Diagnosis and treatment of nasal cavity cancer
Zhang Liqiang
I. Overview
Nasal cavity cancer refers to malignant tumors originating in the nasal cavity, mostly in the lateral wall of nasal cavity, such as middle turbinate, middle nasal passage and inferior turbinate. However, septal cancer is more likely to have cervical lymph node metastasis than lateral nasal wall cancer. Undifferentiated carcinoma and squamous cell carcinoma are the most common types of nasal cavity cancer. Zhang Liqiang, Department of Otolaryngology, Qilu Hospital, Shandong University
Secondary nasal cancers mostly originate from the sinuses, such as maxillary sinus cancer and septal sinus cancer, which invade the nasal cavity more often. Occasionally, malignant tumors from distant organs may metastasize to the nasal cavity, including adrenal cancer, kidney cancer, laryngeal cancer, lung cancer, breast cancer, gastric cancer, liver cancer, etc., but they are rare. The biological behavior of secondary nasal cancer varies greatly depending on its primary site, and all nasal cancers discussed in this section refer to primary nasal cancer.
Conventional diagnosis
Nasal cancer is more common in men. Nasal bleeding, nasal congestion and nasal swelling are the three major symptoms of nasal cancer. In the early stage, there are often only unilateral nasal congestion and nasal bleeding. With the development of the lesion, numbness and fullness of the face and nose, intractable headache, progressive and persistent unilateral nasal congestion, bleeding mucus and olfactory disturbance may appear, and sometimes patients may complain of finding nasal masses or changes in the shape of the nose. With the development of lesion, it may be accompanied by infection, tumor ulceration, foul-smelling bloody pus, and repeated heavy nasal bleeding. In long history, the tumor may block the nasal cavity, push the nasal septum to the opposite side, or break through the septum to involve the opposite nasal cavity. In advanced stage, the tumor may expand widely in the nasal cavity and often invade the sinuses, nasopharynx, orbit, palate, alveolus and other parts of the nose and develop corresponding clinical symptoms, such as vision loss, diplopia, eye displacement, proptosis, cheek bulge, palatal mass, tinnitus, hearing loss and severe headache. Eventually, patients may develop anemia, cachexia, cervical lymph node metastasis or distant metastasis.
Physical examination shows that the tumor is usually exostotic cauliflower-like papillae or mulberry-like masses with bleeding and ulceration, pink to red in color, hard and brittle in texture, prone to infection and necrosis, often accompanied by polyps or purulent sinusitis.
Most of the patients are already in advanced stage when they visit the clinic, and the tumor has extended beyond the nasal cavity to the adjacent organs, so it is difficult to determine the primary site. Early diagnosis depends on the attention and vigilance of early symptoms and timely biopsy. For those over 40 years old who have recently developed unilateral progressive nasal congestion with bloody nasal discharge, or those with long-term sinusitis and recent severe headache and nasal bleeding, or those who recur rapidly after repeated removal of polyps, the possibility of nasal cancer should be suspected and should be repeatedly investigated in detail.
CT scan of sinus can help to clarify the primary site of tumor and its extended invasion range, and should be listed as routine examination. CT scan of sinus can show tumor invasion of bone more clearly, but sometimes it is not easy to distinguish from obstructive inflammation of sinus, so intensive CT examination should be performed at this time. If the tumor involves cavernous sinus, infratemporal fossa, saddle area or invades important structures such as frontal lobe, MRI examination can obtain details of the extent of soft tissue destruction by the tumor in the above areas. However, there is often a layer of necrotic tissues on the surface of nasal cavity cancer, so if the biopsy is superficial, the tumor may not be removed, but if the biopsy is performed on a large piece of deep tissues, it may cause a large amount of bleeding.
Nasal cavity cancer can be clinically divided into four stages: Stage I: tumor is confined to the nasal cavity without metastasis or expansion; Stage II: tumor destroys the bone wall of nasal cavity, invades into the adjacent sinus or expands into the contralateral nasal cavity, but there is no definite cervical lymph node metastasis or stage I tumor is accompanied by movable suspicious lymph node metastasis. Stage IV: tumor invades the skull base with or without metastasis, or any stage of tumor with distant metastasis.
III. Conventional treatment
Patients with nasal cavity cancer should adopt comprehensive treatment mainly based on surgical resection. It should be supplemented with radiotherapy before and after surgery. Radiotherapy can be preferred for undifferentiated cancer and low differentiated cancer, and surgical resection can be performed for those who are not controlled by radiotherapy. The surgical incision is mostly made by lateral nasal incision or sublabial median incision, and as far as possible, the whole piece is removed outside the normal tissues of 1~2 cm beyond the edge of the tumor seen by the naked eye. For nasal septum cancer, if necessary, it should be extensively resected together with nasal tip, nasal dorsum, nasal base, plough bone or palate bone. For those originating from the lateral wall of the nasal cavity, resection of the medial maxilla and orbital contents is feasible. If there is suspicion of cervical lymph node metastasis, cervical lymph node dissection should be performed. Tumors occurring in the lower part of the nasal cavity are easy to be completely removed because there are no important structures around them. The main steps in surgical treatment are as follows.
(1) Incision: The upper boundary does not exceed 0.5cm above the middle of the line between the medial canthus and the nasal root, and goes down along the lateral edge of the nasal dorsum to the nasal flank side. If the tumor is more extensive, the incision can be extended upward to the inner end of the brow arch, and the lower end of the incision can be extended backward around the lateral foot of the greater pterygoid cartilage into the nasal vestibule, and then inward to the lower part of the nasal column. Following this, the upper lip can be incised medially. To reduce bleeding, the incision can be made from the nasal flank upward to the medial canthus, which can significantly reduce the bleeding from the incision, probably because the bleeding from the distal end is reduced after first cutting off the proximal end of the vessel to stop bleeding. (2) The incision should be perpendicular to the skin. After the skin is cut, the subcutaneous layers can be cut with an electric knife straight to the bone, and after exposing the bone, the periosteum together with the soft tissue can be pushed outward, or the flap can be separated and cut along the bone surface with an electric knife. (3) Expose the bone around the nasal bone, lacrimal bone, maxillary frontal process, orbital rim and pyriform foramen. The soft tissue of the lateral wall of the nasal cavity was separated along the lower edge of the nasal bone with a stripper, and then the affected nasal bone and part of the maxillary frontal process were chiseled away along the plane of the medial canthus on both sides. Enlarge the edge of the pear-shaped foramen, cut the mucosa of the nasal cavity, pull the affected nasal cone toward the healthy side, fully expose the nasal cavity and explore the tumor scope. (4) Excise the lateral wall structures of the nasal cavity according to the extent of the lesion. After tumor removal, check again for residual lesions and broken bone fragments, stop bleeding thoroughly, fill the nasal cavity with iodoform gauze, suture the nasal mucosa, subcutaneous tissues and skin with silk thread layer by layer to keep both nasal dorsum symmetrical, and bandage locally.
IV. Diagnostic ideas pointing
Nasal cancer is easy to be misdiagnosed in clinical practice. The main reasons are: some patients have a long-term history of chronic rhinitis or sinusitis, and both doctors and patients lose their alertness to the tumor due to the past medical history when nasal obstruction is recently aggravated. Some of these patients usually have enlarged inferior turbinates and the middle nasal tract and middle turbinate structures are not visible during nasal examination except for the anterior inferior turbinates. If the inferior turbinate is not contracted and then the nasal cavity is carefully examined or if formal nasal endoscopy is not performed, the possibility of missing early nasal cancer is great. For the small amount of nasal bleeding or blood in the snot that is common in clinical practice, most patients are due to dryness of nasal mucosa or bleeding in the septal ligament area, but some patients do have tumor or fungal sinusitis as the cause. Whether it is sinus inflammation or tumor, it is always reflected in the nasal cavity, and a systematic nasal endoscopy is important not only for the detection of nasal lesions but also for the early detection of sinus lesions. Therefore, routine nasal endoscopy is necessary in these cases, provided that the conditions are available. If a lesion is found on nasal endoscopy, it is often followed by imaging to make a scientific and comprehensive assessment of the lesion. Any laziness or laziness in the absence of a full view of the nasal cavity can place the patient at a disadvantage. Always perform a nasal endoscopy for new organisms in the unilateral nasal cavity to be biopsied if necessary. Unless it is a posterior maxillary sinus polyp, nasal polyps mostly occur bilaterally, even small unilateral polyps of the middle nasal tract can be found on the opposite side if a careful nasal endoscopy is performed. There are many malignant tumors that look like polyps, but not many of them occur bilaterally, except in very advanced stages, but then there is no need for differential diagnosis. We have encountered many cases of nasal cancer misdiagnosed as nasal polyps or benign tumors in clinical practice. A 50-year-old female, who was admitted to a provincial hospital for 2 months due to nasal obstruction, was examined and found to have polyp-like neoplasm in the left middle nasal tract. The patient came to our hospital during the waiting process and was proposed to be diagnosed with nasal invagination papilloma, and a biopsy was taken for hypofractionated squamous cell carcinoma. In addition, some adenoid cystic carcinomas also look quite similar to polyps. Usually, head and neck oncologists rarely miss the diagnosis of nasal cancer, because of their specialization, patients with nasal congestion or runny nose think of tumor first, and inflammation only after tumor is excluded, while rhinologists usually think of inflammation first and tumor later. Therefore, one should not have a preconceived diagnostic idea before careful history analysis and physical examination. The clinician’s thinking should be calm, meticulous, and comprehensive, and should not be swayed by external factors. The doctor’s mentality at this time is that although the positive rate is low, it is not easy to miss the diagnosis, which is invariably a subconscious self-justification for a large checklist. But if the patient’s economic conditions are poor, the general doctor may be compassionate, can be prescribed less, “first take some medicine to observe a period of time, such as bad and then come back to see the doctor”, the doctor’s psychology is that these patients do not cost too much, but also because of the medical advice to let its follow-up and not delay the possible existence of serious conditions. However, these patients may come to the hospital once and make a great effort to make up their mind, and if they are let go once, they may never come back for a follow-up visit until their condition is too serious to be treated. Another principle to avoid missed diagnosis is that all tissues removed during surgery must have pathological examination, which should become a routine part of treatment and should not be abandoned due to lower treatment cost or laziness.
V. Treatment idea pointers
First of all, the concept of comprehensive treatment should be established in the treatment of nasal cancer. The head and neck surgeon and radiotherapist should work closely together to discuss and formulate the treatment plan. This is not only due to economic factors, but also due to the different treatment philosophies accepted by doctors of different departments, each of which usually puts the technology of their own department above the others.
The surgical treatment of nasal cavity cancer needs to be handled accordingly according to different lesions. Attention should be paid during surgery: (1) Eye ointment should be applied to the operated side of the eye before surgery, and the eyelid should be sutured to avoid damaging the cornea. (2) When removing the bone and lesion above the middle turbinate, do not use excessive force, do not tear the middle turbinate roughly when removing it to avoid damaging the sieve plate and cerebrospinal fluid leakage, and do not twist the bone when biting it with biting forceps, otherwise the damage will be too great. (3) Keep the knife blade and skin vertical when making incision, avoid cutting the incision obliquely, otherwise the facial skin healing scar will be more obvious after surgery. (4) Try to achieve the whole tumor removal. Usually, it is easier to remove the whole block of nasal cavity cancer such as inferior turbinate or middle turbinate tumor, but once the sieve sinus is involved, because the posterior sieve septum is thin, it is easy to cause the posterior sieve room to be broken, and it is not easy to remove the whole block. After the facial flap is separated, the orbital fascia is first separated along the inferior orbital wall with a small detacher, and then separated backward to the orbital apex. The periosteum and orbital contents were retracted laterally with a small retractor to facilitate excision of the infraorbital portion. The lacrimal sac and nasolacrimal duct are separated from the lacrimal fossa by applying a periosteal stripper and the nasolacrimal duct is crossed. The anterior wall of the maxillary sinus is opened to explore the lesion in the maxillary sinus. If there is no tumor involvement in the maxillary sinus, the nasal wing is retracted to the opposite side and the mucosa of the pyriform foramen is incised to enter the nasal cavity. A bone chisel was used to chisel the inner wall of the maxillary bone horizontally at the base of the nose to reach the posterior margin of the maxillary sinus, and the tip of the bone chisel could be seen from the opening of the anterior wall of the maxillary sinus. The bone of the medial wall of the orbit is then chiseled above. If the tumor involves the septal sinus, the affected nasal bone needs to be removed to facilitate exposure of the septal sinus. After the medial wall of the maxilla is released, the index finger is inserted into the maxillary sinus and the other index finger is inserted into the nasal cavity, and the swelling is gently shaken to dissociate the septal bone. To avoid damage to the orbital tip, the finger can be used to reach the orbital fascia medially to guide the bone chisel. The lateral wall of the nasal cavity, including the septal sinus, middle turbinate, inferior turbinate and the medial wall of the maxillary sinus, is removed in its entirety by cutting the posterior part of the specimen with curved scissors adjacent to the posterior nostril. (5) Protection of nasal facial appearance If the tumor does not involve the external nasal stent, some of the bone can be preserved, especially paying attention to maintain the continuity and contour of the inferior orbital margin and the inner inferior bone margin. For early stage surgical resection of tumor, we suggest to use miniature electric saw more often, and the uninvolved bone of external nasal stent should be preserved and fixed with miniature titanium plate after surgery to reduce the facial deformity as much as possible. When separating the orbital periosteum, the medial canthal ligament is cut and a long silk thread is sewn as a marker. At the end of the surgery, a bone hole is drilled at the nasal bone and the medial canthal ligament is fixed with a non-absorbable thread so that the medial canthal position is consistent with the opposite side and the orbital contents are restored to their normal position. When suturing the skin, the subcutaneous layers can be sutured with absorbable threads, and the skin suture can be interrupted with 5 0’s of fine silk threads.
Advanced nasal cavity cancer may invade the anterior skull base, so a combined craniofacial approach should be performed for resection. The patient is firstly placed in lateral position for lumbar puncture, and a cerebrospinal fluid drainage tube is left in place for cerebrospinal fluid drainage and intraoperative and recent postoperative cerebrospinal fluid pressure monitoring. Transoral tracheal intubation was performed under general anesthesia, and the upper and lower eyelids were closed with fine sutures to protect the cornea intraoperatively. A double coronal incision within the hairline from one side to the contralateral ear screen is performed, which allows full exposure of the anterior cranial fossa. The scalp and subcutaneous tissues are incised to reach the capitellar tendon membrane and cranial periosteum at a superficial level, and the posterior scalp flap is lifted posteriorly several centimeters to expose the cranial periosteum. The posterior scalp flap is pulled posteriorly to obtain a tipped capitellar periosteal flap of sufficient length. The anterior scalp flap is turned up as far downward as possible to fully expose the interbrow area and the upper half of the nasal bone. The anterior wall of the frontal sinus and the frontal osteotomy are marked out. Drill a hole in the midline of the skull with a chainsaw, gently separate the dura mater with a meningeal stripper on both sides around the hole, circumferentially cut the skull along the pre-marked line, and cut only the anterior wall of the frontal sinus in the lower part, pry open the bone flap with a bone chisel, break the septum of the frontal sinus, and carefully remove the bone flap, avoiding damaging the dura mater under it. The septum of the frontal sinus was removed by biting forceps, the mucosa in the frontal sinus was scraped and the posterior bone wall of the frontal sinus was removed, and the opening of the nasofrontal canal was filled with gelatin sponge. At this time, the dura mater was carefully lifted from the anterior cranial fossa, and the dura mater attached to the corpus cavernosum needed to be sharply separated, and the sleeve-shaped dural structures wrapped around the olfactory nerve were cut and ligated on both sides, respectively. Each olfactory nerve surrounded by the dura mater should be severed and ligated. If the tumor penetrates the sieve plate, a dural dissection is performed and the tumor is removed along with the sieve plate. Some cerebrospinal fluid is released from the lumbar puncture drainage tube to retract the brain tissue. The brain is protected with a cerebral compression plate and the sieve plate and pterygoid plane are fully exposed. The skull base plate is incised with a fine high-speed electric drill and wrapped around the entire surgical specimen from above. The incision from the medial canthus can be extended in both directions, with the upward incision continuing along the lateral aspect of the nasal bridge up to the medial aspect of the eyebrow, and if a lower lid incision is required, it needs to be turned 90 degrees outward, immediately adjacent to the skin line nearest the lower eyelid margin to the lateral canthus, and further along the skin line to the zygomatic bone area and beyond the orbit as needed. If the face requires exposure of the nasal bone, the incision can be extended between the eyebrows to the medial aspect of the contralateral eyebrow. If a total maxillary resection or orbital content removal is required, a submasculature incision is possible. The medial orbital periosteum is lifted so that the orbital contents remain intact in the periosteal capsule. The buccal flap was lifted from the surface of the maxilla to protect the infraorbital nerve from the infraorbital foramen. The anterior and posterior septal vessels were dissected and the mucosa of the lateral wall of the nasal cavity was cut along the anteromedial aspect of the maxilla in the nasal vestibule to expose the interior of the nasal cavity. The anterior wall of the maxillary sinus was opened, the soft tissue of the nasal skin was lifted from the nasal bone, the frontal fossa of the maxilla and the anterior portion of the orbital cardboard were incised, and the medial wall of the maxilla was dissected posteriorly with a bone chisel at the base of the nasal cavity. The lateral wall of the nasal cavity was incised posteriorly with nasal scissors placed from the anterior nostril to expose the intracranial field above, and the specimen was separated from the cranial cavity with a bone chisel and excised intact. The medial canthal ligament is sutured and fixed to the residual nasal bone, and the capitellar cranial periosteal flap is placed over the anterior skull base to repair the defect. The cranial incision is closed with a small titanium plate. The scalp is sutured. The nasal cavity was filled with iodoform gauze and the facial skin incision was sutured.
The postoperative treatment of nasal cavity cancer needs to pay attention to the following points: (1) After surgery, patients should be placed in a flat position with head to the affected side, pay attention to breathing, blood pressure, pulse and blood leakage from the incision. Clear pharyngeal secretions at any time, if there is fresh blood, it is necessary to judge whether there is continued bleeding. (2) Pay attention to the ocular condition, whether there is periorbital petechial hemorrhage, vision loss, diplopia, and intraorbital hematoma, etc. The presence of vision loss and intraorbital hematoma needs to be treated urgently. (3) Apply postoperative antibiotics to prevent infection and maintain blood volume and water-electrolyte balance. (4) The nasal gauze should be withdrawn in stages 3-5 days after surgery depending on the extent of the surgery, and the wound sutures should be removed intermittently 5-7 days after surgery. (5) After nasal gauze extraction, nasal rinsing can be performed to remove blood crust and secretions. Compound peppermint oil may be dripped, and if there are crusts, saline may be used to rinse the nasal cavity. (6) If clear water-like secretions are found dripping from the nasal cavity after surgery and the patient has headache and fever, biochemical examination of nasal fluid, such as quantitative sugar and β2 transferrin, should be performed.