Nasal malignancy masquerading as polyposis: Importance of biopsy in powered endoscopic sinus surgery. (Rhinoscopic Clinic).

A 67-year-old man came to us with a complaint of right nasal congestion of several months' duration. Physical examination revealed that extensive polypoid tissue filled the right nasal airway. No deficit was noted in cheek sensation or cranial nerve function. Computed tomography (CT) of the sinuses demonstrated complete opacification of the entire right nasal cavity with extension into the nasopharynx (figure 1, A). There was also opacification of the right maxillary and ethmoid sinuses.

The patient underwent right endoscopic nasal and sinus surgery. At the time of surgery, benign-appearing polypoid tissue filled the right nasal passage and middle meatus (figure 1, B). As dissection with the microdebrider was carried more posteriorly, the tissue became more vascular and friable (figure 1, C). A large piece of the more posterior tissue that extended into the nasopharynx was excised and sent for pathologic analysis (figures 1, C and D). Frozen-section analysis identified an invasive squamous cell carcinoma (figure 2, A). All gross tumor was removed with the microdebrider. Biopsy specimens of the right maxillary and ethmoid sinuses were negative for carcinoma.

Postoperatively, the patient underwent radiation therapy (68.4 Gy) and chemotherapy (cisplatin and 5-fluorouracil). CT of the sinuses 6 months postoperatively showed a clearing of the right nasal cavity and sinuses (figure 2, B). At the 18-month follow-up, the patient is disease-free.

In this patient, the chronicity of symptoms, the failure of medical therapy, and the unilateral nature of the disease were clues to the diagnosis. These clues warranted further investigation, including preoperative coronal and axial CT or MRI to evaluate the extent of the disease. CT evidence of bony erosion or displacement should have been sought.

The intraoperative discovery of a sinonasal malignancy in tissue that is believed to be benign represents a particularly difficult problem during powered endoscopic sinus surgery. All suspicious tissue should be removed if possible, and surgical margins should be biopsied. The use of the microdebrider does not prevent an accurate histologic diagnosis in cases of malignancy. (1) However, the use of powered instrumentation does preclude a determination of the surgical margins of tumor involvement. Those margins should be biopsied with conventional nasal forceps.

Neoplasms of the nose and paranasal sinuses usually appear with symptoms that are identical to those of inflammatory sinus disease. The early symptomatology (nasal stuffiness, facial pain, headache, and intermittent epistaxis) is identical to that seen in benign nasal and sinus conditions. (2) Numbness or hypoesthesia of the infraorbital nerve, cranial neurophathies, (3) proptosis, chemosis, and mass effect in the cheek all suggest malignancy, but these symptoms are more often absent. In fact, 12% of maxillary sinus cancers are asymptomactic. (3) It is particularly important for the otolaryngologist to consider malignancy, because most sinonasal tumors are advanced by the time they are diagnosed.

Combination surgical, radiation, and medical therapy is usually the standard treatment for advanced sinonasal tumors that involve the nasal cavity or the maxillary or ethmoid sinuses. Surgical therapy might entail a medial or total maxillectomy. More advanced lesions might require orbital exenteration, pterygopalatine fossa resection, or skull base resection. Radiation is used in combination with surgery to treat positive margins, perineural or vascular invasions, recurrent tumors, and positive neck nodes. The role of chemotherapy in advanced sinonasal tumors is usually palliative but can be curative.

An accurate determination of the extent of disease in any sinonasal cancer is critical in determining if further surgery is needed, the type of surgery that is needed, and if the patient requires radio- or chemotherapy. (4) The lesion in our patient was considered to be located in polypoid tissue that arose from the middle meatus and did not appear to originate in the maxillary sinus. Our decision to treat with powered excision of the tumor followed by radiation and chemotherapy appears to have been the correct one.

In summary, all polypoid masses in the nasal cavity or sinuses cannot be presumed to be benign. Tissue diagnosis is imperative, particularly in unilateral soft-tissue disease.

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas); the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Marotta and Dr. Yanagisawa); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, and the Section of Otolaryngology, Hospital of St. Raphael, New Haven (Dr. Yanagisawa).

References

(1.) Zweig JL, Schaitkin BM, Fan CY, Barnes EL. Histopathology of tissue samples removed using the microdebrider technique: Implications for endoscopic sinus surgery. Am J Rhinol 2000;14:27-32.

(2.) Sisson GA, Sr., Toriumi DM, Atiyah RA. Paranasal sinus malignancy: A comprehensive update. Laryngoscope 1989;99:143-50.

(3.) Weisberger EC, Dedo HH. Cranial neuropathies in sinus disease. Laryngoscope 1977;87:357-63.

(4.) Hosemann W. Role of endoscopic surgery in tumors. In: Kennedy DW, Bolger WE, Zinreich SJ, eds. Diseases of the Sinuses: Diagnosis and Management. Ch.27. Hamilton, Ont.: B.C. Decker, 2001.