverted papilloma (2)On the left another patient who presented with nasal stuffiness. Study the images on the left. Decide for yourself whether you are looking at a solid mass, inspissated secretions, a combination of both or something entirely different. The pre-contrast T1WI shows a hyperintense area within the maxillary sinus, corresponding to a proteinaceous substance.Medial to it is an area with hypointense signal similar to the signal in the orbital globes (so probably cystic). The majority of the soft tissue in the right maxillary sinus is relatively hypointense on the pre-contrast T1WI, but solidly enhances, meaning tumor. 

The T2W-image on the left confirms the cystic element (yellow arrow). The coronal CT nicely demonstrates remodelling of the bone and expansion (arrowheads).This proved to be an inverting papilloma. The localisation is rather typical.

Malignant tumors of the sinonasal tract

Malignant tumors of the sinonasal tract are extremely rare.The clinical presentation is non-specific and often mimics benign disease.As a result a delay in diagnosis is common.75% of all paranasal sinus tumors are Stage T3 or T4 at the time of diagnosis. Perineural spread is a manifestation of advanced disease and indicates a poor prognosis.

On the left an axial MR-image showing a mass in the ethmoids. The MRI shows no intracranial extension. 

What is the next step?

A CT is necessary to determine the integrity of the adjacent bone. Notice the bony destruction of the fovea ethmoidalis and planumsphenoidale. This indicates that this is a malignant lesion and biopsy demonstrated an adenocarcinoma.If the patient is a surgical candidate, frontal endoscopic sino-nasal surgery won't be enough and a cranio-facial take-down will also be required.

Meningioma

A meningioma can spread transcranially. On the left is a patient with a meningioma, which spreads along the anterior clinoid (arrow). 

Continue with a coronal image more anteriorly.

MRI nicely demonstrates how the meningioma spreads down into the sino-nasal cavity.

Keratocyst

First look at the images on the left. From where is this lesion arising? 

The lesion is expansile with bone remodelling and there is an obvious relation to a tooth. It is very important to determine whether or not sinus pathology has an odontogentic origin, simply because the surgical approach is different. If odontogentic, the surgery will be done preferably by a maxillofacial surgeon. If approached by a sino-nasal route it won't be removed entirely. This is a keratocyst

On the left another case. This patient presented with facial pain. On this contrast-enhanced MRI we see a non-enhancing expansile lesion in the right maxillary sinus. As it doesn't enhance, we know we aren't dealing with tumor.

It is tempting to call this a retention cyst and move on to the next case, but a CT is called for to make the correct diagnosis.

The corresponding CT shows elevation of the maxillary bone (blue arrow). The red arrow in the right image indicates the cyst dissecting around the root of a tooth. This is also a keratocyst.

Silent sinus

On the left a patient who presented with asymmetric eyes. First study the images and try to describe what is going on. Then continue reading. 

This film was originally read as ethmoid sinusitis and post-surgery. However, this patient had never undergone sino-nasal surgery. What you in fact see, is adhesion of the middle right turbinate (red arrow) and the uncinate process to the floor of the orbit. There is also volume loss of the right maxillary sinus.

This is called the silent sinus syndrome, which consists of painless facial asymmetry and enophthalmos caused by chronic maxillary sinus atelectasis.The most characteristic imaging feature of the silent sinus syndrome is the inward retraction of the sinus walls into the sinus lumen with associated decrease in sinus volume and enlargement of the middle meatus (2). In many cases the infundibulum is occluded due to lateral retraction of the uncinate process.

Fibro-osseous Lesions

Fibro-osseous lesions are very common incidental findings and often misinterpreted as tumor. CT is usually diagnostic, so when you see a bizarre lesion at the skull-base, think of a fibro-osseous lesion and get an unenhanced CT. The most common skull base lesion is fibrous dysplasia, followed by osteomas.Osteomas are usually located in the sino-nasal cavities. Fibromas are less common and can be ossifying or non-ossifying.Malignancies are rare.

Fibrous dysplasia

On the left images of a patient who was thought to have a chondrosarcoma. On the T2W-images there is a hypointense lesion (yellow arrow) with a cystic component (red arrow). On the pre- and post-contrast T1W-images there is solid enhancement of a mass with peripheral enhancement of the cystic portion. 

Question: what should be the next step?

Next step: get a CT! On CT this is classic fibrous dysplasia (FD) with cortical sparing and ground-glass appearance. Many of the fibrous dysplasia lesions in the clivus, skull base or sino-nasal cavity and in children may have large cystic components, so don't let that dissuade you from the diagnosis!

Fibrous dysplasia (2)On the left another example of fibrous dysplasia. This lesion originates from the middle turbinate.

Fibrous dysplasia (3)On the left another patient read as having a soft tissue tumor (yellow arrow) anterior to the temporal bone.

These are the corresponding axial CT images showing classic fibrous dysplasia of the sphenoid wing. The differential diagnosis is a meningioma.

Fibrous dysplasia (4)On the left images of a different patient with soft tissue in the sphenoid sinus on the left, and an abnormality of the left sphenoid wing, which is about 3 times its normal size whilst maintaining its normal shape.On the post-contrast images there is solid enhancement. Again the diagnosis is fibrous dysplasia. Fibrous dysplasia is a very vascular lesion and can enhance avidly.

Osteitis

In contrast, this is a patient with osteitis of the middle turbinate and ethmoid septae. Note the laminated high density, due to chronic inflammation and recurrent periostal reaction with neo-osteogenesis around the septae.

Osteoma

This is a patient who had been having brain MRI for the past 1,5yrs for frontal headaches. On the MRI (not shown) it looked as if the patient had a little mucosal disease of the frontal sinus. The sinus CT clearly shows an osteoma with a bony defect (arrow) indicating progressive growth. This lesion requires surgical excision. Note: multiple para-nasal osteomas are found in Gardner's syndrome, which also includes cutaneous and soft tissues tumors in addition to colonic polyps with a predilection to malignant degeneration.

Monitoring response to therapy

Imaging can also be used to monitor treatment response. This patient had a skull-base B-cell lymphoma. Pre-treatment we see the extent of the lesion, which is FDG-avid.

Three months into therapy the skull-base mass has resolved.There is no more pathological FDG uptake, and there is remineralisation of the bone.

The patient on the left had a resection of a carcinoma.Now there is a recurrence (blue arrow on MR and fusion image). The green arrow, however points to post-radiation tissue changes.

On the left a patient who had a prior cranio-facial resection (yellow arrows) for an undifferentiated carcinoma.This patient was treated with chemoradiation. The T2WI on the left shows tumor recurrence intracranially.Continue with the contrast enhanced images.

In cases like this a recurrence tend to show bizarre patterns such as these extensive dural implants.

Nasal Cavity and Paranasal Sinus CancerThis is Cancer.Net’s Guide to Nasal Cavity and Paranasal Sinus Cancer. Use the menu below to choose the Overview section to get started. Or, you can choose another section to learn more about a specific question you have. Each guide is reviewed by experts on the Cancer.Net Editorial Board, which is composed of medical, surgical, radiation, gynecologic, and pediatric oncologists, oncology nurses, physician assistants, social workers, and patient advocates.

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2014

ON THIS PAGE: You will find some basic information about these diseases and the parts of the body they may affect. This is the first page of Cancer.Net’s Guide to Nasal Cavity and Paranasal Sinus Cancer. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

Cancer begins when normal cells in the body change and grow uncontrollably, forming a mass called a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can spread to other parts of the body. A benign tumor means the tumor will not spread and usually can be removed without growing back.

Nasal cavity and paranasal sinus cancer are malignant tumors that begin in the inside of the nose or paranasal cavities around the nose. The nasal cavity is the space just behind the nose where air passes on the way to the throat. The paranasal sinuses are air-filled areas that surround the nasal cavity on the cheeks, the maxillary sinuses; above and between the eyes, the ethmoid and frontal sinuses; and behind the ethmoids, the sphenoid sinuses. The maxillary sinus is the most common location of paranasal sinus cancer.

Nasal cavity and paranasal sinus cancer are two of the major types of cancer in the head and neck region and belong to a group of tumors known as head and neck cancer.

Types of nasal cavity and paranasal sinus cancer

The nasal cavity and paranasal sinuses contain several types of tissue, and each contains several types of cells. Different cancers can develop from each kind of cell. The differences are important because they determine how fast growing the cancer is and the type of treatment needed.

The nasal cavity and paranasal sinuses are lined by a layer of mucus-producing tissue with the following cell types: squamous epithelial cells, minor salivary gland cells, nerve cells, infection- fighting cells, and blood vessel cells. Some tumor types found in these cells and tissues include the following:

Squamous cell carcinoma. This is the most common type of nasal cavity and paranasal sinus cancer. Squamous cells are flat cells that make up the thin surface layer of the structures of the head and neck.

Adenocarcinoma. This is the second most common type of nasal cavity and paranasal sinus cancer. It begins in the gland cells.

Malignant melanoma. This develops from cells called melanocytes that give the skin its color. It is usually an invasive, fast growing cancer; however, it only accounts for about 1% of tumors found in this area of the body. Learn more about melanoma.

Inverting papilloma. These are benign, wart-like growths that may develop into squamous cell carcinoma. Approximately 10% to 15% of these can develop into cancer.

Esthesioneuroblastoma. This type of cancer is related to the nerves that control the sense of smell. It occurs on the roof of the nasal cavity and involves a structure called the cribriform plate, a bone located deep in the skull between the eyes and the sinuses. This type of cancer looks similar to neuroendocrine cancer, so it is important to figure out which one it is.

Midline granuloma. This refers to a group of several unrelated conditions that cause the breakdown of the healthy tissue of the nose, sinuses, and nearby tissues. Some cases are due to immune system problems, and many others are actually a type of lymphoma, a cancer of the lymphatic system. The lymphatic system carries lymph, a colorless fluid containing a type of white blood cell, called lymphocytes. Lymphocytes are part of the immune system and help fight germs in the body.

Lymphoma. This is a type of cancer that originates in the lymph tissue within the lining of the nasal cavity and paranasal sinuses, called the mucosa.

Sarcoma. Sarcoma is a type of cancer that begins in muscle, connective tissue, or bone.

ON THIS PAGE: You will find out more about the factors that increase the chance of developing these types of cancer and things you can do to help prevent them. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

Two risk factors greatly increase the risk of nasal cavity and paranasal sinus cancer:

Tobacco use. Use of tobacco is the single largest risk factor for head and neck cancer. Tobacco products include cigarettes, cigars, pipes, chewing tobacco, and snuff. Eighty-five percent (85%) of head and neck cancer is linked to tobacco use. Additionally, recent research suggests that

people who have used marijuana may be at higher risk for head and neck cancer. Secondhand smoke may also increase a person’s risk of head and neck cancer.

Alcohol. Frequent and heavy consumption of alcohol is a risk factor for head and neck cancer. Using alcohol and tobacco together increases this risk even more.

Other factors can raise a person’s risk of developing nasal cavity or paranasal sinus cancer:

Human papillomavirus (HPV). Research indicates that infection with this virus is a risk factor for nasal cavity and paranasal sinus cancer. HPV is most commonly passed from person to person during sexual activity. There are different types, or strains, of HPV, and some strains are more strongly linked with certain types of cancers. HPV vaccines protect against specific strains of the virus.

Specific inhalants. Breathing in certain substances, most commonly found in the work environment, may increase the risk of developing nasal cavity or paranasal sinus cancer. These substances include:

Dust from the wood, textiles, or leather industries Flour dust Nickel dust Chromium dust Mustard gas Asbestos Rubbing alcohol, also called isopropyl alcohol, fumes Radium fumes Glue fumes Formaldehyde fumes Solvent fumes used in furniture and shoe production

Exposure to air pollution. Being exposed to air pollution may increase a person’s risk of nasal cavity and paranasal sinus cancer.

Gender. Nasal cavity and paranasal sinus cancer occurs twice as often in men than women.

Age. This type of cancer is most commonly found in people between the ages of 45 and 85.

Prevention

Research continues to look into what factors cause this type of cancer and what people can do to lower their personal risk. There is no proven way to completely prevent nasal cavity and paranasal sinus cancer, but there may be steps you can take to lower your cancer risk. Talk with your doctor if you have concerns about your personal risk of developing these types of cancer.

Although some risk factors for nasal cavity and paranasal sinus cancer cannot be changed, such as a person’s age and gender, several can be avoided by making lifestyle changes. Stopping the

use of all tobacco products is the most important thing a person can do, even for people who have been smoking for many years.

Also, avoiding exposure to substances that have been known to increase the risk of cancer and wearing a protective facemask to reduce breathing in potentially harmful substances may help reduce this risk. Workplace exposure and industrial-related hazards can be reduced by appropriate air filtering, and workers in these areas need to be aware of their potential risk of exposure.

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread, as well as the way the tumor cells look when viewed under a microscope. This is called the stage and grade. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

One tool that doctors use to describe the stage is the TNM system. TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor and where is it located? (Tumor, T) Has the tumor spread to the lymph nodes? (Node, N) Has the cancer metastasized to other parts of the body? (Metastasis, M)

The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Here are more details on each part of the TNM system for nasal cavity and paranasal sinus cancer:

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below.

TX: The primary tumor cannot be evaluated.

T0: No evidence of a tumor is found.

Tis: This is a very early stage cancer when cancer cells are found only in one layer of tissue. It is also called carcinoma (cancer) in situ.

Tumors of the paranasal sinuses are also evaluated by their exact location. See the Overview section for descriptions.

Primary tumor (T) in the maxillary sinus

T1: The tumor is limited to the inside of the sinus and does not erode or invade bone.

T2: The tumor erodes or invades bone surrounding the sinuses.

T3: The tumor invades the surrounding bone, the skin of the cheek, or the other sinuses.

T4a: The tumor invades the bone surrounding the eye, the skin of the cheek, or the bones in the back of the throat.

T4b: The tumor invades any of the following: the back of the eye, the brain area, or the bones of the skull, other than those behind the nose and the back of the head.

Primary tumor (T) in the nasal cavity and ethmoid sinus

T1: The tumor is limited to the inside of the sinus with no involvement with the bone.

T2: The tumor extends into the nasal cavity.

T3: The tumor extends into the maxillary sinus or to the bone surrounding the eye.

T4a: The tumor has spread throughout the facial bones or into the base of the skull.

T4b: The tumor invades any of the following: the back of the eye, the brain area, or the back of the head.

Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the head and neck are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. Since there are many nodes in the head and neck area, the doctor’s careful evaluation of lymph nodes is an important part of staging.

NX: The regional lymph nodes cannot be evaluated.

N0: There is no evidence of cancer in the regional lymph nodes.

N1: The cancer has spread to a single lymph node on the same side as the primary tumor, and the cancer found is 3 centimeters (cm) or smaller.

N2: This describes any of the following three conditions:

N2a: The cancer has spread to a single lymph node on the same side as the primary tumor, and it is larger than 3 cm but not larger than 6 cm.

N2b: The cancer has spread to more than one lymph node on the same side as the primary tumor, but none measure larger than 6 cm.

N2c: The cancer has spread to more than one lymph node on either side of the body, but none measure larger than 6 cm.

N3: The cancer is found in at least one nearby lymph node and is larger than 6 cm.

Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Distant metastasis cannot be evaluated.

M0: The cancer has not spread to other parts of the body.

M1: The cancer has spread to another part(s) of the body.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications (or T, N, M and G, used to describe the tumor grade, which is explained below).

Stage 0: This is a very early cancer (Tis) with no spread to lymph nodes (N0) or distant metastasis (M0).

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Stage I: This is a noninvasive cancer (T1) with no spread to lymph nodes (N0) and no distant metastasis (M0).

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Stage II: This is an invasive cancer (T2) that has not spread to lymph nodes (N0) or to distant parts of the body (M0).

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Stage III: This includes invasive cancer (T3) with no spread to regional lymph nodes (N0) and no metastasis (M0), as well as invasive cancer (T1, T2, T3) that has spread to regional lymph nodes (N1) but shows no sign of metastasis (M0).

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Stage IVA: This is an invasive cancer (T4a) that either has no lymph node involvement (N0) or has spread to only one same-sided lymph node (N1) but with no metastasis (M0). It is also used for any cancer (any T) with more significant nodal involvement (N2) but with no metastasis (M0).

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Stage IVB: This is an invasive cancer (any T) that has spread to lymph nodes (any N) but has no metastasis (M0). It is also used for any cancer (any T) that is found in lymph nodes and is larger than 6 cm (N3) but has no metastasis (M0).

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Stage IVC: This refers to any tumor (any T, any N) when there is evidence of distant spread (M1).

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Recurrent: Recurrent cancer is cancer that has come back after treatment. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

Grade

Doctors also describe this type of cancer by its grade (G), which describes how much cancer cells look like healthy cells when viewed under a microscope. The doctor compares the cancerous tissue with healthy tissue. Healthy tissue usually contains many different types of cells grouped together. If the cancer looks similar to healthy tissue and contains different cell groupings, it is called differentiated or a low-grade tumor. If the cancerous tissue looks very different from healthy tissue, it is called poorly differentiated or a high-grade tumor. The cancer’s grade can help the doctor predict how quickly the cancer will spread. In general, the lower the tumor’s grade, the better the prognosis.

GX: The grade cannot be evaluated.

G1: The cells look more like healthy tissue and is well differentiated.

G2: The cells are only moderately differentiated.

G3: The cells don’t resemble healthy tissue and is poorly differentiated.

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net.

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

People with nasal cavity or paranasal sinus cancer may experience the following symptoms or signs. Sometimes, people with nasal cavity or paranasal sinus cancer do not show any of these symptoms. In fact, these types of cancer are usually diagnosed in their later stages because early stage cancer typically does not cause any symptoms. Nasal cavity or paranasal sinus cancer is often discovered when a person is being treated for seemingly benign, inflammatory disease of the sinuses, such as sinusitis. However, these symptoms may be caused by a medical condition that is not cancer.

Nasal obstruction or persistent nasal congestion and stuffiness, which is often called sinus congestion 

Chronic sinus infections that do not respond to antibiotic treatment Frequent headaches or pain in the sinus region Pain or swelling in the face, eyes, or ears Persistent tearing of the eyes Bulging of one of the eyes or vision loss Decreased sense of smell Pain or numbness in the teeth Loosening of teeth A lump on the face, nose, or inside the mouth Frequent runny nose Frequent nosebleeds Difficulty opening the mouth A lump or sore inside the nose that does not heal Fatigue Unexplained weight loss A lump in the neck 

A person who notices any of these warning signs should talk with a doctor and/or dentist right away and ask for a detailed physical examination, particularly if the symptoms continue for several weeks. Nasal cavity and paranasal sinus cancer has a much better chance of being treated successfully when they are found early.

Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

Because many of these symptoms can be caused by other, noncancerous health conditions, it is always important to receive regular health and dental screenings; this is particularly important for people who routinely drink alcohol or who currently use tobacco products or have used them in the past. In fact, people who use alcohol and tobacco should receive a general physical examination at least once a year even if they do not have any symptoms. This is a simple, quick office visit in which the doctor looks in the nose, mouth, and throat for abnormalities and feels for lumps in the neck. If anything unusual is found, the doctor will recommend a more extensive examination using one or more of the diagnostic procedures mentioned in the Diagnosis section.

If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

ON THIS PAGE: You will learn about the different ways doctors use to treat people with these types of cancer. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care, the best proven treatments available, for these specific types of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For nasal cavity or paranasal sinus cancer, the team may include medical and radiation oncologists (doctors who specialize in treating people with cancer), surgeons, otolaryngologists (ear, nose, and throat doctors), dentists, maxillofacial prosthodontists (specialists who perform restorative surgery in the head and neck areas), physical therapists, speech pathologists, psychiatrists, nurses, dietitians, and social workers. A neurosurgeon (a doctor who specializes in surgery on the brain and spinal cord) should also be part of this team when a tumor in the skull or facial area needs to be removed.

Nasal cavity and paranasal sinus cancer can often be cured, especially if found early. Although curing the cancer is the primary goal of treatment, preserving the function of the nearby nerves, organs, and tissues is also very important. When doctors plan treatment, they consider how treatment might affect a person’s quality of life, such as how the person feels, looks, talks, eats, and breathes.

Descriptions of the most common treatment options for nasal cavity and paranasal sinus cancer are listed below. The three main treatment options are surgery, radiation therapy, and chemotherapy. One of these treatments, or a combination of them, may be used. Your care plan

may also include treatment for symptoms and side effects, an important part of cancer care. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Surgery

Surgery is frequently used to remove cancer of the paranasal sinus or nasal cavity. A surgical oncologist is a doctor who specializes in treating cancer using surgery. The goal of surgery is to remove all of the tumor and leave no trace of cancer in the healthy tissue, also called negative margins. However, usually it’s not possible to completely remove the cancer with an operation, so additional treatments may be necessary. This may include more than one operation to remove the cancer and to help restore the appearance and function of the tissues affected.

Common types of surgery for nasal cavity and paranasal sinus cancer include:

Excision. During an excision, the doctor performs an operation to remove the cancerous tumor and some of the healthy tissue around it, called a margin.

Maxillectomy. This is a surgery that removes part or all of the hard palate, which is the bony roof of the mouth. Artificial devices called prostheses or, more recently, flaps of soft tissue with and without bone can be placed to fill gaps from this operation. A maxillectomy is sometimes recommended to treat paranasal sinus cancer. Occasionally, it is possible to save the eye on the side of the cancer.

Craniofacial resection/skull base surgery. This is an extensive surgery often recommended for paranasal sinus cancer that removes more tissue than a maxillectomy. It requires the close cooperation of the health care team, particularly cooperation between a neurosurgeon and a head and neck surgeon.

Endoscopic sinus surgery. This relatively new approach is less destructive to healthy tissue than traditional operations. Occasionally, it can be used for nasal cavity and paranasal sinus tumors, especially if they are benign. The surgeon makes a small incision to remove the tumor using a thin, telescope-like tube inserted into the nasal cavity or sinus. As mentioned in the Diagnosis section, endoscopic sinus surgery is often used for chronic sinusitis, and cancer may be discovered during such surgery.

Neck dissection. This is the surgical removal of lymph nodes in the neck area. If the doctor suspects the cancer has spread, a neck dissection may be performed, often at the same time as another surgery. A neck dissection may cause numbness of the ear, weakness when raising the arm above the head, and weakness of the lower lip. The side effects are caused by injury to nerves in the area. Depending on the type of neck dissection, weakness of the lower lip and arm may go away in a few months. Weakness will be permanent if a nerve is removed as part of a dissection.

Reconstructive (plastic) surgery. If surgery requires removing large or specific areas of tissue, reconstructive surgery may be recommended. If the eye is removed, a specialist called a prosthodontist can provide an artificial replacement, called a prosthesis. More often, when the upper jaw, called the maxilla, is removed, a prosthodontist may play a large role in the rehabilitation process.

In general, surgery often includes risks because the eyes, mouth, brain, and important nerves and blood vessels are nearby. Surgery often causes swelling of the face, mouth, and throat, making it difficult to breathe; sometimes a hole in the windpipe, called a tracheostomy, may be necessary to make breathing easier for some period of time after surgery. It is important to talk with your surgeon(s) about which side effects to expect before having the surgery and your plan for recovery. Learn more about cancer surgery.

Radiation therapy

Radiation therapy is the use of high energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist.

For this type of cancer, radiation therapy is most often used in combination with surgery, given either before or after the operation. It may also be given along with chemotherapy (see below). For some types of tumors in the nasal cavity or paranasal sinus, radiation therapy may be the main treatment. It can also be an option if a person cannot have surgery or decides not to have surgery.

The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. Specific types of external radiation therapy include intensity-modulated radiation therapy (IMRT) and proton therapy. IMRT allows more effective doses of radiation therapy to be delivered while reducing the damage to healthy cells and causing fewer side effects. Proton therapy uses protons, rather than x-rays. At high energy, protons can destroy cancer cells. Proton therapy may be used in nasal cavity or paranasal sinus cancer when the tumor is located close to the eye or central nervous system, which includes the brain and spinal cord. An external-beam radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Internal radiation therapy involves tiny pellets or rods containing radioactive materials that are surgically implanted in or near the tumor site. The implant is left in place for several days while the person stays in the hospital.

Before beginning any type of radiation therapy for these types of cancer, people should receive a thorough examination from a dentist experienced in treating people with head and neck cancer. Because radiation therapy can cause tooth decay, damaged teeth may need to be removed. Often, tooth decay can be prevented with proper treatment from a dentist before beginning cancer treatment. After radiation therapy for nasal cavity or paranasal sinus cancer, dental care should continue to help prevent further dental problems. People may receive fluoride treatment to

prevent cavities, also called dental caries. Read more about dental and oral health during cancer treatment.

In addition, radiation therapy to the head and neck may cause redness or skin irritation in the treated area, dry mouth or thickened saliva from damage to salivary glands, bone pain, nausea, fatigue, mouth sores, and/or sore throat. Other side effects may include pain or difficulty swallowing; loss of appetite, due to a change in sense of taste; hearing loss, due to buildup of fluid in the middle ear; and buildup of earwax that dries out because of the radiation therapy’s effect on the ear canal. Radiation therapy may also cause a condition called hypothyroidism in which the thyroid gland, located in the neck, slows down, causing people to feel tired and sluggish. Every patient who receives radiation therapy to the neck area should have his or her thyroid checked regularly. Researchers are conducting numerous studies to find ways to reduce or better relieve the side effects of radiation therapy.

Learn more about radiation therapy.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The use of chemotherapy before or after surgery and/or radiation therapy or in combination with radiation therapy, called concurrent chemoradiotherapy, is frequently recommended for these types of cancer. However, chemoradiotherapy is still being investigated and should be done as part of a clinical trial.

For nasal cavity or paranasal sinus cavity cancer, chemotherapy may also be used to treat advanced cancer (see below) or to treat symptoms. Some chemotherapy is available in clinical trials that may treat cancer at an earlier stage.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, and radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. Learn more about palliative care. 

Metastatic nasal cavity and paranasal sinus cancer

If cancer has spread to another location in the body, it is called metastatic cancer. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.

Your health care team may recommend a treatment plan that consists of chemotherapy or a combination of surgery, radiation therapy, and chemotherapy. Supportive care will also be important to help relieve symptoms and side effects.

For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. 

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s

important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the cancer’s stage has changed. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above, such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

ON THIS PAGE: You will read about your medical care after cancer treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

After treatment for nasal cavity or paranasal sinus cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.

ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

If the cancer recurs, it most commonly happens within the first two or three years after diagnosis, so follow-up visits will be more frequent during the first two or three years. Diagnostic examinations, such as CT scans, may be needed to watch for any signs of recurrences or to monitor how well the current treatment is working.

Rehabilitation is a major part of follow-up care after head and neck cancer treatment. People may receive physical therapy and speech therapy to regain skills, such as talking and swallowing. Supportive care to manage symptoms and maintain nutrition during and after treatment may be recommended. Some people may need to learn new ways to eat or adjust to eating foods that have been prepared differently. After surgery, a prosthodontist can help in the restoration and rehabilitation of any oral cavity structures that were removed during surgery.

Rehabilitation of physical changes resulting from a maxillectomy often requires a prosthesis. Prevention of dental decay by fluoride application is very important to avoid loss of existing teeth. Special eye care may also be necessary. Many times when a maxillectomy is done, fluid will accumulate in the middle ear on the side of surgery. Surgery to the eardrum, called a myringotomy, to drain this fluid may be required. Very frequently, especially after craniofacial resection, people will lose their sense of smell, called anosmia. It is important for these people to receive special coping strategies, especially around the house and work area, in case of chemical spills, smoke from a fire, and other potentially harmful situations. People who have received radiation therapy should avoid exposing the skin that received treatment to the sun. If radiation therapy included the neck, the thyroid gland should be checked regularly through blood tests.

People who have received treatment for nasal cavity or paranasal sinus cancer may look different, feel tired, and be unable to talk or eat the way they did before treatment. Many people experience depression. The health care team can help people cope with these physical and emotional changes and connect them with support services. Support groups may help people cope with changes following treatment.

People recovering from nasal cavity or paranasal sinus cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, limiting alcohol consumption, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes.

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if it spread to another part of the body, called metastasis. Some tests may also determine which treatments may be the most effective.

For most types of cancer, a biopsy is the only way to make a definitive diagnosis. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has spread. This list describes options for diagnosing these types of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition Type of cancer suspected Signs and symptoms Previous test results

To make the diagnosis, a complete medical history and physical examination are necessary. Signs of nasal cavity and paranasal sinus cancer are often very similar to symptoms of chronic or allergic sinusitis. The physical examination is important, and doctors may perform one or more of the tests listed below to reach a diagnosis. There are no specific blood or urine tests that can be performed to help make an early diagnosis of either of these types of cancer

The following tests may be used to diagnose nasal cavity or paranasal sinus cancer:

Physical examination. The doctor feels for any lumps on the neck, lips, gums, and cheeks. Also, the doctor will inspect the nose, mouth, throat, and tongue for abnormalities, often using a light and/or mirror for a clearer view.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.

Endoscopy. This test allows the doctor to see inside the body with a thin, lighted, flexible tube called an endoscope. The person may be sedated as the tube is inserted through the mouth or nose to examine the head and neck areas. Sedation is the use of medication to help a person become more relaxed, calm, or sleepy. The examination has different names depending on the area of the body that is examined, such as laryngoscopy, which examines the larynx; pharyngoscopy, which examines the pharynx; or nasopharyngoscopy, which examines the nasal cavity and nasopharynx.

In some cases, a diagnosis of paranasal sinus cancer will be made during an endoscopic surgery for what is believed to be benign chronic sinusitis. During the endoscopic sinus surgery, it is important for the surgeon to take a biopsy sample of normal-looking tissue and confirm the diagnosis in a procedure called a frozen section examination before completing the endoscopic surgery for benign chronic sinusitis. For more information about surgery, see the Treatment Options section.

X-ray. An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. An x-ray can show if the sinuses are filled with something other than air. If

so, it is usually not cancer but, instead, an infection that is treatable. If treatment doesn’t work to clear the sinuses, then other more specialized x-ray tests may be done to identify the blockage. Signs of cancer on an x-ray may be followed up with a computed tomography scan, also called a CT scan.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can also be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill to swallow. CT scans are very useful in identifying cancer of the nasal cavity or paranasal sinus.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body, especially images of soft tissue, such as the eye in its socket and the part of the brain near the sinuses. MRI can also be used to measure the tumor’s size. A contrast medium may be injected into a patient’s vein or given as a pill to swallow to create a clearer picture.

Bone scan. This test may be done to see if cancer has spread to the bones. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.