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Cancers of the Nose and the Paranasal Sinuses

		What are the nose and Nasal Cavity? What are the Paranasal Sinuses?
		What is cancer of the Nasal Cavity? What is cancer of the Paranasal Sinuses?
		How do cancers of the nose and the paranasal sinuses present?
		How are cancers of the nose and the Paranasal Sinuses detected?
		What are staging and grading?
		How are cancers of the nose and the Paranasal Sinuses treated?
		What are the side effects of nasal and paranasal sinus cancer treatment?
		What is the importance of follow up?

What are the nose and Nasal Cavity? What are the Paranasal Sinuses?

The nose forms the central part of our face, and serves a cosmetic and utilitarian purpose. While right from the days of Cleopatra, the nose has been looked upon as a parameter for looks, the basic fact remains that it is an organ of smell and breathing, and helps to collect and deliver air inside the body.

The inside of the nose consists of a variegated chamber called the nasal vestibule.

The Paranasal Sinuses are multiple, hollow, empty pockets of bone, of various sizes, arranged at various strategic places around the Nasal Cavity. They normally contain air. They are lined by mucus secreting cells. They serve a dual purpose; the mucus secreted keeps the nose form drying out and keeps the air we breathe in moist, and because they contain air, they make the voice we produce echo and resonate.

The various Paranasal Sinuses are:

The Nose and the Paranasal Sinuses

The maxillary sinuses, located on either side, within the upper parts of the cheek bones.

The frontal sinuses, located in the forehead, just above the nose.

The ethmoid sinuses, located on either side, just behind the upper part of the nose.

The sphenoidal sinus, behind the ethmoid sinuses, in the center of the skull.

What is cancer of the Nasal Cavity? What is cancer of the Paranasal Sinuses?

	Usually, cancers of this region start from the lining of the nasopharynx, or oropharynx. These are the carcinomas. The oropharynx includes:
		The back one-third of the tongue.
		The soft palate.
		The palatine tonsils.
		And the part of the throat behind the mouth.
	The nasopharynx includes:
		The area of the pharynx behind the Nasal Cavity, extending upto the commencement of the oropharynx.It is the topmost part of the pharynx, or the throat.
	Rarely, the cancer could be a melanoma, which arises from the pigment producing cells called melanocytes. Even more rarely, there can be a cancer arising from the muscles or the soft tissues of this region, and these lesions are called sarcomas. Only occasionally do you get lesions called midline granulomas, which arise in the nose or from the Paranasal Sinuses, and eat into surrounding tissues. Also rare is the occurrence of a slow growing cancer called an inverting papilloma.

How do cancers of the Nose and the Paranasal Sinuses present?

	Following are the ways in which cancers of the nose and the Paranasal Sinuses usually present:
		A persistently blocked nose.
		Persistent 'cold' or blocked sinuses, or repeated infections of the nose, or repeated 'sinusitis'.
		Bleeding without provocation from the nose or the Paranasal Sinuses.
		Swelling of the upper part of the face or around the eyes.
		Closing up of one eye, or blurring of vision.
		Persistent aches in the forehead, the front of the skull or over the cheekbones.
		A swelling in the roof of the oral cavity.
		Painless falling of upper teeth, or change in denture fitting, or bleeding from upper teeth sockets.

How are cancers of the nose and the Paranasal Sinuses detected?

There are several steps to establishing the presence of a nasal or paranasal sinus cancer:
	The doctor takes a history of the patient's symptoms.
	The doctor examines the patient physically.
	A series of investigations are performed. Those specific for nasal or paranasal sinus cancer include:
		A posterior rhinoscopy, in which the doctor sees the nasopharynx and the back of the nose using a light and a special mirror.
		A nasoscopy, which utilizes a special instrument called the nasoscope for looking at the Nasal Cavity and the Paranasal Sinuses.
		A CT scan, which is a series of detailed pictures with very thin slices taken radiologically through the body and which are decoded with the help of a computer.
		An MRI, which consists of detailed pictures, but instead of using x-rays, a powerful magnet is used to polarize electrons inside the body in order to get images, which are then interpreted by a computer.
	Once a lesion is identified, the doctor performs a biopsy, which is the removal of a sample of tissue which appears to be suspicious, for study under the pathologist's microscope.

What are staging and grading?

	These are terms with which you must become familiar, if you are dealing with any form of cancer. When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs. The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive. Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome. Staging may require additional imaging tests such as CT Scan of the brain, Sonography of the abdomen, Bone scanorchest X-ray. Although no clear cut staging per se exists for cancers of the nose and the less common cancers of the Paranasal Sinuses, the following practical staging exists for cancer of the maxillary sinuses, the commonest cancer of this area: Stage 1. Cancer only in the maxillary sinus, with no bony destruction. There has been no spread to the lymph nodes (Lymph nodes are small bean-shaped structures, which act as stations for drainage of lymph, a clear watery fluid, which courses through out the body in transparent, thin tubes called lymph channels or lymphatics, from various organs). Stage 2. The cancer has commenced to destroy the surrounding bones, but as yet there is no spread to lymph nodes. Stage 3. Cancer has followed either of the following pathways:
		Spread no further than its bony cage, and also to one node on the same side of the neck, which is no greater than 3 cms in size.
		Spread to the cheek, the back of the sinus, the eye socket or the ethmoid sinus. There may or may not be spread to lymph nodes on the same side of the neck.
	Stage 4. Cancer has followed either of the following pathways:
		Spread to the eye, other sinuses, or tissues adjacent to the sinuses. There may or may not be spread to lymph nodes on the same side of the neck.
		Spread restricted only to the sinus itself, or the tissues adjacent to it, but with spread to nodes in the neck on one or both sides, or to any node which measures greater than 6 cms. Spread to distant parts of the body.
	Recurrent maxillary sinus cancer. That disease which has come back, either in the same locus or in a different one after primary treatment has been completed.

How are cancers of the nose and the Paranasal Sinuses treated?

	A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an otorhinolaryngologist (ear, nose, throat specialist), an oncosurgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy or biological therapy may become add ons. Treatment strategies. The bastion of nasal and paranasal cancer treatment is surgery. A section of the Nasal Cavity or the paranasal sinus may have to be removed, and some of lymph node dissection may have to be performed in the neck, depending upon the staging and grading. These surgeries, because they can be mutilating, are usually followed by some form of reconstruction or plastic surgery. The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It also affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the nose or the Paranasal Sinuses is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks). Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after.
	For stage 1, one of the following options may be entertained:
	Cancer of the maxillary sinus:
		Surgery.
		This may be followed by radiation.
	Cancer of the ethmoid sinus:
		Radiation.
		Surgery followed by radiation, if lesion amenable to excision (removal).
	Cancer of the sphenoid sinus:
		Radiation.
	Cancer of the Nasal Cavity:
		Surgery.
		Radiation.
		Both.
	For stage 2, one of the following options may be entertained:
	Cancer of the maxillary sinus:
		Surgery. This may be followed by, or preceded by radiation.
	Cancer of the ethmoid sinus:
		Radiation.
		Surgery followed by radiation, if lesion amenable to excision (removal).
	Cancer of the sphenoid sinus:
		Radiation.
	Cancer of the Nasal Cavity:
		Surgery.
		Radiation.
		Both.
	For stage 3, one of the following options may be entertained:
	Cancer of the maxillary sinus:
		Surgery. This may be followed by, or preceded by radiation.
		Chemotherapy combined with radiation.
	Cancer of the ethmoid sinus:
		Surgery followed by radiation, if lesion amenable to excision (removal).
		Chemotherapy, followed by surgery or radiation.
		Surgery, followed by chemotherapy, with or without radiation.
		Chemotherapy combined with radiation.
	Cancer of the sphenoid sinus:
		Radiation.
	Cancer of the Nasal Cavity:
		Surgery.
		Radiation.
		Both.
		Chemotherapy, followed by surgery or radiation.
		Surgery, followed by chemotherapy, with or without radiation.
		Chemotherapy combined with radiation.
	For stage 4, one of the following options may be entertained:
	Cancer of the maxillary sinus:
		Radiation.
		Chemotherapy, followed by surgery or radiation.
		Chemotherapy combined with radiation.
		Chemotherapy following radiation.
	Cancer of the ethmoid sinus:
		Surgery followed by radiation, if lesion amenable to excision (removal).
		Radiation, followed by surgery.
		Chemotherapy, followed by surgery or radiation.
		Surgery, followed by chemotherapy, with or without radiation.
		Chemotherapy combined with radiation.
	Cancer of the sphenoid sinus:
		Radiation.
	Canc er of the Nasal Cavity:
		Surgery.
		Radiation.
		Both.
		Chemotherapy, followed by surgery or radiation.
		Surgery, followed by chemotherapy, with or without radiation.
	Chemotherapy combined with radiation.
If the cancer is a melanoma or sarcoma, one of the following options may be entertained:
	Surgery.
	Chemotherapy or radiation, if lesion not amenable for surgery.
If the cancer is a midline granuloma, the following option may be entertained:
	Radiation.
If the cancer is an inverting papilloma, the following option may be entertained:
	Surgery.
For recurrent cancers of the nose and the Paranasal Sinuses, the treatment depends basically upon where the disease has returned and what was the treatment offered initially.

What are the side effects of nasal and paranasal sinus cancer treatment?

	Surgery can be mutilating and since these areas are involved in the very important functions of breathing and smelling, very careful reconstruction and rehabilitation by trained personnel has to be carried out. Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.