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Tumors of the nose and paranasal sinuses, sarcoidosis

Tumors of the nose and paranasal sinuses

In the area of the nose, consisting of tissues of different embryogenetic origin, various tumor-like formations, benign and malignant tumors with a complex, often combined structure, can develop. The nose is a narrow, sometimes rather thin-walled cavity, well supplied with blood vessels and nerves.

The close connection of the nose with the surrounding tissues, brain, eyes, pharynx leads to the growth of malignant tumors and their rapid spread to nearby organs. As a result, certain difficulties are created in the treatment of tumors of this localization.

Benign nasal tumors - angiomas, papillomas, fibromas, pigmented tumors (nevi), tumor-like formations.

Benign tumors of the nose and paranasal sinuses

Among benign tumors of the nose, there are angiomas, papillomas, fibromas, pigmented tumors (nevi), tumor-like formations. A special place is occupied by the so-called bleeding polyp of the nasal septum (angioma), during the histological examination of which a connective tissue tumor of the fibroma type with a well-developed network of blood vessels is often revealed. A bleeding polyp is located in the anterior part of the nasal septum. This is a soft-elastic tumor up to 6-8 mm in size, red or bluish, bleeding easily when touched.

Angioma is usually found on the nasal septum or inferior turbinates, and papilloma - on the eve of the nose. Chondroma and osteoma in children are extremely rare, more often come from the frontal sinuses, then germinating into the nasal cavity and orbit. X-ray and computer examination helps in the diagnosis of these tumors. Difficulty breathing through the nose, deformation of the facial skeleton, headache, visual impairment (with a displacement of the eyeball) are their characteristic symptoms. Other tumors do not differ in any special symptoms and are diagnosed by rhinoscopy, probing, palpation, and X-ray examination. Histological examination confirms the final diagnosis.

Computed tomography of the cavity and paranasal sinuses (CT) is used to diagnose a tumor.

 

Treatment of benign tumors of the nose and paranasal sinuses

For benign tumors, surgical intervention is mainly used. In some cases, especially with vascular tumors, electrocoagulation, surgical diathermy, cryo- and beta-therapy can be used.

 

Malignant tumors of the nose and paranasal sinuses

Malignant tumors can be connective tissue and epithelial. Among connective tissue tumors, there are various types of sarcomas: round-cell, spindle-cell, giant cell, fibrosarcoma, osteosarcoma, chondrosarcoma, reticulosarcoma, lymphosarcoma. In young children, nasal sarcoma occurs more often than other malignant tumors and grows very quickly. A representative of epithelial tumors of the nose is cancer (usually squamous cell) in various forms: basal cell, cylindrical cell, adenocarcinoma, etc. In children, cancer, unlike adults, is rare. Most often, malignant tumors of the nose come from the upper jaw and ethmoid sinus, but they can grow from different parts of both the external nose and its cavity. Sarcoma arises from the periosteum and perichondrium of the nasal bones. It is generally accepted that nasal cancer is more common in older children, and nasal sarcoma at a younger age, but this convention has exceptions.

 

Symptoms of malignant neoplasms of the nose and paranasal sinuses

Signs of malignant neoplasms of the nose largely depend on their location and stage of the disease. Breathing through the nose is often difficult, the sense of smell is impaired, especially when the tumor is located in the upper part of the nasal cavity, i.e. in the area of olfactory analyzer receptors. There is nasal discharge, often mixed with blood, bleeding, sometimes toothache and inflammation in the gum region, swelling or asymmetry of the hard palate. With the spread of the process to the orbit, a displacement of the eyeball, limitation of its mobility, and visual impairment are noted. In the future, the shape of the nose may change, neuralgic pain joins, the nasal discharge becomes fetid, with a specific odor, headache, and pain in the face area intensify. In the case of tumor invasion into the cranial cavity, meningeal symptoms appear. Later, cachexia may develop. On the side of the tumor, many physiological functions of the nose are disrupted.

In addition to a decrease in the sense of smell (to pronounced hypo- and anosmia) and nasal breathing, the excretory function of the nasal mucosa decreases: mucus is secreted in much greater quantities than usual, which, can be explained by irritation of the mucous glands. The function of the ciliated epithelium, the sensitivity, and absorption capacity of the nasal mucosa, and the resonator function are impaired. In patients with malignant tumors of the nose, not only olfactory but also trigeminal sensitivity decreases. Smell thresholds increase markedly (2-3 times) at the very beginning of the disease. In some cases, there is a history of indications of previous operations in the nasal cavity (polypotomy, polypoetmoidotomy), since tumors sometimes look like polyps in appearance. However, the tuberous surface of the tumor, its fusion with the underlying tissues, bleeding, decay, wide base, as well as the deformation of the nasal bones, and the growth of the tumor beyond its limits in various directions (in later stages) indicate its malignant nature.

X-ray and histological examinations clarify the diagnosis. At the very beginning of development, malignant tumors can be asymptomatic and masked by rhinitis. Only a thorough examination can suggest the presence of a malignant tumor. To distinguish a malignant tumor from tuberculosis, a histological examination is performed.

Sometimes malignant tumors of the nose in appearance resemble typical benign ones - angioma, papilloma, or polyp, sometimes they are similar to a bulla.

Sometimes the swelling is like an ulcer with a foul, offensive discharge. After a biopsy, the shape of the tumor may change. During radiation therapy, a malignant tumor shrinks or disappears, which is important to consider when assessing its condition and drawing up a treatment plan. The data of objective examination help in diagnostics: rhinopneumometry, olfactometry, endoscopy, endophotography, and endophotography of the nasal cavity.

Often, patients with malignant neoplasms of the nose seek help in the later stages of the disease, when the classic symptoms appear: nasal bleeding, unpleasant odor, deformation of the facial skeleton, exophthalmos, disintegration of the tumor and separation of its pieces, lack of breathing through one half of the nose, etc. An enlarged Jacobson's organ, various types of deformation of the nasal septum in the form of thickening, ridges with an inflammatory process of the mucous membrane should always raise suspicion of a tumor process. In rare cases, the nasal cavity (especially in children) can be affected by scleroma. Sometimes malignant tumors of the nose in appearance resemble typical benign ones - angioma or papilloma, sometimes they are similar to a bulla.

Osteomyelitis of the nasal bones, inflammation of the periosteum are similar to a tumor process. A malignant tumor of the ethmoid sinus may resemble a mucopyocele. Differential diagnosis is based on X-ray data and clinical manifestations (timing of the disease, absence of bleeding, and other symptoms). Quincke's edema of the orbit and eyelids can also be similar to a malignant tumor. Malignant tumors of the naso-orbital region deserve special attention. The nasal cavity and paranasal sinuses are located between the orbits and due to this close connection, malignant tumors from the nose and sinuses can grow almost unhindered into the orbit and, conversely, from the orbit into the nasal cavity. Malignant tumors of the nose are often accompanied by various kinds of eye symptoms.

Among malignant tumors of the naso-orbital region, like other localizations, sarcoma and cancer are more common. If the tumor originates from the orbit, exophthalmos, diplopia, and limitation of the mobility of the eyeball appear. When a tumor grows from the nasal cavity and ethmoid sinus, the eyeball is displaced outward and somewhat anteriorly, from the frontal sinus - outward, from the maxillary sinus - upward and outward, from the wedge-shaped - anteriorly.

Mucocele, similar in appearance to a tumor of the nose, in the cavity of the orbit and nose is visualized on MRI.

Sometimes children develop diplopia (when the tumor of the eyeball is displaced). This can be a relatively early symptom of a tumor in the nose or orbit. Even a weakly expressed exophthalmos and diplopia indicate that the tumor has grown into the orbit.

In children aged 1-2 years, sarcomas, especially round-cell ones, grow extremely quickly and after 1-2 months. the tumor process is classified as far gone, which emphasizes the importance of oncological alertness in children's practice. Polymorphic-cell sarcomas grow into the orbit very quickly, and round- and small-cell sarcomas are much more malignant than large-cell sarcomas, and immediately grow from the nose into the sinuses.

In the recognition of nasal tumors, a special examination of the patient by an otorhinolaryngologist (rhinoscopy, etc.), an ophthalmologist (examination of fields and visual acuity, fundus, etc.) and a radiologist (X-ray examination, tomography, etc.) is essential. In some cases, the radiograph shows in which direction the remaining part of the bone wall separating the nasal cavity from the orbit is pushed, which helps to determine the direction of tumor growth (from the orbit to the nasal cavity or vice versa). Computed tomography (CT) or magnetic resonance imaging (MRI) complements the findings. The prognosis for tumor growth into the orbit is always serious.

 

Treatment of malignant neoplasms of the nose and paranasal sinuses

The treatment plan is made only after the histological examination of the tumor. Combined treatment is recommended (surgical combined with radiation therapy, chemotherapy). For inoperable nasal tumors, radiation treatment, chemotherapy, palliative measures in the form of bandaging and cutting of large adducting blood vessels (external carotid arteries) are performed. However, even despite the earlier treatment, timely treatment, surgical intervention, quite often malignant tumors recur after a few months.

 

Rare nasal tumors

Rare nasal tumors include esthesioneuricytomas, esthesioneuroblastomas, esthesioneuroepitheliomas, etc.

Esthesioblastomas occur in both children and adults. They often recur, and sometimes not immediately, but after 7-11 years. Occasionally, the tumor metastasizes to the upper cervical and other lymph nodes, to the mediastinum, lungs, pleura, parotid gland, etc. Estesioblastoma is usually localized in the superior turbinate, sometimes spreads to the nasopharynx, and often causes only local destruction of the ethmoid sinus. The color of the tumor varies from grayish brown to dark red. Most often it is of soft consistency, but sometimes it is dense, spongy, or in the form of a polyp that fills one half of the nose. Difficulty nasal breathing, bleeding from the nose, a disorder of smell, sometimes swelling at the root of the nose, lacrimation, some soreness in the area of the tumor. In the case of the spread of the process to the eyes, paranasal sinuses, into the cranial cavity and other adjacent organs, corresponding symptoms arise. The prognosis for these tumors is quite serious; they are prone to recurrence and metastases.

Chemodectoma - a tumor, often originating from the carotid body, is usually located at the bifurcation of the common carotid artery, but it can be of different localization: in the wall of the jugular vein, along the tympanic, vagus, glossopharyngeal, intermediate, and other nerves, in organs with a well-developed sympathetic nervous system ... Its other names are also known: "glomus tumor", "nonchromaffinic paraganglioma", "tumor of the paraganglium", etc. organs located in many places in the body. These formations are considered a sympathetic node, a receptor device, or a gland. The chemodectoma grows slowly, but rapid infiltrative growth is also possible. In the malignant variant of chemodectoma, mild histological signs of a malignant nature are determined. Chemodectoma often has a pronounced capsule, there is a slight difference in cell size, rare figures of mitosis. Despite exophytic growth, the tumor can destroy the surrounding tissues and spread to adjacent organs and cavities. Metastases are possible in regional lymph nodes and distant organs.

Among the existing methods of treating chemodectoma tumors - surgical and radiation - are the main and most effective. The chemical method of treatment, which consists of cauterizing the tumor by various means (concentrated solution of silver nitrate, "snow" of carbonic acid, etc.), is ineffective, tumor recurrence often occurs, etc.

 

Sarcoidosis (Benier-Beck-Schaumann disease)

The disease is more common in adults. In many cases, it is characterized by the involvement of extrathoracic lymph nodes, tonsils, and parotid salivary glands in the process. There are 3 forms of the disease:

  • polypoid non-ulcerating tumor of a rather dense consistency;
  • dense nodules the size of a pinhead or millet grain, surrounded by an area of hyperemia;
  • diffuse infiltration with abundant mucous secretion.

Usually, mucosal involvement precedes cutaneous manifestations and is similar to changes in atrophic rhinitis. The bones of the nose, as well as its soft tissues, can be affected in isolation or simultaneously. Sarcoidosis of the nasal bones is usually accompanied by a tumor-like change in the root of the nose, which becomes thicker and wider.

Sarcoidosis is differentiated from generalized tuberculosis of the nasal mucosa and atrophic processes in the nasal cavity. X-ray examination reveals changes in the type of cystic osteitis. Fibrous dysplasia is a disease of childhood and adolescence and is more common in girls. The tumor is considered a malformation of the bone in the embryonic period. They admit the possibility of its occurrence in the postnatal period and regard the process as a change in bone tissue, close to a tumor. Fibrous dysplasia is often referred to as borderline tumors; it has a bone consistency and is painless. It is characterized by the appearance of a "swollen" bone. Cases of fibrous dysplasia not only of the nose but also of its sinuses (maxillary, ethmoid) have been noted. Multiple damages to the bones of the facial skeleton and skull are possible. Radiographically, with a focal form of fibrous dysplasia, well-defined zones of enlightenment with a noticeable border of sclerosis along the edges are visible. Thinning of the cortical layer is typical. Sometimes areas of depression are visible when the bone structure has a cellular appearance. In childhood and adolescence, the tumor grows relatively intensively, however, with the onset of maturity, its growth may stop.

For various tumors of the nose and its paranasal sinuses, depending on their nature, size, location, and age of the patient, different approaches are used.

If the tumor is localized in the deep parts of the nasal cavity or the maxillary sinus, and extended radical operation is advisable in older children and adults. After local anesthesia under the upper lip along the transitional fold of the vestibule of the mouth, a horizontal incision of the mucous membrane and periosteum is made from the bridle to the level of the 2nd large molar or somewhat longer. Soft tissues are exfoliated together with the periosteum up to the canine fossa. Then a part of the facial wall of the maxillary sinus is resected and a tumor or other pathological formation is removed. After that, a part of the nasal or medial wall of the sinus is resected in the region of the lower nasal passage, thereby forming a communication between the sinus and the nasal cavity.

The anastomosis should be as wide as possible, without a threshold between the bottom of the nose and the sinus. With a large tumor, the operation is complemented by a wider resection of the medial wall of the maxillary sinus, the edge of the piriform opening (with a wide removal of the front wall of the sinus), the inferior and middle turbinates, etc. Such an intervention provides a good view of the sinus, complete removal of the tumor, and stable communication with the nasal cavity. Along with broad approaches, modifications of the operation can be used, when the incision is made not along the transitional fold, but below it, i.e. along the gums, and the sinus is opened somewhat lateral to the canine fossa, above the 1st molar.

The prognosis for malignant neoplasms of the nose and sinuses is poor.

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