Surgery for Nasal Cavity and Paranasal Sinus Cancers

Understanding surgery for nasal cavity and paranasal sinus cancers

The nasal cavity and paranasal sinuses are close to many important nerves, blood vessels, and other vital structures, including the brain, eyes, and mouth. This can make surgical planning and the surgery itself challenging.

The goal of surgery in these areas is to remove the entire tumor and a small amount of normal tissue around it (sometimes including bone), while preserving appearance and functions such as breathing, speech, chewing, and swallowing as much as possible.

Rebuilding or repairing the area after the tumor is removed is often an important part of the surgical plan. It might involve a plastic (reconstructive) surgeon and/or an oral and maxillofacial surgeon.

Surgical margins

When removing the cancer, the surgeon also tries to take out some surrounding normal tissue, called margins. The removed tissue is then checked in the lab to see if there are cancer cells at the edges.

• Negative (clear) margins: No cancer cells are found at the edges, meaning it is less likely that cancer was left behind.
• Positive margins: Cancer cells are found at the edges, meaning some cancer might still remain. This often means further treatment is needed, such as more surgery or radiation therapy.

Surgical approaches for nasal or paranasal sinus cancers

There are different surgical approaches for treating cancers of the nasal cavity and paranasal sinuses, including:

• Open surgery. The surgeon makes cuts through the skin and sometimes bone to reach and remove the tumor.
• Endoscopic surgery. The surgeon uses a thin, flexible tube with a light and camera, called an endoscope, that is passed through the nose to see and remove the tumor, without making large cuts in the face.
• Endoscopic-assisted surgery. Endoscopic techniques can also be used together with open surgery. This approach can help surgeons better see and remove the tumor.

Many tumors are now treated with endoscopic surgery when possible, especially at major medical centers. Endoscopic surgery usually causes less damage to healthy tissue, and many people recover more quickly. In carefully selected patients, long-term results are now as good as those seen with open surgeries.

In the past, open surgery was more commonly used for most tumors. It might still be better than endoscopic surgery for very large tumors or tumors that involve important nearby structures. However, open surgery is also more likely to cause both short- and long-term side effects (discussed below).

Choosing the surgical approach

The choice between open surgery, endoscopic surgery, and endoscopic-assisted surgery depends on several factors, including:

• Size of the tumor. Smaller tumors are more likely to be removed using endoscopic surgery.
• Location of the tumor. Tumors close to important structures such as the eyes, brain, or major nerves might require open surgery for safe removal.
• Extent of spread. Tumors that have grown into nearby bones or tissues might be better treated with open surgery.
• A person’s overall health. Endoscopic surgery might be preferred if a person isn’t healthy enough for a more extensive operation.
• Surgeon experience and available technology. Some approaches require specialized training and equipment that might not be available at all centers.

Choosing the right surgical team

Surgery for nasal cavity or paranasal sinus cancer is complex and requires special training and experience, especially when endoscopic techniques are used. These surgeries are best done by teams at specialized centers.

No matter which approach is used, it’s important to ask about your surgeon’s training and experience.

Surgery by location

Different surgical approaches are used depending on whether the cancer is in the nasal cavity or the paranasal sinuses.

Possible risks and side effects of surgery

All surgery carries some risks, including bleeding, infection, blood clots, problems with anesthesia, and pneumonia. These risks are higher with more complex operations.

Common side effects after nasal or sinus surgery include:

• Pain
• Nasal drainage and crusting
• Changes in smell
• Swelling and scarring

More extensive surgery might lead to:

• Problems with eating, talking, or breathing
• Vision changes
• Changes in facial appearance

Because these cancers are often near the eyes, surgeons try hard to save the eye when possible. But sometimes removing the eye and surrounding tissues  might be needed to fully remove the cancer.

Body image and emotional effects

Surgery for nasal and sinus cancers can cause visible changes to the face, which can be emotionally difficult. Changes  might range from a small scar to more noticeable differences in appearance.

It’s important to talk with your doctor before surgery about:

• Possible changes in your appearance
• Reconstructive options
• Prosthetic devices that might be helpful

Support from counselors, rehabilitation specialists, and support groups can also be helpful.

Serious but less common complications

The nasal cavity and paranasal sinuses are near many important structures inside the head. Because of this, rare but serious complications can occur, including:

• Vision loss or blindness
• Leakage of cerebrospinal fluid (the fluid around the brain and spinal cord)
• Meningitis
• Facial numbness or weakness
• Jaw muscle stiffness
• Deep infections (abscesses)

Your surgical team will discuss these risks with you and take steps to reduce them.

Neck dissection (neck lymph node removal)

Nasal cavity and paranasal sinus cancers can sometimes spread to lymph nodes in the neck. If this happens, or if the risk is high, lymph nodes  might be removed in a procedure called a neck dissection.

Types of neck dissection include:

• Selective neck dissection, which removes only certain lymph nodes that are most likely to contain cancer
• Modified radical neck dissection, which removes most lymph nodes but preserves some muscles and nerves
• Radical neck dissection, which removes nearly all lymph nodes on one side of the neck, along with some muscles, nerves, and veins. This is used less often today than it was in the past.

Possible risks and side effects of neck dissection

Common side effects include:

• Numbness of the ear
• Shoulder and neck pain
• Weakness when raising the arm
• Weakness of the lower lip

Some of these problems improve over time, especially after less extensive surgery. Physical therapy can help restore movement and strength.

Removing lymph nodes can also affect fluid drainage out of the head and neck area. This can lead to lymphedema (swelling) of the face or neck. This can happen months or even years later. Specialized lymphedema therapists can help manage this condition.

Surgery to place a gastrostomy tube (feeding tube)

Cancers of the nasal cavity and paranasal sinuses and their treatments can make it hard to swallow food. When this happens, it can become hard to maintain good nutrition and a healthy weight, which  might make you feel weak and can interfere with completing treatment.

To help prevent this, some people  might need a feeding tube, most often called a gastrostomy tube or G-tube.

What is a G-tube?

A G-tube is a soft tube that goes directly into the stomach through the skin of the abdomen (belly). Liquid nutrition, fluids, and medicines can be given through the tube when swallowing is difficult.

How is a G-tube placed?

In many cases, the tube is placed using a procedure called a percutaneous endoscopic gastrostomy (PEG).

In this procedure, an endoscope is passed through the mouth into the stomach. The feeding tube is then placed through the skin into the stomach. This is usually done while you are sedated (not fully asleep).

In some situations, a G-tube  might be placed during surgery or using imaging guidance, depending on a person’s needs.

How long is a G-tube needed?

For most people, the feeding tube is temporary. It is often used during cancer treatment and removed once swallowing improves and you can get enough by mouth again.

Even if you get most of your nutrition through a G-tube, doctors and speech/swallowing therapists often encourage you to keep swallowing when it is safe to do so. This helps keep the swallowing muscles active and improves the chance of returning to normal eating after treatment.