Tumours of the nose

Benign tumours

Osteomas of the nasal skeleton are not uncommon and are usually detected on X-ray as an incidental finding. They are usually seen in the frontal and ethmoid sinuses (Fig. 39.14). Some may produce symptoms such as headache or recurrent sinusitis if the location interferes with the drainage of one of the paranasal sinuses. Plain X-rays demonstrate a calcified, well-demarcated tumour of variable size. In symptomatic individuals the osteoma can be removed via the frontal sinus or an external ethmoidectomy.

Transitional cell papilloma (inverted papilloma) can occur in both the nasal cavity and the nasal sinuses. They can be quite extensive (Fig. 39.15) and give rise to nasal obstruction and sometimes epistaxis. Although usually unilateral, red, firm and vascular they can sometimes look like simple nasal polyps, and in 25 per cent of cases the diagnosis is made by the pathologist after a routine nasal polypectomy. When large they can erode the lateral nasal wall and infiltrate the antrum and ethmoid. Calcification within the tumour may be seen on CT scanning along with sclerosis of bone at the margins of the growth. Transitional cell papilloma can undergo malignant change; synchronous lesions occur in 5—10 per cent, while metachronous lesions develop in 1 per cent of cases.

For this reason more radical surgery is employed than for simple polyps to ensure complete removal of all papillomata and will usually involve a partial maxillectomy.

  Benign nasal tumours summary

  Osteomas are frequently asymptomatlc

      Transitional papilloma may undergo malignant change

Malignant tumours

Skin tumours involving the nose are not uncommon. Basal cell carcinomas (rodent ulcer) are confined to the head in 86 per cent of cases and of these 26 per cent occur on the nose. Adequate surgical excision may require some form of reconstructive flap procedure to eliminate the resulting defect. Keratinising squamous cell carcinoma is the second most common tumour of the external nose, which should be adequately excised with a generous margin of healthy skin and the defect reconstructed with a local flap. About 10 per cent of all melanomas occur in the head and neck. Wide surgical excision is mandatory, frequently requiring the skills of a plastic surgeon for reconstruction (see Chapter 13 on ‘Plastic surgery’).

The most common tumours to occur within the nasal cavity and paranasal sinuses are squamous cell carcinoma (Fig. 39.16), adenoid cystic carcinoma and adenocarcinoma. (Table 39.3). Presenting symptoms include unilateral nasal obstruction, chronic nasal discharge, which is often haemor­rhagic and offensive, and loss of skin sensation on the face (trigeminal nerve). There may be swelling of the cheek, buccal sulcus or the medial canthus of the eye and a feeling of fullness or pressure within the nose or face. Suspicious signs of invasion of neighbouring tissues include diplopia, proptosis, loosening of the teeth (Fig. 39.17), trismus, cranial nerve palsies and regional lymphadenopathy. Biopsy via nasal endoscopy will permit a tissue diagnosis, while assessment of bone errosion and the extent of the disease can be determined by CT scanning (Fig. 39.18). If invasion of the skull base is suspected then angiography will be required, and distant metastases to lung, bone, brain and liver should be excluded.

Patients with sinus or intranasal malignancy are best managed in a combined clinic where the expertise of ear, nose and throat (ENT) surgeons, maxillofacial surgeons and radiotherapists can be employed. Detailed surgical management is outside the scope of this book, but the adequacy of any surgical resection will need to be confirmed by frozen section control of soft-tissue margins. Inevitably reconstruction will require the use of myocutaneous flaps or free grafts with microvascular anastomosis. Surgery is followed by radiotherapy. At present chemotherapy is reserved for palliation of inoperable tumours.

Malignant nasal tumours summary

Skin cancer of the nose requires wide excision and expert reconstruction

May present late with signs of invasion

Should be managed by ENT and maxillofacial surgeons with a radiotherapist