Clinicopathological study of sinonasal malignancy

This cross sectional study was done in the Otolaryngology and Head-Neck Surgery Department of Banghabandhu Sheikh Mujib Medical University, Dhaka Medical College Hospital and Sir Salimullah Medical College Hospital during the period of September 2003 to February 2004. In this study 30 patients of sinonasal malignancy were studied and to observe the clinicopathological pattern of sinonasal malignancy. The diagnosis was made by detailed history, clinical, radiological and histopathological examinations. In this study majority of the patients were within 40 to 70 years of age (77%). Male to female ratio was 2.33:1. Majority of the malignancy came from maxillary sinuses 15(50.00%); ethmoidal sinuses were involved in 8(26.66%) cases, multiple sinuses were involved in 5(16.66%). Neck node metastases was found in 4(14%) cases. Squamous cell carcinoma was the most common histological type (70.00%); the other less common histological types were adenoid cystic carcinoma (06.66%), adenocarcinoma (06.66%), Non-Hodgkin's lymphoma (06.66%), least frequent types were malignant fibrous histocytoma, transitional cell carcinoma, olfactory neuroblastoma. Key words: Sinonasal malignancy; clinicopathological study. DOI: 10.3329/bjo.v15i2.5058 Bangladesh J Otorhinolaryngol 2009; 15(2): 55-59


Introduction:
Sinonasal malignancy is not an uncommon finding in the ENT Department.It is found in almost all age groups of people 1 .A wide variety of malignant tumours of different histological types are found in nasal cavity & paranasal sinuses are rare constituting less than 1 percent of all malignancies (3% of head and neck tumours) 2 .The presenting symptomatology of all tumours are similar and histological examination is necessary to decide whether any particular tumour is malignant.The majority 55% of sinonasal malignancy appear to be of antral origin, 35% arise in the nasal cavities and the remaining 9% arise from the ethmoids.Primary frontal & sphenoid tumours are very rare 1% 3 .The relative unawareness of the primary physician about the disease and the similarity of the symptoms with the more common upper respiratory tract infection results in failure of true diagnosis before the tumour extend beyond the bony margins of the sinuses 4 .
Sinonasal malignancy is usually diagnosed late; therefore it is important to determine the most common signs and symptoms that should alert the physician and dentist to suspect the possibility of this disease.The initial symptoms reported by the patients are diverse and in the majority of cases are related to the face, nose & oral cavity 5 .The Peculiarity of antral malignancy is that the involvement of the surrounding structures with the lesion is much more extensive than the symptoms revealed at presentation 5 .
The results in the past have been unsatisfactory with a 30% over all 5-year survival 6 .The unsatisfactory results could be attributed to a number of factors: (a) The disease was invariably advanced on presentation, (b) The complex anatomy of the region and close relationship to the orbit and skull base, (c) The reluctance of surgeon and radiotherapist to treat aggressively for fear of increasing the natural mutilation of the disease complication 3 .
The presentation of sinonasal malignancy depends on the primary site, the direction and extent of spread.The most common initial symptoms are nasal obstruction, epistaxis, proptosis, epiphora, diplopia, loose teeth, facial pain & swelling, buccal or palatal swelling.Exposure to industrial fumes, wood dust, nickel refining process, and leather tanning have been implicated in the carcinogenesis of certain types of sinonasal malignant tumour.Other industrial exposures associated with an increased incidence of sinonasal cancer include mineral oils, chromium, lacquers paint, soldering and welding 7,11 .
Histologically, most common type is squamons cell carcinoma (about 80%), 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 17 .Non-Hodgkin's lymphoma may occur but Burkitt's lymphoma rarely occurs in children of this subcontinent 8,18 .
The presence of nodal involvement drastically reduces the prognosis and 5 years survival rate come down from 27.2% to 6.8%. 9Overall incidence of distant metastases of antral malignancy is about 0.8%.The most common site of distant metastases are bone.Metastases may also occur in the lungs, liver, brain and kidney 10,12 .

Materials and Methods:
This was a cross sectional study done during the period from September 2003 to February 2004 in the Department of Otolaryngology and Head-Neck Surgery of BSMMU, Dhaka Medical College Hospital, Sir Salimullah Medial College & Mitford Hospital.A representative sample (30) were collected from respective Otolaryngology and Head-Neck Surgery Department.

Aims and Objectives
1. To find out the relative frequency of different sinonasal malignancy.
2. To assess the clinical presentation of sinonasal malignancy.
3. To find out the histopathological types of sinonasal malignancy.

Results:
The age range of the patient was from 5 years to 80 years with the mean of 56 years.Most of the patients were in 5 th to 7 th decade (75.65%).

Discussion:
Sinonasal malignancy is rare, comprising less than 3% of all aerodigestive tract tumours.Malignant tumours of the nasal cavity and paranasal sinuses occur predominantly in 4th, 5th and 6th decade with a mean of 56 years, which is not consistent with Mundy 13 , Who showed median age of 60.3 years.This discrepancy due to the fact that the longevity of European people are greater than those of our country.
The age range in this study was 5-80 years with male to female ratio of 2.33:1, which differs with the findings of N. Hopkins 14 , who showed age range of 5-92 years and male to female ratio of approximately 3:2.
Regarding clinical presentation, the figures of nasal obstruction, epistaxis, diplopia and anaesthesia of check are consistent with the findings of N. Hopkins who showed nasal obstruction in 45.40% of cases, epistaxis 29.40%, diplopia 5.10% and anaesthesia of check in 3.2% of cases 15 .The number of the patients presented with facial swelling agrees with Mundy who showed facial involvement in 69.7% of cases.Symptoms of sinonasal malignancy in our series are not consistent with the findings of N. Hopkins and Mundy and this discrepancy is provably due to late presentation of most of the patients.
Lymphatic spread to regional nodes becomes apparent in 25-35% of patients at sometime during the course of their disease, though only 14% have nodal disease at the time of presentation.Those with involved nodes almost always have locally advanced disease.The submandibular and jugulodigastric nodes are the most commonly involved.

Conclusion:
Most of the patients of sinonasal malignancy presented late with multiple symptoms.The initial symptoms reported by the patients at presentation were diverse.The possibility of early diagnosis of sinonasal malignancy on the basis of clinical presentation in early stage remains a problem, because at this stage there may be a few or no symptoms and require a high index of suspicion for diagnosis due to the overlapping presentation of these neoplasm with more commonly encountered infections disease states.The rarity of these lesions in combinations with the multiple histologies that are encountered have limited large scale studies.Once a paranasal sinus neoplasm is diagnosed, aggressive multimodality therapy is often necessary.

Table - I
Age distribution in sinonasal malignancy (n=30) Poor : Less than taka 5,000.00 per month per unit family.Middle : between taka 5,000.00 to 10,000.00 per month per unit family.Affluent: more than taka 10,000.00per month per unit family 19 in size) N 2 .As to the nodal involvement, 4(14%) had cervical lymph node involved (submandibular 3 & Jugulodigastric 1) which nearly agrees with the findings of S.E Kent and B. Majumder19but differ with the findings of 16.4% of P.E.Robin and D. Jean Powell 20 .