Surgery for Nasal Cavity and Paranasal Sinus Cancers

Studies have shown that people who are treated at centers that treat a lot of head and neck cancers with surgery, tend to live longer. And because of the complicated types of surgeries, along with the need for coordination between cancer specialists to make a complete treatment plan, it’s very important to have treatment at cancer centers by surgeons who have experience in these cancers.

Quit smoking before nasal cavity and paranasal sinus cancer surgery

If you smoke, you should quit. Smoking during cancer treatment is linked to poor wound healing, more side effects, and less benefit from treatment which can raise your risk of the cancer coming back (recurrence). Smoking after treatment can also increase the chance of getting another new cancer. Quitting smoking for good (before treatment starts, if possible) is the best way to improve your chances of survival.  It is never too late to quit. For help, see How To Quit Using Tobacco.

What kind of surgery is done to treat nasal cavity or paranasal sinus cancer?

For most nasal cavity or paranasal sinus cancers, surgery to remove the cancer (and some of the surrounding bone or other nearby tissues) is a key part of treatment. Often, surgery is used with other treatments, like radiation therapy and/or chemotherapy to get the best results.

The nasal cavity and paranasal sinuses are close to many important nerves, blood vessels, and other structures. The brain, eyes, mouth, and carotid arteries (arteries that supply blood to the brain) are also close by, making surgical planning and surgery itself difficult. The goal of surgery in these areas is to take out the entire tumor and a small amount of normal tissue around it while keeping appearance and function (such as breathing, speech, chewing, and swallowing) as normal as possible. Rebuilding and/or repairing the area around the tumor is an important part of the surgery plan and may require the help of a plastic surgeon.

Surgical margins: When removing the cancer, the surgeon also tries to take out a border (margin) of surrounding normal tissue. The tissue that's removed will be checked in the lab to see if there are cancer cells at the edges. If the edges don’t have cancer cells, the cancer is said to have been removed with negative or clear margins. Negative margins mean that it's less likely that any cancer was left behind. If the edges do have cancer cells, the margins are said to be positive. Positive margins mean that it's more likely that some cancer was left behind. Often this means more treatment, such as more surgery or radiation.

Surgery for nasal cavity cancers

Nasal cavity cancers are often removed in a procedure called wide local excision. This means removing the tumor plus an edge of normal tissue around it. The goal is to remove enough tissue so that no cancer cells remain.

If the tumor is in the middle dividing wall of the nasal cavity (the nasal septum), sometimes the entire septum or a large portion of it will be taken out.

If the tumor is in the lateral (side) wall of the nasal cavity, this wall may need to be removed by a procedure called an open medial maxillectomy. To do this, the surgeon will usually cut through the skin along the side or edge of the nose and fold the external nose toward the opposite side to see and work on the tumor. Then the side of the nasal cavity can be removed by cutting the bone and soft tissue as needed. Sometimes, if the cancer is in a certain spot, the surgeon can reach the tumor by cutting under the upper lip instead. This approach has the advantage of avoiding any cuts, and maybe scars, on the skin. Ask your head and neck surgeon how your surgery will be done.

Reconstructive surgery: If the cancer has reached the skin or deeply invades the tissue of the external nose, part (or all) of the nose may need to be removed. There are many ways to rebuild a nose using tissue from the face or other areas. In some cases, a cosmetic prosthesis (made of artificial materials) may be used to make a new nose.

Surgery for paranasal sinus cancers

Operations for paranasal sinus tumors vary, depending on the tumor type, location, size, and growth into other parts of the head and neck.

If the tumor is small and/or it's not cancer (benign) and is only in the ethmoid sinuses, an open external ethmoidectomy may be done. The surgeon will cut through the skin on the upper side of the nose next to the upper eyelid. Bone on the inner side of the orbit (eye socket) and nose will be removed to reach tumors inside the ethmoid sinuses.

If the tumor also has grown into the maxillary sinus, an open maxillectomy may be done. The type of maxillectomy depends on where the tumor is and whether it has grown into nearby tissues. The surgeon may make an incision (cut) along the side of the nose from the eyebrow or upper eyelid down to or through the upper lip. Or the incision may be made under the upper lip. The bones around the maxillary sinus are cut so that the entire tumor and some surrounding tissue can be taken out in one piece. This operation might remove bone from the hard palate (the roof of the mouth), upper teeth on one side of the mouth, part or all of the orbit (eye socket), part of the cheekbone, and/or the bony part of the upper nose.

If the cancer is a higher stage, has spread into the base of the skull or brain, or is in the ethmoid sinuses, frontal sinuses, and/or the sphenoid sinuses, an operation called an open craniofacial resection may be done. This operation is a lot like a maxillectomy except that the surgeon may also remove upper parts of the eye socket and the front base of the skull. This is a major operation that's usually done by a surgical team that includes an otolaryngologist (head and neck surgeon) and a neurosurgeon (a surgeon who operates on the brain, spinal cord, and other nerves).

Reconstructive surgery: Depending on how much tissue or bone is removed during surgery, reconstruction of the hard palate with a soft tissue flap with or without a bone graft might be done to help someone eat and talk after surgery. Reconstruction of the eye socket might also allow the placement of an ocular prosthesis (glass eye or fake eye).

What is endoscopic surgery for nasal cavity or paranasal sinus cancer?

In this type of surgery, the surgeon uses an endoscope (a thin, flexible tube with a light on the end that's put into the nose to reach the nasal cavity or sinus) to see and remove the tumor in the nasal cavity or sinus. This way, the surgeon doesn't have to cut through skin and bone to open up the whole cavity, as is typically done in an open operation. This reduces the damage to normal tissue. In general, recovering from this type of surgery takes less time. And for some of these cancers, long-term outcomes for endoscopic surgery are as good as other open surgeries used to treat these cancers.

Endoscopic surgery may also be used alone or along with some of the more invasive open surgeries listed above. In this case, it may help limit damage to healthy tissues. It also may help the doctor better see the area to try to be sure all of the cancer has been taken out. (You may hear this called endoscopic-assisted surgery.)

Endoscopic surgery is most often used for small tumors. For larger tumors, it may be used to help try to control the tumor in people who are not healthy enough for a bigger operation.

Endoscopic approaches to remove nasal and sinus cancers are becoming more common as more surgeons are trained in these techniques. These approaches are best done by teams of experienced surgeons at specialized centers. Some medical centers (and surgeons) have more experience than others with endoscopic surgery for nasal and sinus cancers. If you're considering endoscopic surgery as a part of your treatment, be sure to ask about your surgeon’s training and experience, which are key to successful endoscopic surgery.

Removing lymph nodes in nasal cavity or paranasal sinus cancers

Cancers of the nasal cavity or paranasal sinuses sometimes spread to the lymph nodes in the neck. Depending on the stage and location of the cancer, these lymph nodes may need to be removed in an operation called a neck dissection.

There are several types of neck dissection procedures. The goal of these procedures is to remove lymph nodes known to or likely to contain cancer. The amount of neck tissue removed depends on the cancer’s size and the extent of spread to lymph nodes.

• A radical neck dissection (comprehensive neck dissection) removes nearly all lymph nodes on one side of the neck as well as major muscles, nerves, and veins. This can make it hard to move your neck or shoulder well.
• A modified radical neck dissection (modified comprehensive neck dissection) removes most lymph nodes on one side of the neck between the jawbone and collarbone, but only some muscle and nerve tissue.
• A selective neck dissection is more limited and removes only a few lymph nodes from specific areas of the neck where the cancer most likely spread.

Gastrostomy tubes (feeding tubes)

Cancers in the nasal cavity and paranasal sinuses might make it hard for you to swallow enough food to maintain good nutrition and a healthy weight. This can make you weak and make it harder to finish treatment.

Some people with these cancers might need to have a feeding tube, usually called a gastrostomy tube (or G-tube), put in place before treatment. A G-tube is a feeding tube that's put through the skin and muscle of your abdomen (belly) right into your stomach. The tube is often put in place with the help of a flexible, lighted instrument (endoscope) passed down your mouth and into the stomach. This is done while you are sedated. When it's placed through an upper endoscopy, it's called a percutaneous endoscopic gastrostomy, or PEG tube. Another option is to put the tube in during an operation. Once in place, liquid nutrition and medicines can be put right into the stomach through the tube.

Often, the gastrostomy tube is only needed for a short time to help you get enough nutrition during cancer treatment. The tube is often removed once you can swallow again after treatment. It's important to keep swallowing even when you're getting most of your nutrition through a G-tube. This helps keep those muscles working and gives you a better chance of going back to normal swallowing after treatment is complete.

Possible risks and side effects of surgery for nasal cavity or paranasal sinus cancer

All surgery has some risks, including blood clots, infections, complications from anesthesia (medicine to put you to sleep), poor wound healing, and pneumonia. These risks are generally low, but are higher in more complicated operations. Rarely, some people may not survive the surgery.

Pain is a common side effect of surgery. It's also common to have nasal drainage and crusting. Sometimes it smells bad. This usually starts getting better about 6 months after surgery, but may last longer if you're getting radiation. 

Surgery for cancers that are large or hard to reach may be very complicated, in which case side effects may include infection, nose bleeds, scarring, problems eating and talking, and vision changes. Surgery also can be disfiguring, especially if bones in the nose or face need to be removed.

Eye changes: Because these cancers tend to not cause problems until they're quite large, they often involve the eye or orbit (the bone and tissue around the eye) by the time they are noticed or cause symptoms. Most of the time the eye can be saved, but sometimes the entire orbit and eyeball needs to be removed to give the best chance for cure.

Body image: Because the changes from surgery can be visible, these procedures can have a major effect on how people see themselves. The surgeon will take into account how the face will look and function after surgery. But, depending on the extent of the operation needed, you might look different after surgery. This can range from a simple scar on the side of your nose to major changes if nerves, parts of bones, or other structures need to be removed. It’s important to talk with your doctor about these changes before the surgery. Your doctor might be able to help you prepare for them. They can also give you an idea about your options, such as reconstructive surgery, tissue grafts, or a prosthesis (man-made replacement). For example, an obturator is a custom-made prosthesis used to help restore function in the nose and mouth. An obturator that replaces the roof of the mouth can help you speak and swallow normally. Noses can be made out of plastic, tinted to match the skin, and attached to the face. All of these things can help a person’s self-esteem.

More serious side effects and complications: Since there are many important structures in the nasal cavity and paranasal sinus areas, some surgeries can cause severe complications including blindness, leakage of the cerebral spinal fluid (the fluid around the brain and spinal cord), meningitis (inflammation of the lining of the brain and spinal cord), weakness or numbness of the middle part of the face, spasm of the jaw muscles making it hard to open your mouth, or an abscess (a collection of pus from an infection).

Possible risks and side effects of neck dissection for nasal cavity or paranasal sinus cancer

The most common side effects of any neck dissection are numbness of the ear, weakness in raising the arm above the head, pain in the shoulder and neck, and weakness of the lower lip. These develop when nerves are damaged. After a selective neck dissection, the weakness of the arm and lower lip usually go away after a few months. But if a nerve has been removed as part of a radical neck dissection or because of tumor spread, the weakness will be permanent. After any type of neck dissection, physical therapists can teach the patient exercises to improve neck and shoulder movement.

While some swelling is normal after surgery, it should go away over time. When lymph nodes are removed, it changes how fluid drains from the head, face, and neck. The fluid might not be able to drain like it should. This can cause swelling in these areas called lymphedema. This side effect can develop anytime after lymph node dissection, even many years later. You might be referred to a lymphedema therapist who is specially trained in handling this type of edema in the head and neck area.