Presentation of sinonasal carcinoma

Objective: To observe the pattern of clinical presentation according to site of origin of sinonasal carcinoma. Methods: This cross-sectional study was done in the Department of Otolaryngology-Head and Neck Surgery, BSMMU and Dhaka Medical College Hospital, Dhaka during the period from January 2008 to December 2009. Patients of sinonasal carcinoma were evaluated by detailed history, clinical examination and relevant investigations. Results: The present study included 40 patients of sinonasal malignancy bearing age limits of 4 years to 75 years with mean age 48.29. Male and female ratio was 2.6:1. Most patients (77.5%) came from rural area and illiterate (40%) and most of them were farmers (40%), having poor socio-economic condition (50%). About 35% of them were smokers and more than one other personal habit. Majority patients presented with multiple sinuses involvements (72.5%) and among single sinus involvement maxillary sinus was most common (63.63%), followed by nasal cavity (27.27%) and ethmoidal sinus (9.09%) as primary site. Conclusion: Though carcinoma of the nose and paranasal sinuses is relatively uncommon, it is not uncommon in our country. This disease generally presents in an advanced stage. Overall prognosis was directly related to diseases stages.


Introduction
Carcinoma of the nose and paranasal sinuses are rare. 1 Sinonasal malignancies have an incidence of 0.5-1 per 1,00,000 per year.They account for 0.2-0.8% of all malignancies and 3% of all upper aero-digestive tract neoplasm.Most of the tumours develop in the 5 th and 6 th decades of life.The incidence in men is twice than that of women. 2 Cancer of the paranasal sinuses occurs mainly in the maxillary and ethmoid sinuses.Because the maxillary sinuses provide room for the cancer to grow, most people do not develop symptoms until the cancer is fairly advanced.
They are most commonly found in whites, with the incidence in males being twice that of females.Exposure to industrial fumes, wood dust, nickel refining process and leather tanning have been implicated in the carcinogenesis of certain types of sinonasal malignant tumours.Cigarette smoking and heavy alcohol consumption have long been known to increase the risk of head and neck malignancies, but no significant association has been shown with sinonasal cancer. 3stologically most common sinonasal malignancy is squamous cell carcinoma (about 80%).Others include adenocarcinoma, adenoid cystic carcinoma, transitional cell carcinoma and neuroblastoma may occur but their incidences are less.Sarcomas are also rare and tend to occur at younger age and behave in a very malignant fashion.Non-Hodgkin's lymphoma may occur but Burkit's lymphoma rarely occurs in children of this subcontinent.Melanomas are also rare but usually occur in nasal septum or lateral nasal wall of 5 th to 8 th decade of male population. 4te distribution of sinonasal malignancy varies in different studies.One study showed that almost half of all sinonasal tumours arise from lateral nasal wall, which represent 45%, maxillary antrum 30%, ethmoid sinus 5%, frontal & sphenoid sinus 2% and in 18% cases site could not ascertain due to disease extent. 6Another study showed that 55% tumour arises from maxillary antrum, 30% from nasal cavity and 10% from ethmoid sinus and 5% from others sinus. 5e high mortality rate and poor prognosis of carcinoma of the maxillary sinuses are related to late diagnosis, which is caused by the early symptomatic latency of these tumours.Therefore, the extent of the disease is the main prognostic factor. 6,7

Methods
This cross-sectional study was done in the Department of Otolaryngology Head and Neck Surgery, BSMMU and Dhaka Medical College, Dhaka during the period of January 2008 to December 2009.Patients suspected of sinonasal carcinoma were evaluated properly by detailed history taking, clinical examination and relevant investigation like rigid endoscopy, CT scan, MRI and punch biopsy.The results were presented here as tables, graphs and figures.Considering the sex, majority of the patients in this study were male and male to female ratio is 2.6:1.This was more or less similar to other study. 1 .In this series most of the patients came from rural areas (77.5%).This is due to the fact that this is a tertiary centre and patients were referred from all corners of the country.

Table-I
In this study majority of the patient were poor socioeconomic group (50%) and most of them were illiterate (40%), followed by secondary 25%, primary 20% and graduate 15%.This study is similar to a study done in our country. 8is study revealed (35%) patients had a history of smoking habits for 10-20 years.Non smoker, 25%, tobacco and betel leaves chewing 17.5%, betel nut 15% an betel leaves users 7.5% this finding varies from a study done in our country and abroad.A study done in Bangladesh showed 53.33% of patient of sinonasal carcinoma were cigarette smoker which was more or less similar to other studies 8,9 .
Staging of the tumour were assessed by through clinical and radiological examination shows a decreasing order of frequency T 4 (40.0%),T 3 (32.5%),T 2 (17.5%) and T 1 (10%).This was consistent with a study in this country 6,9 and abroad by Zy³ka et al. 13 In present series there were 07 cases of nodal involvement were found e.g.(17.5%).Among them submandibular nodes were 57.1% and jugolodigastric 42.8%.This finding is consistent with the findings of Kim et al.
Squamous cell carcinoma was the commonest type 63%.Adenocarcinoma 17.5% is the second most common carcinoma in this study.Among other carcinoma adenoid cystic carcinoma was 12.5% and other carcinoma 7.5%.
CT scan was carried out systematically on all of the patients.Intracranial involvement found at the time of diagnosis in 30% of the patients.25% showed orbital involvement.These findings were consistent with the study of Nunez et al. 14 From this series it is obvious that carcinoma maxillary antrum presents in advanced stage.
In case of single site involvement maxillary antral carcinoma was more common than other paranasal sinus carcinoma.

Conclusion
Though carcinoma of the nose and paranasal sinuses is relatively uncommon, it is not uncommon in Bangladesh.This disease generally presents in an advanced stage.As prognosis is directly related to the stage of the disease it is essential to increase awareness of our health professionals and peoples, so that the disease can be detected at an early stage.