SUPPORT CANADIANS LIVING WITH CANCER
Surgery for nasal cavity and paranasal sinus cancer
Most people with cancer in the nasal cavity or a paranasal sinus will have surgery. The type of surgery you have depends mainly on the size of the tumour, the location of the cancer and the stage of the cancer. When planning surgery, your healthcare team will also consider factors such as your age and other health conditions which may make surgery risky, and whether or not reconstruction needs to be done.
Surgery may be done for different reasons. You may have surgery to:
- completely remove the tumour
- relieve pain or ease symptoms (called palliative treatment)
Surgery for cancer in the nasal cavity or paranasal sinuses is difficult. The goal of surgery is to remove the cancer while trying not to change your appearance or how well you can breathe, chew, swallow, see and talk. As a result, your healthcare team may include different specialists, including an ear, nose and throat (ENT) surgeon (called an otolaryngologist), a brain surgeon (called a neurosurgeon) and a reconstructive surgeon. They will carefully plan and do surgery to avoid damage to nerves, blood vessels, the eyes and the brain, which are all near the nasal cavity and paranasal sinuses.
If your healthcare team thinks you need to have certain types of surgery, such as a maxillectomy, they will likely have you see a dentist who specializes in cancer (called an oncologic dentist) before surgery. The dentist will do an exam and decide if you need to have any dental work done before surgery. Depending on the surgery, some teeth may not be useful after surgery and may be difficult to clean properly, creating an environment for bacteria to grow. The dentist may need to remove these teeth before you have surgery.
You may also need to see a maxillofacial prosthodontist before and after surgery. This doctor is specially trained to make replacements (called prosthesesprosthesesAn artificial device used to replace a part of the body.) for structures in the head and neck, such as the roof of the mouth (called the hard palate).
Depending on the type of surgery and how much tissue is removed, the surgeon may suggest that you have a temporary prosthesis made before surgery. The temporary prosthesis can be put in place at the time of surgery. A permanent prosthesis is made about 6 months after surgery, once the area is completely healed and all swelling has gone away.
Learn more about prostheses for nasal cavity and paranasal sinus cancers.
The surgeon often needs to be able to look at the bones and tissues around the nasal cavity and paranasal sinuses to plan the best way to remove a tumour. Most types of surgery for nasal cavity and paranasal sinus cancer will start with an incision (surgical cut) on the face, such as a lateral rhinotomy. In some cases, the incisions may be hidden inside the mouth or nose, such as midfacial degloving. Some types of surgery for nasal cavity and paranasal sinus cancer also use endoscopic surgery.
A lateral rhinotomy allows the surgeon to look inside the nasal cavity and around the paranasal sinuses. With this approach, the surgeon can see and reach the part of the upper jaw bone closest to the nose (called the medial maxilla), the ethmoid sinus, the sphenoid sinus and the bone between the eyes (called the medial wall of the orbit). Surgeons can remove most tumours in the nasal cavity easily with a lateral rhinotomy.
During a lateral rhinotomy, the surgeon tries to make an incision (surgical cut) that follows the natural lines on the face to help make the scars less noticeable after surgery. The surgeon makes an incision from the start of the eyebrow closest to the nose to the corner of the eye, down the edge of the side of the nose, and then around the nostril and down to the middle of the upper lip.
In some cases, the surgeon can make a bigger incision around the eye and down the upper lip to look at the rest of the maxilla, the rest of the orbit, the soft tissues below and behind the cheek bone and the floor of the nose.
Midfacial degloving allows the surgeon to look at the bones of the face without making an incision on the face itself. The surgeon makes an incision inside the mouth, behind the upper lip, and inside of the nose to look at the front of the maxilla. This allows the surgeon to look inside the nasal cavity, the nasopharynxnasopharynxThe upper part of the pharynx (throat) behind the nose and above the soft palate (the back, soft part of the roof of the mouth). and the maxillary sinus.
Endoscopic surgery uses a rigid tube-like instrument with a light and a lens (called an endoscope) to view structures or organs or to remove tissue. The doctor places the endoscope in the body through small incisions or through a natural opening, such as the nostril.
Endoscopic surgery is used to biopsy a suspicious area and to remove a tumour. It may also be used with open surgery to remove a tumour that has grown into the brain. Endoscopic surgery isn’t used to remove a tumour that has spread to the soft tissues of the face, to the eye, the skin or to large areas of surrounding bone.
Endoscopic surgery doesn’t make big incisions, as open surgery does. This means that endoscopic surgery has fewer complications such as bleeding. This approach can also give the surgeon a better view of the inside of the nasal cavity and paranasal sinuses and less contact with blood vessels and nerves that could become damaged during surgery. People who have endoscopic surgery also tend to recover faster. Their appearance is changed less compared to those who have open surgery.
The following are the types of surgery used to treat cancers in the nasal cavity and paranasal sinuses. You may also have other treatments before or after surgery.
Wide local excision
Wide local excision removes the tumour along with a wide margin of healthy tissue around it. This type of surgery is used for small, early stage tumours in the nasal cavity or maxillary sinus.
A rhinectomy is sometimes done to remove a tumour in the nasal vestibule. This surgery removes part or all of the nose. When part of the nose is removed, it is called a partial rhinectomy. When the entire nose is removed, it is called a total rhinectomy.
Reconstructive surgery using skin grafts and flaps can be done to repair or rebuild the nose after a rhinectomy. In some cases, a prosthesis will be specially made to replace the nose, rather than doing reconstructive surgery.
A maxillectomy is done to remove tumours in the maxilla. It is also used to remove some nasal cavity tumours.
The maxilla is the upper jaw bone. It forms walls that include part of the roof of the mouth (called the hard palate), part of the bones around the base of the eye socket (called the orbit) and the side walls of the nasal cavity. During maxillectomy, the surgeon removes all or part of the maxilla on one or both sides of the head.
There are different types of maxillectomies. The type of maxillectomy done will depend on how far the cancer has grown into nearby structures.
A medial maxillectomy is used to remove a tumour on a side wall of the nasal cavity or on the wall of the maxilla closest to the nose. The surgeon may also remove the ethmoid sinus and the wall of the orbit closest to the nose if the tumour has grown into any of these structures. A medial maxillectomy is usually done by endoscopic surgery.
Partial and infrastructure maxillectomies
A partial maxillectomy removes part of the maxilla. An infrastructure maxillectomy is a type of partial maxillectomy. During an infrastructure maxillectomy, the surgeon removes part of the maxilla, part of the hard palate and part of the side wall of the nose. Some upper teeth may also be removed.
Surgeons use an infrastructure maxillectomy to remove tumours that have grown into the floor of the maxillary sinus or the hard palate. It is also used to remove any maxillary sinus tumour that is below Ohngren’s line. This is an imaginary line drawn from the inner corner of the eye to the angle of the jaw bone (just below the ear lobe) on the same side of the face.
A total, or radical, maxillectomy is used to remove maxillary sinus cancer that has spread throughout the maxilla or outside of the maxilla into the side wall of the nose, surrounding soft tissues of the face, the orbit (group of bones that make up the eye socket) or the ethmoid sinus.
During a total maxillectomy, the surgeon removes the maxilla as well as surrounding tissues and upper teeth. If the tumour has grown into the eye, the surgeon may need to remove the eye as well.
A craniofacial resection is done to remove a tumour that started in the nasal cavity, the ethmoid sinus, the sphenoid sinus or the frontal sinus and has grown into the base of the skull (area where the brain sits). This surgery is often done with the help of a neurosurgeon who removes the outer covering of the brain, called the dura mater. A craniofacial resection can be done using endoscopic surgery, open surgery or a combination of both methods.
During craniofacial resection, the surgeon removes the front part of the base of the skull, the ethmoid sinus, the frontal sinus and the wall of bone that divides the nasal cavity into right and left sides (called the nasal septum). If the cancer has spread to the dura mater or to the orbit, a neurosurgeon will also remove the areas of these structures that contain cancer.
This surgery is usually done in 2 steps, which allows surgeons to better reach the tumour and gives them a better chance of completely removing it. This approach can also help lessen the chance that the brain, nerves and other structures will be damaged during surgery.
The first step of an open craniofacial resection is usually a lateral rhinotomy, which allows the surgeon to reach the tumour behind the face. During the second step, the surgeon makes an incision in the scalp to reach the inside of the skull where the brain sits (called the cranium). This allows the surgeon to remove a part of the skull to reach the tumour.
Once the surgeon makes these incisions, the tumour is removed along with other structures that the cancer has spread to such as the maxilla, the hard palate, the bones around the eye (called the orbit) and the lower part of the skull above the eye (called the skull base).
If the tumour has grown into the eye, the surgeon will also remove the eye (called orbital exenteration).
This surgery removes quite a bit of tissue. Doctors will often have to use metal plates and screws to replace and attach parts of the skull that the surgeon needed to remove to reach the tumour. Reconstructive surgery will be also done to rebuild the face, but there may be significant changes to the person’s appearance.
A neck dissection removes lymph nodes from the neck (called cervical lymph nodes). The surgeon will do a neck dissection only if a CT scan shows that the cancer has spread to these lymph nodes.
Partial neck dissection
Partial, or selective, neck dissection removes some of the lymph nodes on the same side of the neck as the tumour. The lymph nodes are sent to a lab and checked to see if they contain cancer (called positive lymph nodes). People who have positive lymph nodes after a partial neck dissection will have more treatment, such as chemotherapy or radiation therapy.
Modified radical neck dissection
This surgery removes most of the lymph nodes from one side of the neck. The surgeon may also remove one or more of the following:
- the sternocleidomastoid muscle (a muscle on the side of your neck)
- the accessory nerve
- the internal jugular vein
This surgery may be used if tests show that the lymph nodes in the neck contain cancer.
Radical neck dissection
Radical, or comprehensive, neck dissection removes most of the lymph nodes from one side of the neck as well as all of the following:
- the sternocleidomastoid muscle
- the accessory nerve
- the internal jugular vein
This surgery is used when diagnostic tests show that the lymph nodes in the neck contain cancer and the cancer has also spread to the sternocleidomastoid muscle, accessory nerve or the internal jugular vein.
In rare cases, a neck dissection needs to be done on both sides of the neck. This may be done if the tumour is at or near the midline of the body because cancer cells from these tumours can spread to lymph nodes on both sides of the neck.
Learn more about neck dissection.
Surgery for nasal cavity and paranasal sinus cancer may damage the structure of the nose and face, which can affect the way you look, speak and swallow. Reconstructive surgery may be needed to repair damage after surgery, to improve appearance or to make sure you can speak and swallow as normally as possible. If you had surgery to the base of the skull, you will need reconstructive surgery to make a new watertight barrier between the cranium and the nasal cavity and paranasal sinuses.
Most reconstructive surgery for nasal cavity and paranasal sinus cancers is done at the same time as the surgery to remove the cancer.
A skin graft is a piece of healthy skin taken from one part of the body (called the donor site) and placed over the area where skin cover is needed. The upper leg is a common donor site for skin grafts.
Skin grafts used in reconstructive surgery for nasal cavity and paranasal sinus cancers are usually split-thickness grafts. The surgeon uses a special instrument to remove the outer layer of skin (called the epidermis) and part of the inner layer of skin (called dermis) from the donor site. The skin is then placed over the surgical wound, and the donor site heals on its own.
Flaps are used to repair large surgical wounds. A flap is a piece of tissue that may include muscle, skin, fat and bone. A flap has its own blood supply. Some common donor sites for flaps include the forearms, legs, back, chest and abdomen.
A pedicle flap is created by cutting away one end of the tissue from the body, while the other end remains attached to the body. The flap is placed over the wound and stitched in place.
A free flap uses a piece of tissue that has been completely removed from the donor site and moved to the wound site. The tiny blood vessels of the flap are connected to the vessels of the wound site. This type of surgery is known as microvascular surgery.
In some cases, the surgeon needs to place a tube in the neck to help you breathe while the flap around the nose and sinuses heal. This is called a tracheostomy, and it is usually temporary. The tube is removed once the swelling from the surgery has gone down.
A bone graft may be used to reconstruct the nose, cheekbone or other bones in the face that are removed during surgery. Common donor sites for bone grafts are the shoulder blade, the hip bone or a bone from the lower leg (called the fibula). The bone is reshaped and used to replace bone in the face.
Surgery may be used to remove part of a tumour that blocks the nasal cavity or paranasal sinuses. This surgery can help relieve symptoms and ease pain, such as a blocked sinus.
While you are still in the operating room, the healthcare team usually sends tissue samples to the pathology lab to be examined. The tissue is frozen, cut into thin slices and placed on a glass slide (called a frozen section). The pathologist looks at the tissue to see if there are cancer cells at the cut edges of the tissue (called the margins). The pathologist tells the surgeon if there is or isn’t cancer in the margins. If there is cancer in any of the margins (called positive surgical margins), the surgeon will likely remove more tissue until the margins are free of cancer.