|
The external nasal area is susceptible to direct sun injury and as such has a relatively high incidence of skin cancers especially Basal Cell Cancers and Squamous Cell Cancers. Sun-protection such as regular use of sunblock is of vital importance in preventing these tumors. These tumors can occur anywhere along the top surface of the nose, but have a proclivity for the tip area that tends to have more sun exposure. Unfortunately the tip and the ala (lateral aspect of the tip) are some of the more difficult areas of the nose to reconstruct, and require great expertise.
is the most common and the least aggressive type of skin cancer. It often appears as a pearly white lesion that grows very slowly. (Fig. 1)
(Figure 1) Basal Cell Carcinoma
Click on image for larger view
It can show up as a painless lump on the skin that does not cause any discomfort, at times however it can ulcerate, become painful, and bleed. This tumor has a very slow growth rate and a very low potential for spread to other parts; due to these special characteristics we are able to treat it with a much less radical surgical treatment (meaning the tumor does not need to be removed with a large rim of normal tissue to assure cure). Although it can be treated with radiation therapy, radiation is reserved for more difficult cases that are in locations that are unusually difficult to reconstruct, or in very advanced cases. In certain cases we advocate a Moh’s procedure, performed by specialized dermatologist that carefully remove the tumor one piece at a time and assess it under the microscope to assure the most minimal surgery possible. This creates the smallest defect that will be easier to reconstruct. (Fig. 2)
 |
|
|
(Figure 2)
Small MOHS Defect & Reconstruction
Click on images for larger view
|
tend to be more aggressive than basal cell tumors and as such require a larger surgical excision (the tumor needs to be removed with a larger rim of normal tissue as compared to a basal cell cancer). The tumor is more destructive, tends to grow deeper, and has a much higher potential to spread. These tumors need to be treated immediately. At the time of operation, immediate pathologic examination of the skin at the periphery of the surgical defect is done to assure there has been no tumor left behind. The depth of the defect is often more. Reconstruction of these defects is often more challenging, and requires expertise. Our team carefully assesses the defect and plans the most appropriate reconstructive surgery. (Fig. 3)
(Figure 3)
Defect from a Large Tumor & Reconstruction
Click on image for larger view
Nasal cavity tumorsoccur in the internal nasal structures, which include the nostrils, the passageway just behind the nostrils, septum (dividing wall), and the paranasal sinuses. (Fig. 4)
(Figure 4) Sinus & Nasal Anatomy
Click on image for larger view
The paranasal sinuses have a complex anatomy and include multiple compartments including, the maxillary sinuses found beneath the cheeks and on the sides of the nose, the frontal sinuses in the forehead area, the ethmoid sinuses found at the roof of the nasal cavity between the eyes, and the sphenoid sinuses found deep behind the nose between the roots of the eyes. Most masses in the nasal cavity and the sinuses are benign and not cancerous. Due to the open exposure of these structures to the outside environment infection and inflammation is a common finding in these cavities leading to development of lesions that can appear very similar to a tumor. Evaluation by a specialist is of utmost importance to distinguish between a benign lesion and a more aggressive one, and to begin appropriate treatment.
|
Pathology |
Benign |
Polyps
Pyogenic
Granuloma |
Benign Tumors |
Septal Papilloma
Inverting pilloma
|
Malignant Tumors |
Squamous Cell Carcinoma
Adenocarcinoma
Esthesioneuro-blastoma
Sarcoma (Variable Types)
Lymphoma
Melanoma
|
Tobacco use increases the risk of squamous cell cancer in all areas of the head and neck. Prolonged exposure to wood dust has a correlation with development of adenocarcinoma. 10% of patients who have the benign tumor inverting papilloma go on to develop squamous cell carcinoma. Inverting papilloma, although benign, is a very destructive tumor and needs to be dealt with expediently and appropriately, because both the rate of recurrence and cancer transformation is high.
The symptoms of nasal cavity and sinus cancer can be quite similar to those of other common diseases like allergies and sinusitis. These symptoms often include one sided runny nose, nosebleed, headache, sinus pressure, and/or blurred vision, but in a great proportion of patients there are no symptoms at all. When these cancers are detected and treated early, survival rates are greatly improved, so it’s important not to disregard seemingly minor ailments that linger. Unfortunately, due to the commonality of the symptoms most patients present later with larger tumors requiring aggressive treatment. Patients generally undergo diagnostic imaging, usually a , to identify the cause of the symptoms. If a mass is found, is then required to identify whether the mass is cancerous or not. MRI and PET Scanning may be needed and will be decided by your head and neck surgeon
– The standard treatment of inverting is surgical removal (). Traditionally, this was done through a facial incision on the lateral aspect of the nose termed lateral rhinotomy. In most cases now however the tumor is removed through the nostril (without any facial scars) by using the cutting edge techniques and technology: is performed with small endoscopes (thin scopes that show the images on the video screen) and . (Fig. 5)
|
(Figure 5) Nasal Endoscope |
Click on image for larger view |
| |
|
(Figure 5) Nasal Endoscope & Position in the Nasal Cavity
Click on image for larger view |
The image guidance equipment allows exact radiologic visualization of the tumor and the patient’s anatomy in the operating room (as if the surgeon is having access to live x-ray of the patient in the operating room); this guides the surgeon in deciding the extent and accuracy of the surgery. (Fig. 6)
|
(Figure 6) Image Guidance System
Click on Image for larger view
|
This approach greatly minimizes the risk to the patient.
– The type and stage of the tumor shapes the treatment plan. Lymphomas are treated with non-surgical treatments. The other malignancies require surgical removal as the primary mode of therapy, the decision to use radiation and possibly chemotherapy is very much dependent the particular characteristics of the tumor. Small tumors can be excised with endoscopic approaches and image guidance. Larger tumors may require an open approach to allow complete removal. are very aggressive, and need to be removed completely with a margin of normal tissue around them to assure removal of small/microscopic pieces that may not be visible to the eye. The size of the tumor dictates the extent of surgery, and it can range from endoscopic excision to radical surgery (Craniofacial Resection, Maxillectomy, etc.) and reconstruction. If the tumor extends beyond the confines of the nasal cavity into the eye or the brain then the surgery will need to involve those areas as well; in such cases experts in those fields will be present to assure a thorough and successful surgery. (Fig. 7)
|
(Figure 7) Frontal View of Nasal Cavity -
Tumor Involving the Eye & the Brain
Click on image for larger view |
- can also be aggressive. This tumor arises from the nerve fibers in the roof of the nose in charge of our sense of smell. Due to the location of these tumors they often erode through the bone in the roof of the nose into the brain’s cavity and the brain itself. (Fig. 8)
|
(Figure 8) Tumor Eroding through the
Ethmoid Roof into the Brain
Click on image for larger view |
As such most cases will need a cooperative surgical approach with both the head & neck surgeon and neurosurgeon present. A great majority of cases, despite extension into the brain, can be removed through the nose without the need to make a separate scalp (craniotomy) incision, and with the aid of image guidance systems, endoscopes, and micro-instruments. The decision for chemotherapy and radiation is again made based on the extent of the tumor.
of patients on a regular basis is imperative for a variety of reasons: 1. The treatments are often rigorous and the effects are profound both physically and psychologically; a close relationship between the patient and the head & neck surgeon assures all the early and late side effects of therapy are dealt with appropriately, and some even avoided. 2. Close monitoring and appropriate surveillance allows early detection of a cancer if it recurs, thus allowing us to have an opportunity to successfully treat the tumor, and also detect it early enough so that the treatment may be minimal.
The nasopharynx is the uppermost part of the throat (pharynx). It extends from just behind the nose to the oropharynx, the part of the throat found just above the soft portion of the palate. Adenoids are in this region, however in most people the adenoids shrink in the teenage years. Persistent adenoid tissue in adults may be mistaken for a tumor, thus necessitating a biopsy. (Fig. 9)
|
(Figure 9) Nasopharyngeal Carcinoma
Click on image for larger view |
According to the World Health Organization (WHO), NPC is classified into three histologic types: keratinizing squamous cell carcinoma (WHO type 1), nonkeratinizing squamous cell carcinoma (WHO type 2), and undifferentiated or poorly differentiated carcinoma, including lymphoepithelioma and anaplastic variants (WHO type 3)
Unlike most head and neck cancers, tobacco and alcohol use are not primary factors in causing nasopharyngeal cancer. Men have a higher risk, as do people of Asian descent (it is very prevalent in certain provinces in China and in Hong Kong). There is direct correlation with history of exposure with the Epstein-Barr virus, which plays a role in causing this type of cancer.
Common symptoms of nasopharyngeal cancer are hearing loss, nasal congestion, facial pain, poor appetite, weight loss and nosebleeds. However, many patients may have no symptoms at all. Your physician will perform a flexible endoscopy, which is where a tube-like camera is used to look inside the nose and then further back in the nasopharynx. If a tumor is suspected, a tissue sample (biopsy) may be obtained. In addition, diagnostic imaging may be performed, such as a CAT scan, MRI and/or PET scan.
The primary mode of therapy for nasopharyngeal cancer is radiation therapy that is most often combined with chemotherapy. This type of combination therapy is called herapy. Surgery is used in rare exceptional cases or if the tumor returns after chemo-radiation. If the decision has been made to treat this tumor surgically, we use a multiple-specialty approach that makes it possible to both remove the cancer and reconstruct the area.
of patients on a regular basis is imperative for a variety of reasons: 1. The treatments are often rigorous and the effects are profound both physically and psychologically; a close relationship between the patient and the head & neck surgeon assures all the early and late side effects of therapy are dealt with appropriately, and some even avoided. 2. Close monitoring and appropriate surveillance allows early detection of a cancer if it recurs, thus allowing us to have an opportunity to successfully treat the tumor, and also detect it early enough so that the treatment may be minimal.
|
)
)
)
)
)
)
)
)
)
)
)
)
)
