Ear, Nose, Throat, Head and Neck Surgery Specialist
Prof. Dr. Murat Topdağ

Born in Malatya in 1978, Murat Topdağ completed his primary and secondary education, then attended high school in Istanbul. He graduated from the English program of Cerrahpaşa Tıp Fakültesi. Prof. Dr. Murat Topdağ is married and has two children.

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What Is a Paranasal Sinus Tumor?

A paranasal sinus tumor is a type of cancer that develops in the air-filled spaces around the human nose. These tumors can originate from various tissues in the sinuses, such as membranes, bones, or nerves. They can often grow without showing any symptoms; therefore, early diagnosis is vital. The earlier treatment starts, the higher the chance of overcoming the disease.

Paranasal sinus tumors can be benign or malignant. Benign tumors are generally harmless and do not tend to spread. In contrast, malignant tumors can be aggressive and may invade surrounding tissues. Examples of benign tumors include:

• Nasal polyps
• Hemangioma

Examples of malignant tumors include:

• Squamous cell carcinoma
• Adenocarcinoma
• Neuroblastoma
• Adenoid cystic carcinoma
• Sarcoma

The main difference between a nasal tumor and a paranasal sinus tumor is the site where the tumor originates. Nasal tumors occur in the nasal cavity, just behind the nose. Paranasal sinus tumors originate in the sinuses surrounding the nose. Both types of tumors may require similar treatment methods, but they can present different symptoms due to their specific locations.

Origins of Paranasal Sinus Tumors

Paranasal sinus tumors exhibit diversity in etiological factors. Approximately one-third of these tumors are related to occupational exposure. Work environments with nickel and volatile hydrocarbons are known to increase the risk of certain cancer subtypes. In particular, two substances show a strong correlation with certain tumor types:

1. Nickel: Implicated in the development of squamous cell carcinomas.
2. Volatile hydrocarbons and wood dust: Increase the risk of adenocarcinoma.

Additionally, human papillomavirus (HPV) strains are frequently observed in some of these tumors. Two HPV types are found in a certain percentage of cases:

1. HPV types 6 and 11: Detected in 24% of inverted papillomas and 4% of squamous cell carcinomas.

Moreover, a direct relationship between smoking and alcohol use—commonly recognized risk factors for head and neck cancers—and sinonasal malignancies has not been established. This indicates that the etiology of these tumors is more complex and requires further research.

In summary, paranasal sinus tumors have a multifactorial origin. Understanding risk factors is crucial for developing effective prevention and treatment strategies.

What Causes Paranasal Sinus Tumors?

Paranasal sinus tumors are associated with various factors. Exposure to industrial chemicals can lead to DNA changes. Human papillomavirus (HPV) infection is another factor that can trigger tumor formation. Certain workplace dust exposures can also increase risk:

• Wood dust
• Leather dust
• Flour dust
• Textile dust
• Nickel dust
• Chromium dust

Radiation exposure can cause mutations in DNA, contributing to tumor development. Smoking similarly causes harmful changes in paranasal sinus cells. These tumors occur in the nasal cavity or the sinuses surrounding it. Changes in the DNA of these cells lead to uncontrolled growth. As tumor cells grow excessively, they can damage healthy tissue and even spread to other parts of the body. Metastatic cancer describes this process of spread.

Characteristics of Nasal and Paranasal Sinus Tumors

Nasal and paranasal sinus tumors have a special significance in ENT (Ear, Nose, and Throat) medicine. Their diagnosis and treatment pose several challenges. Benign and malignant tumors can show similar symptoms in the early stages, leading to delayed diagnosis.

On average, there is a six- to eight-month interval between the initial symptoms of a malignant tumor and the point at which it is identified. For early diagnosis, malignancy should be suspected if sinonasal symptoms persist despite appropriate medical treatment. Advanced sinonasal cancers lead to distinct findings, such as:

1. Facial asymmetry
2. A visibly detectable or palpable mass in the oral cavity
3. Observation of a mass in the nasal cavity during anterior rhinoscopy

Diagnosis of Nasal and Paranasal Sinus Tumors

Diagnosing nasal and paranasal sinus tumors requires a comprehensive ENT examination. This process includes a detailed evaluation of sinonasal structures, the eyes, and the nervous system. The first step involves assessing the sensitivity of the infraorbital nerve and eye movements.

Any loosening or loss of teeth should also be checked. After these steps, a nasal endoscopy is performed under adequate local anesthesia. During endoscopic evaluation:

1. A biopsy should be taken from suspicious tissues (except vascular lesions).
2. Biopsy should ideally be performed following radiologic imaging to preserve tissue integrity.

In cases of maxillary sinus tumors, biopsy is often done under general anesthesia. This procedure is carried out via antrostomy, allowing for evaluation of the biopsy site if a maxillectomy is needed later.

If radiotherapy will be administered, draining secretions and necrotic material becomes important. However, the Caldwell-Luc approach is not recommended due to the risk of tumor spread to the cheek mucosa and skin.

Radiologic imaging is also critical in the diagnostic process:

1. CT scans are particularly useful for assessing bony pathologies and the orbital walls.
2. MRI is used to evaluate soft-tissue spread and to differentiate between mucus and tumor tissue.

Major Benign Tumors of the Nose and Paranasal Sinuses

Tumors in the nose and paranasal sinuses are usually benign, but there are various types. One of the most commonly seen is osteoma, which is rarely detected on routine X-rays. The frontal sinus is the most frequent location. It typically occurs in older adults. Surgery is advised if it causes symptoms or pressure on surrounding tissues.

Fibrous dysplasia is characterized by abnormal transformation of bone tissue. It is more common in younger individuals and can affect one or more bones. Swelling can occur in the affected bone. When associated with McCune-Albright syndrome, the disease becomes more complex.

In such cases, skin pigmentation and early puberty can also be observed. In the head and neck region, the maxilla and mandible are most frequently involved. Treatment typically involves surgery. Radiotherapy is avoided because of the risk of malignant transformation.

Schneiderian papillomas appear in three main types: inverted, fungiform, and cylindrical.

1. Fungiform papillomas make up 40% of cases and arise from the nasal septum.
2. Cylindrical papillomas make up 3% of cases and are found on the lateral walls of the nasal cavity.
3. Inverted papillomas account for 57% of cases and generally develop at the level of the middle meatus.
4. Treatment for these tumors is surgical.

Finally, juvenile nasopharyngeal angiofibroma is a rare tumor seen in adolescent males. Its tendency to expand and its vascular nature make it a leading cause of morbidity. In the absence of cavernous sinus involvement, embolization is performed prior to surgical resection. In cases where the cavernous sinus is involved or if there is recurrence, radiotherapy is recommended.

Major Malignant Tumors of the Nose and Paranasal Sinuses

Squamous Cell Carcinoma is the most common type of cancer in the paranasal sinuses. It typically occurs in the maxillary and ethmoid sinuses. This disease is generally identified in men over 60 years of age.

At the time of diagnosis, the cancer often extends beyond the sinus. In approximately 90% of patients, at least one sinus wall is affected. Tumor size and spread into surrounding tissues are critical for prognosis.

Minor Salivary Gland Tumors arise from the minor salivary and mucous glands in the lining of the oral cavity and upper airways. About 14-17% of tumors in the paranasal sinuses are minor salivary gland tumors.

The most common types are adenoid cystic carcinoma and mucoepidermoid carcinoma. Adenoid cystic carcinoma tends to exhibit perineural invasion, recurrent foci, and distant metastasis. As a result, patients require long-term, careful follow-up.

Adenocarcinoma ranks second among paranasal sinus malignancies (5-20% of cases) and is most often found in the ethmoid sinuses. Treatment approaches vary based on the characteristics of the affected region and the patient’s overall health. Therapy is tailored to the needs of the patient and the tumor’s extent.

Stages of Paranasal Sinus Tumors

Paranasal sinus tumors are malignant growths in the nose and sinus area. In Stage I, the tumor is confined to the sinus, indicating that the disease is localized. Stage II means the tumor has spread to other parts of the sinus. At this point, it has expanded beyond its origin. Stage III indicates the tumor has reached the sinus bones and the eye socket (orbit). It may also spread to nearby organs, and one lymph node may be involved. In the most advanced stage, Stage IV, the tumor spreads to vital organs such as the brain. It may also penetrate the neck, the skull base, and other areas. Lymph nodes are usually affected, and the tumor may metastasize to distant parts of the body.

• Stage I: Tumor is confined within the sinus.
• Stage II: Tumor spreads to other regions of the sinus.
• Stage III: Tumor extends to the sinus bones and the orbit; one lymph node may be involved.
• Stage IV: Tumor invades the brain, neck, and other parts of the skull base, and lymph nodes are usually involved.

These stages help determine the extent and progression of the tumor in the body. Each stage guides different treatment approaches. The choice of treatment depends on how far the tumor has spread and its location. Staging allows doctors to better understand the disease and select the most appropriate therapy.

Treatment Methods for Nasal and Paranasal Sinus Cancers

Surgery and radiotherapy play an important role in treating sinonasal tumors. Often, these tumors are diagnosed at an advanced stage, complicating treatment. Removing the tumors can lead to functional and cosmetic losses.

In particular, tumors near the skull base and around the eyes can be challenging to treat because of their proximity to vital structures. Even after treatment, recurrences can occur. Treatment options include:

1. Surgery: Aimed at complete removal of the tumor.
2. Radiotherapy: Often used following surgical intervention.
3. Preoperative radiotherapy: May be used to preserve the orbit when necessary.

Chemotherapy is typically considered for recurrent, metastatic, or inoperable tumors after surgery. These treatments are personalized based on the patient’s condition and tumor characteristics. In summary, sinonasal cancer treatment requires an individualized approach for each patient.

Postoperative Recovery Process

The postoperative recovery process is vital for a patient’s health. After endoscopic sinus surgery, patients must carefully follow a set of instructions. First and foremost, wound care requires close attention. For the first week, it is important to avoid forceful nose blowing. Additionally, one should sneeze with the mouth open. Light bleeding may occur during the first few days and after medical check-ups. If bleeding occurs, tilt the head back and gently clean the nose.

• Medications should be taken exactly as prescribed.
• Antibiotics must be used according to the specified dosage, and in case of severe diarrhea, consult the physician.
• Painkillers should be taken as directed; an extra dose may be taken before a check-up if needed.

Nasal irrigations are also extremely important. It is recommended to start these immediately following the surgery, twice a day. During the first few weeks, dark brown or yellowish-white nasal discharge may appear, which is part of the natural healing process.

• Oral steroids and other prescribed medications should be used regularly to reduce infection risk and control swelling.
• Taking pain medication about 45 minutes before an appointment can help manage pain.

Activity level is also important during recovery. Taking at least one week off from work is recommended. For those engaged in strenuous activities, a longer period might be necessary. It is advisable to avoid heavy lifting and exercise for the first two weeks. The physician will advise when it is safe to resume exercise.

Dietary and Lifestyle Changes After Surgery

Following surgery for a paranasal sinus tumor, patients should adopt certain dietary and lifestyle changes to optimize recovery. Key considerations include:

Diet:

• Early on, consume soft foods like mashed potatoes or yogurt that are easy to swallow.
• Hard or spicy foods may irritate the surgical site and should be avoided.
• Adequate fluid intake keeps mucous membranes moist and supports recovery; water and herbal teas are beneficial.
• Nutrient-rich foods can accelerate healing; vegetables, fruits, and whole grains should be introduced gradually.
• Avoid alcohol, caffeine, and tobacco as they can irritate the area and slow recovery.

Lifestyle:

• Getting enough rest is necessary for the body’s repair mechanisms.
• Keeping the head elevated while sleeping helps reduce swelling and discomfort.
• Using a humidifier can help maintain adequate moisture in the air.
• Nasal irrigation helps clear the sinuses and promotes healing.
• Consistent follow-up visits with your doctor ensure proper management of the recovery process.

Frequently Asked Questions

Is there a chance of cure for paranasal sinus tumors at Stage 4?

Paranasal sinus tumors at Stage IV are quite serious. The average survival rate at this stage is around 43%. However, the progression of the disease and response to treatment varies from person to person. Some patients may have a limited but real chance of recovery. Treatment options and expectations differ for each patient. Therefore, a careful evaluation of the patient’s overall health, tumor characteristics, and treatment options is necessary.