Clinicopathological Study of Sinonasal Malignancy-Experience in a Tertiary Level Hospital in Bangladesh

: Objectives: To assess the clinical presentation and histopathological types and extensions of the disease at the time of presentation. Methods: Cross sectional observational study of 40 patients with sinonasal malignancy from the department of otolaryngology and Head neck surgery, Sylhet MAG Osmani Medical College Hospital, Sylhet Bangladesh, period from May 2019 to April 2020. The patients were examined after admission into hospital pre-operatively and in the postoperative period. The surgical specimens were sent for Histopathology. Results: Majority patients were at 4th to 6th decade where male outnumbered the female with male female ratio was 3.4:1. Out of 40 patients, the majority of patients complaints of nasal obstruction followed by nasal discharge, facial pain, facial swelling and headache. About the site of the lesion maximum patients having the lesion in Maxillary sinus (60%) followed by nasal cavity (15%) multiple sinuses (12.5%) involvement in Ethmoidal sinus (10%) lateral wall of nose (2.5%) Conclusion: Sinonasal Malignancy is usually a disease of middle age and elderly people. Most of the patients (in this study 65% patients come at T3 & T4 stage) presented late with multiple symptoms.


Introduction:
Cancer is one of the few diseases still unconquered in spite of relentless efforts of medical scientists all over the world. Sinonasal Malignancies have an incidence of 0.5-1 per 1000000 cases per year. They account for 0.5-0.8% all Malignancies and 3% of upper aero-digestive tract neoplasm 1 . Age incidence of sinonasal malignancy are 4 th , 5 th and 6 th decades 2 . Cancer of Maxillary Sinus is predominant in male having male to female ratio is 2:1.3.
The lining of the anterior part of the nasal cavity and vestibule is continuous with skin and posteriorly by pseudostratified ciliated (respiratory) epithelium reach in goblet cells 3 . The Maxillary sinus is the most common site of Sinonasal Malignancy (60-70%), followed by the nasal cavity (20-30%), ethmoid sinus(10-15%) and frontal and sphonoidsinuses (1-2%) 4 .
Several carcinogenic compounds have been identified as aetiological factors of Sinonasal Malignancies. Inhalation of these carcinogens is responsible for about 40% of reported Sinonasal Malignancies 5 . Workers exposed to hard wood have a 70 times increased incidence of Sinonasal adenocarcinoma particularly in ethmoid sinuses, soft wood exposer increases the risk of developing squamous cell carcinoma 5 . Exposer to nickel, smoking, radiation, viral and genetic causes have also been proposed 5 . Epstein-barr virus is strongly associated with development of malignant lymphoma 6 .
Though carcinoma of the nose and paranasal sinuses is relatively uncommon but it is not so uncommon in Bangladesh 7 . But regarding this many things are still unknown to us. We have seen our previous discussion that the wood workers are high risk for Sinonasal malignancy and wood dust can lead to Sinonasal cancer is now become the part of basic medical arrogation. But in our country, we don't see such strong evidence of this statement though a portion of percentage is seen all time. We know it; risk factors don't tell us everything. Though strong evidence is not proved why ratio of wood workers are not in first position among risk factors in our region but a hypothesis is said that in our country most of the wood used in wood factory is procywood but in Africa wood used in wood industry are not processed; processed wood may have less carcinogen. Also, it may another fact that our country is an agricultural country. This study is primarily focused on the evolution of clinical behviour, histopathological type and treatment of Sinonasal masses, so as to avoid recurrence and increase the patients quality of life. The purpose of this study is to compare the recent findings of data with previous study of such topic.

Objectives: •
To assess the clinical presentation of Sinonasal malignancy.
• To find out the of histopathological types of Sinonasal malignancy.

Methods
In this study observed that 24(60%) patients were found in maxillary sinus, 6(15%) in nasal cavity 5(12.5%) in multiple sinuses 4(10%) in ethmoidal sinus and 1(2.5%) in lateral wall of nose involvement. This is consistent with the findings of some other studies 9,14,15 . Breathing in certain substances may increase the risk of developing nasal cavity and paranasal sinus cancers. Here nasal cavity and maxillary sinus is relatively more exposed area. So that may be the cause higher percentages in both of these are to be involved. In our study observed that 16(40%) patients were found in T3 stage followed by 10(25%) in T2,10(25%) in T4 10 and 4(10%) in T1.This is consistent with other studies of our countries and abroad 7,9,[16][17][18] . In this study observed that only 4 patients have nodal metastasis and among them three were submandibular reason (75%) and one was jugulodiagastric region (25%). Neck-node involvement in Sinonasal malignancy about 10% in our study. In this study observed that 28(70%) patients were found in squamous cell carcinoma, 4(10%) in adenoid cystic carcinoma,3(7.5%) in adenocarcinoma, lymphoma, 1(2.5%) in Olfactory neuroblastoma,1(2.5%) in malignant fibrous histiocytoma and 2(5%) Rhabdomyosarcoma.This is consistent with other studies of home and abroad 8,9,19,20 . In present study observed that intracranial involvement found in 05(12.5%) and orbital involvement in 3(7.5%). Haque et al 7 reported intracranial involvement at the time of diagnosis was 30% and orbital involvement was 25%. These findings were consistent with the study of Nunez et 21 Al. Ali et al 9 found intracranial involvement (45%) and orbital extension (17.5%). This is not consistent with other studies because those studies were 10-30 years back. Now-a-days patients come earlier to doctors because of consciousness, increase level of education, positive effect of digitalisation, availability and low cost of CT scan, now ENT specialists are available in almost all districts and some upazillas and overall development of socio-economic condition of the people of Bangladesh.

Conclusion:
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 maybe a few or no symptoms and a require a high index of suspicion for diagnosis due to the overlapping presentation of this neoplasm with more commonly and countered infections states. Imaging is essential for staging nasal cavity tumours locally and rule out the presence of metastases. The present study is a hospital-based study with a total of 40 cases only. Most of the results are similar and few are dissimilar to the studies of others in our country and abroad. Further studies should be carried out in a broader spectrum.