Nasal Cancer

The nasal cavity is a space behind the nose, above the roof of the mouth that curves down at the back to join the throat. The nasal cavity is divided into two nasal passages by the nasal septum.

Paranasal means near or around the nose; sinuses are small tunnels or spaces. Paranasal sinuses are air-filled, hollow spaces in the bones lying above and behind the nose and behind cheekbones. They are of four types.

Together, the nasal cavity and paranasal sinuses perform various functions:

• Make the air warm and moist and filter tiny particles and bacteria from the air before it goes towards the lungs
• Give the voice its resonance
• Lighten the skull
• Provide a bony structure for the eyes and the face

Tumours are more likely to form in the nasal cavity. In the case of sinuses, tumours tend to develop in the maxillary sinuses (located behind the cheeks). Usually, most tumours are benign. However, there are some that are cancerous or turn cancerous if left untreated, growing and multiplying out of control with the potential of spreading to other parts of the body (metastasizing).

There are various types of nasal and paranasal sinus cancers. Some of the common ones are:

• Squamous Cell Carcinoma: Squamous cells are thin, flat cells that form the lining of the nasal and sinus passages. Squamous Cell Carcinoma is the most common type of nasal and sinus cancer, occurring in more than 60% of the cases.
• Adenocarcinoma, Adenoid Cystic Carcinoma: This is the second most common type of nasal cancer and occurs in the minor salivary gland cells.
• Olfactory Neuroblastoma: This presents as tumours on the top part of the inside of the nose and develops in the lining responsible for the smell.
• Sarcoma: These are cancers of muscles, fibrous cells, bones and cartilage.
• Melanoma: This cancer develops in cells that give the skin its colour. Although this is usually found in areas that are exposed to the sun but can also develop inside the body such as on the lining of the nasal cavity and the sinuses.
• Inverting Papilloma: These are benign wart-like tumours that develop inside the nose, with the potential to turn into squamous cell carcinoma.
• Lymphoma: These cancers begin in the lymph nodes along the lining of the nasal cavity and paranasal sinus.

In the early stages, there are often negligible signs of nasal and paranasal sinus cancer. When they do appear, the symptoms can resemble other sinus-related conditions, with the difference being that symptoms of nasal and paranasal sinus cancer are persistent. Some of these are:

• Lesion or sore on the roof of the mouth
• Congestion on one side of the nose that does not go away
• Ongoing blockage in the sinus
• Nosebleeds
• Reduced sense of smell
• Discharge from the nose
• Problem breathing through the nose
• Watery eyes
• Partial or complete loss of vision
• Pain around the eye
• Difficulty in opening the mouth
• Enlarged lymph nodes in the neck
• Facial swelling, pain, or numbness
• Sinus headaches
• Loss of hearing

Similar to several other cancers, nasal and sinus cancer is associated with damage to the DNA in the cells. Some of the factors that lead to a high risk of developing nasal and paranasal sinus cancer are:

• Smoking – whether active or passive
• Occupational exposure to certain substances such as leather dust, wood dust, nickel compounds, radioactive metals, isopropyl alcohol (used in household products)
• Infection with the human papillomavirus (HPV), causes the growth of small warts. HPV is transmitted through unsafe sex.
• Men greater than 55 years of age are at higher risk for developing nasal and sinus cancer.
• Undergoing radiotherapy for treating other cancers such as hereditary retinoblastoma and nasopharyngeal cancer has been associated with the development of nasal and sinus cancer.

In most cases of nasal and sinus cancer, there are no identifiable risk factors, so it may not be possible to prevent cancer.

However, people can address the recognized risk factors to reduce their chances:

• Occupational safety: wearing appropriate safety gear around harmful chemicals and dust to avoid exposure to those
• Quitting smoking
• Safe sex practices and a full course on the HPV vaccine, to avoid contracting HPV
• Regular exercise and a healthy diet
• Periodical health check-ups, especially for survivors of other cancers

If a person exhibits the above symptoms, it is recommended to consult with an ENT doctor.

The doctor will begin by taking the medical history to understand the prevalence of potential risk factors such as occupation, the onset of symptoms and prior treatments done if any. This is followed by a physical examination to assess the eyes, ears, mouth, face, nose, neck and throat for pain, numbness, and firmness in the face, issues with vision and the lymph nodes in the neck.

Further procedures are carried out to confirm the diagnosis and evaluate the extent of the disease:

• Nasal Endoscopy: in this, a thin, flexible hollow tube with a tiny camera and light is inserted into the nose. The camera captures and transmits pictures for the doctor to identify the location and size of the tumours.
• CBC: a complete blood count is carried out to evaluate secondary conditions such as anaemia, risk of infection, etc.
• Imaging tests: An X-ray is undertaken to check whether sinuses are filled with anything other than air. Since nasal and sinus cancer spreads to the lungs, apart from lymph nodes in the neck, an x-ray of the chest may also be done to examine whether the cancer has spread.
• CT Scan: This test utilises x-rays to create detailed images of the inside of the body and is quite helpful in diagnosing cancers of the nasal cavity and paranasal sinus. It is also useful in measuring the tumour’s size and its staging.
• MRI Scan: This test utilises radio waves and magnets and assists in distinguishing between a cancerous tumour from a benign one.
• PET Scan / PET-CT scan: PET scan uses a special drug to look for metabolic activity and can help diagnose the likely areas of cancer spread, including in the bones, in case CT or MRI scan do not depict an obvious tumour. PET scan is often done in conjunction with a CT scan.
• Biopsy: A small sample from the suspected area/tumour is removed and tested in the lab to confirm the nature of the malignancy and how fast it could grow and spread. There are various methods of conducting a biopsy such as incisional and excisional and endoscopic biopsy.

Reviewing the results of the person’s medical history, physical examination, endoscopy and radiological tests, the doctor recognises the existence of nasal and sinus cancer and the stage where it is at.

Treatment of nasal and sinus cancer could involve a multidisciplinary team of doctors such as oncologists, neurosurgeons, ENT specialists, dentists and maxillofacial prosthodontists (who perform restorative surgery on the head and neck).

A combination of radiation therapy and surgery is used to treat nasal and sinus cancer. If the surgery has spread to lymph nodes as well, the affected nodes are also removed. Surgical options are:

• Excision: Cancerous tumour is removed along with some healthy tissue around it, which is referred to as "margin".
• Maxillectomy: In this, the hard palate at the roof of the mouth is removed partially or wholly. The gap created is filled with flaps of soft tissue with/without bone or prostheses. It is recommended for treating paranasal sinus cancer.
• Skull Base Surgery: Also called craniofacial resection, this is an extensive surgery in which more tissue is removed compared to maxillectomy.
• Rhinectomy: For people with extremely high-risk cancer, part of the nose or the entire nose is removed
• Minimally invasive surgery: In certain cases, the surgery may be carried out through special tools and endoscopy, which are inserted through the nose and the tiny camera allows surgeons to carry out the operation.
• Neck dissection: surgical removal of affected lymph nodes in the neck, when cancer has spread to those.
• Reconstructive surgery: When large or specific areas of tissue are removed during surgery, reconstructive surgery is carried out.

Other treatment options which are applied along with surgery are:

• Radiation therapy: high powered energy such as x-rays or protons are used to kill cancer cells. It can be used singly, before surgery or post-surgery.
• Chemotherapy: Using specialized drugs to kill cancer cells. It may be used in combination with radiation therapy.
• Immunotherapy: Using certain drugs to boost the immune system response against cancerous cells.

There is a multitude of physical, emotional and financial side effects of a cancer treatment regimen. Accordingly, counselling for the person suffering from the disease and their family is required. To help with problems that could occur with speech, hearing and swallowing, the person may require rehabilitation and therapy.

After treatment, imaging tests may be carried out to ensure remission. Further, continuous follow-up visits are necessary to rule out recurrence and to detect any other cancer that might develop.

The outlook for nasal cancer depends on the stage in which the cancer was diagnosed. Outlook also depends on the parts of the nasal cavity and paranasal sinus which were affected. Early detection increases the chances of survival.

Localised cancers that have not spread to lymph nodes have more than an 80% chance of relative five-year survival. Locally advanced cancers that have spread to nearby structures have about a 50% chance, while cancer that has metastasised has a lesser five-year survival rate.

It is also to be noted that recovery from advanced cancer may not be always possible. Further, survivors of cancer of the nasal cavity and sinus are at increased risk for developing certain other types of cancers.