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Sinonasal Malignacy
Although rare, sinonasal malignancies (SNM) can be lesions of immense importance. They
produce few if any signs while the tumor is in its early stages. This problem is exacerbated by
the fact that the initial manifestations such as unilateral nosebleeds and nasal obstruction may
mimic signs and symptoms of many common but less serious conditions. Therefore, the patient
and clinician may ignore or minimize the initial presentation of these tumors and treat early-stage
malignancy as a benign sinonasal disorder. As such, malignant tumors are often diagnosed at a
later stage.

By the time ominous signs and symptoms (such as severe intractable headache, visual
disturbance, or cranial neuropathy) occur, the neoplasm is often advanced. The anatomy of the
nasal cavity and paranasal sinuses cause these tumors to manifest in advanced stages and
complicate their treatment. They are located adjacent to important structures such as the skull
base, orbits, cranial nerves, and vital vascular structures. The obvious morbidity and
complications associated with traditional open surgical resection of such tumors can be severe.
Minimally invasive endoscopic resection (MIER) may provide a treatment alternative. The
evolution of computer assisted surgical navigation and sophisticated surgical instrumentation has
facilitated endoscopic management of complicated sinonasal pathology such as CSF leaks,
benign tumors, and complications of sinusitis; conditions that may have previously required open
approaches. Management of sinonasal malignancies is thus a logical progression of the use of
such techniques. Endoscopic surgical techniques provide improved visualization and
magnification over traditional open procedures, and when combined with modern CT scanning,
MRI, advanced surgical instrumentation and image guidance, allow for decreased bleeding, lack
of external facial incisions, and shorter hospital stays than the external surgical approaches.
Moreover, morbidity can be minimized with MIER as important vital structures can be
preserved, and craniotomies and brain retraction avoided.

The central tenets of surgical oncology remain the same with regards to MIER of sinonasal
malignancies. The first priority and goal is complete tumor resection. Second, the surgical
objective should be achieved while minimizing morbidity and adverse impact on patients’
quality of life. MIER allows for possible preservation of neurologic function, vision, and
physical appearance while achieving the oncologic surgical goals.

The endoscopic approach allows for superb visualization of tissues and delineation of tumor
boundaries, thus allowing complete tumor resection while minimizing morbidity and preserving
uninvolved structures such as the eye and brain. In addition, patients can also be followed with
similar endoscopic techniques, allowing for unparalleled visual surveillance of a surgical site.
Patients can actually be diagnosed, treated, and followed with the same endoscopic approaches
and techniques.
While minimally invasive techniques can be very beneficial in treating sinonasal malignancies,
MIER should only be attempted by highly trained rhinologic surgeons adept with advanced
endoscopic techniques. Appropriate instrumentation and image guidance are pre-requisites as
well. In addition, a multi-disciplinary approach should also be paramount when managing
sinonasal malignancies as patients oftentimes require chemotherapy and radiation.

Types of Sinus and Nasal malignant Tumors:

  • Squamous cell carcinoma
  • Adenoid cystic carcinoma
  • Adenocarcinoma and its variants
  • Malignant melanoma
  • Sinonasal neuroendocrine tumors
  • Esthesioneuroblastoma
  • Sinonasal undifferentiated carcinoma
  • Small cell neuroendocrine carcinoma
  • Verrucous carcinoma
  • Lymphomas and related conditions
  • Salivary-type neoplasms
  • Sarcoma
  • Metastatic tumors