CARCINOMA OF THE MAXILLARY ANTRUM

CLINICAL FEATURES
Early
Carcinoma of the maxillary antrum is seldom diagnosed until it has spread to surrounding structures.In its earliest stages it will give rise to no symp- toms, but blood-stained nasal discharge and increasing unilateral nasal obstruction should raise suspicion.

Late
1 Swelling of the cheek.

 2 Swelling or ulceration of the bucco-alveolar sulcus or palate.

3 Epiphora,owing to involvement of the nasal lacrimal duct.

4 Proptosis and diplopia,owing to involvement of the floor of the orbit.

5 Pain—commonly in the distribution of the second division of the fifth nerve,but may be referred via other branches to the ear,head or mandible.

Spread
Local extension beyond the bony confines of the antrum is not long delayed and may involve the following:cheek,buccal sulcus,palate,nasal cavity and naso-lacrimal duct,infra-orbital nerve,orbit and pterygopalatine fossa. Lymphatic spread is to the submandibular and deep cervical nodes and occurs late. Distant metastases are rare.

INVESTIGATIONS

1.CT scanning is invaluable to assess the extent of invasion and bone erosion.

2 MR scanning will show the extent of soft tissue mass.

3 Biopsy—often the tumour will have spread into the nasal cavity,whence a biopsy is easily obtained. If the tumour is still within the confines of the antrum,a specimen is obtained via the antronasal wall.

TREATMENT

A combination of surgery and radiotherapy offers the best chance of cure. First, maxillectomy (with exenteration of the orbit if involved) is carried out. This results in fenestration of the hard palate, for which a modified upper denture with an obturator is provided.The fenestration allows drainage and access for inspection of the antral cavity. Following maxillectomy,a radical course of radiotherapy is given. This aggressive combination of treatments is justified by the poor prognosis of the disease if not treated adequately from the outset.

PROGNOSIS

Even with radical treatment,carcinoma of the antrum has a poor prognosis, with only about 30% of patients surviving to 5 years.

CARCINOMA OF THE ETHMOID SINUSES

The clinical features are similar to those of maxillary carcinoma, but inva- sion of the orbit and facial skin below the inner canthus is early. Treatment is by radical surgery and radiotherapy.

MALIGNANT DISEASE OF THE NASOPHARYNX

Rare in Europe but relatively common in southern China,malignant disease of the nasopharynx often causes difficulty in diagnosis because of the absence of local symptoms.

PATHOLOGY

Virtually all malignant tumours of the nasopharynx are squamous cell carcin- oma,but rarely lymphoma or adenoid cystic carcinoma may occur.Cancer of the nasopharynx spreads locally to invade the skull base and Eustachian tube and metastasizes early to the upper deep cervical lymph nodes. The Epstein–Barr virus may play a role in the aetiology of nasopharyngeal malignancy.

CLINICAL FEATURES:

Local. Nasal obstruction, blood-stained nasal discharge—usually a late development.

Otological. Unilateral serous otitis media will result from Eustachian tube obstruction.

Neurological.Invasion of the skull base causes paralysis of various cranial nerves,especially nerves V, VI,IX,X and XII.

Cervical.Spread to the upper deep cervical nodes occurs early and may be bilateral. Such a node is typically wedged between the mastoid process and angle of the jaw. It is inexcusable, and dangerous, to biopsy such nodes until the na- sopharynx has been examined and biopsied.The combination of unilateral deafness, enlarged cervical nodes and cranial nerve palsies proclaims the diagnosis of nasopharyngeal cancer loud and clear.

TREATMENT

Treatment of nasopharyngeal cancer is by radiotherapy following confirma- tory biopsy.Once the primary site has been controlled,radical neck dissec- tion is carried out if there were involved nodes at diagnosis or if any subsequently develop.The prognosis is poor,but the earlier the diagnosis is made,the better the outlook.

OTHER TUMOURS OF THE NASAL REGION

Osteomata

Osteomata occur in the frontal and ethmoidal sinuses. They are slow- growing and cause few symptoms but may eventually call for surgical removal.

Nasopharyngeal angiofibroma

Nasopharyngeal angiofibroma is a rare tumour of adolescent boys. It presents as epistaxis and nasal obstruction and is usually easily visible by posterior rhinoscopy. Being highly vascular, the tumour is locally destruc- tive and extends into the surrounding structures. Diagnosis is confirmed by angiography and treatment is by surgical removal.

Malignant granuloma Though not truly neoplastic, malignant granuloma is a sinister condition characterized by progressive ulceration of the nose and neighbouring structures.There are two main varieties:the Stewart type,in which the le- sion is limited to the skull and is characterized by a pleomorphic histiocytic infiltration and which is a form of lymphoma; and the Wegener type, in which the kidneys, lungs and other tissues may show periarteritis, the local nasal lesion containing multinucleated giant cells. It is probable that Wegener’s granuloma is an auto-immune disease.Radiotherapy,steroids and cytotoxic agents are used in its treatment and occasionally are successful.

Malignant melanoma

Malignant melanoma is fortunately rare in the nose and sinuses.Treatment is by radical surgery but the prognosis is extremely poor.