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INTRODUCTION

ESSENTIALS OF DIAGNOSIS

  • Symptoms of paranasal sinus neoplasms may mimic rhinosinusitis, leading to a delay in diagnosis and advanced disease presentation.

  • The histologic subtype and stage at presentation of sinonasal malignances drive outcomes.

  • The anatomic proximity of paranasal sinus neoplasms to critical structures, including the orbit and skull base, requires that each surgical procedure be individualized.

  • Malignant disease is generally treated with multimodal therapy.

Neoplasms of the nasal cavities, frontal sinus, ethmoid complex, sphenoid sinus, and maxillary sinuses are rare, accounting for only 3.0% of head and neck tumors. The nasal cavity and paranasal sinuses are lined by Schneiderian mucosa, consisting of pseudostratified columnar ciliated epithelium with interspersed goblet cells. Seromucinous glands are dispersed through the nasal cavity and sinuses. Paranasal sinus neoplasms are histologically diverse and most commonly arise in the maxillary sinus. Tumors of the frontal and sphenoid sinuses occur with lower incidence. Symptoms of paranasal sinus tumors are similar to those of common benign disorders, such as rhinosinusitis. These similarities in symptoms at presentation unfortunately often result in a delay in diagnosis and presentation of advanced stage malignancy. Given the location of the paranasal sinus, local invasion into surrounding structures such as the skull base, cranial nerves, orbit, brain, and the carotid artery may make clinical treatment decisions complex. Advances in technology, including endoscopic skull base surgery and image guidance surgery, have opened new approaches to primary surgical treatments for both benign and malignant lesions.

CLINICAL EVALUATION

Neoplasms of the nasal cavity and paranasal sinuses often mimic symptoms of chronic rhinosinusitis including nasal obstruction, rhinorrhea, and sinus pressure. Some clinical symptoms can suggest a neoplastic process, such as unilateral swelling, pain, and epistaxis. Orbital symptoms, such as diplopia, proptosis, visual loss, and epiphora can occur with either tumor invasion or expansion into the orbit. Tumors extending into the nasopharynx can obstruct the eustachian tube, resulting in middle ear fullness and hearing loss. Advanced tumors may present with cranial neuropathies, and occasional frontal lobe symptoms if the anterior cranial fossa is invaded. Tumors may also invade through the floor of the nasal cavity and present as a hard palate, oral cavity mass with loose dentition. Persistent nasal symptoms refractory to conservative medical treatment may suggest a neoplastic process rather than an infectious or inflammatory etiology.

Physical exam should include a full head and neck exam. Anterior rhinoscopy as well as a full endoscopic nasal examination after decongestion should be performed. The nasal mucosa should be closely examined for masses or lesions. The septum can be deviated to the contralateral side from an expansile mass, or invaded directly by disease. Superiorly, the ethmoid roof should be closely inspected for lesions arising in the space including esthesioneuroblastomas and encephaloceles. Examination of the oral cavity should be included to determine if invasion into the maxilla has occurred. Expansion of the alveolar ridge or loose dentition may indicate bone invasion into ...

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