Describe the tumours of the nose and paranasal sinuses.

Benign Tumours

• The single most important principle: unilateral nasal obstruction, unilateral blood-stained discharge, or a unilateral mass in an adult is a tumour until proved otherwise — and must be endoscoped, imaged and biopsied
• Osteoma — the commonest benign bony tumour, most often in the frontal sinus. an incidental finding needing no treatment; removed if it obstructs drainage, causes a mucocele, or extends into the orbit or cranium. Gardner syndrome — multiple osteomas with colonic polyposis and soft tissue tumours — must be excluded where osteomas are multiple.

Malignant Tumours

• Squamous cell carcinoma accounts for the majority, arising most often in the maxillary sinus
• Adenocarcinoma arises characteristically in the ethmoid, and is strongly associated with hardwood dust exposure in furniture and woodworkers — a classical occupational association which must be asked about
• Other occupational associations — nickel refining (squamous carcinoma); chromium; leather work; and radium
• Other histologies — adenoid cystic carcinoma, notable for perineural spread, late distant metastasis and very long-term recurrence; olfactory neuroblastoma (esthesioneuroblastoma), arising from olfactory epithelium high in the nose, with a bimodal age distribution; mucosal melanoma.
• Presentation is late, because the tumour grows silently in an air-filled cavity until it breaches a wall — which is the fundamental reason for the poor prognosis
• Early symptoms mimic sinusitis — unilateral obstruction, blood-stained discharge and facial pain
• The features OF spread indicate the direction and are worth listing by wall: medial → nasal obstruction, epistaxis, mass; superior (orbital floor) → proptosis, diplopia, epiphora, visual loss; anterior → cheek swelling and infraorbital numbness.
• Unexplained loosening of teeth, an ill-fitting denture, infraorbital numbness or new trismus in an adult are the signs that should prompt imaging, and each is commonly attributed to something benign for months
• Ohngren’S line — a theoretical plane from the medial canthus to the angle of the mandible, dividing the maxilla into a superoposterior (suprastructure) and an anteroinferior (infrastructure) part. Tumours above the line have a worse prognosis, being close to the orbit, skull base and pterygoid region and presenting later
• Lymph node metastasis is uncommon at presentation.
• Investigation — endoscopy with biopsy.
• Do not biopsy before imaging where an angiofibroma or an encephalocele is possible
• Treatment is surgery with postoperative radiotherapy, decided by a multidisciplinary team
• Surgical options — endoscopic resection for selected tumours, which has grown considerably; medial maxillectomy, partial or total maxillectomy, with orbital exenteration where the orbit is invaded; and craniofacial resection for tumours involving the anterior skull base
• Reconstruction and rehabilitation matter greatly — an obturator or prosthesis after maxillectomy, free flaps, and dental, speech and swallowing rehabilitation
• Prognosis remains poor, with five-year survival for maxillary carcinoma of the order of 30 to 50%, chiefly because of late presentation
• The practical message for the general clinician is that the diagnosis is made early only by taking unilateral nasal symptoms seriously and looking with an endoscope
• Unilateral symptoms in an adult mean a tumour until endoscopy, imaging and biopsy have said otherwise
• Infraorbital numbness is an early sign of maxillary malignancy and is attributed to something benign for months
• Loosening teeth and an ill-fitting denture in an adult should prompt imaging rather than another dental adjustment
• New trismus indicates posterior spread into the pterygoid region, and is never a benign finding
• Inverted papilloma is fleshy and mulberry-like, quite unlike the pale glistening inflammatory polyp
• Drill the bone at the attachment site, since recurrence of inverted papilloma arises exactly there
• Five to ten per cent become squamous carcinoma, which is why inverted papilloma needs long-term endoscopic follow-up
• A cerebriform pattern on MRI suggests inverted papilloma, and helps separate it from carcinoma and retained secretion