Surgery for nasal cavity and paranasal sinus cancer

Most people with nasal cavity and paranasal sinus cancer 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 other factors, such as your age, overall health and whether you will need reconstruction.

Surgery may be done for different reasons. You may have surgery to:

• completely remove the tumour
• reduce pain or ease symptoms (called palliative surgery)

Surgery for cancer in the nasal cavity or paranasal sinuses is difficult. The goal of surgery is to remove the cancer while trying to not change how you look (your appearance) or how well you can breathe, chew, swallow, smell, see and talk. If the surgery will affect these functions, then a plan will be made to give you the best reconstruction possible. Your healthcare team may include different specialists, including an ear, nose and throat (ENT) surgeon (called an otolaryngology head and neck surgeon), 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, where possible.

For some types of surgery, you may need to see a dentist who specializes in cancer. 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, allowing bacteria to grow. The dentist may need to remove these teeth before you have surgery. A dentist will also be involved if you need dental prosthetics.

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 the nasal cavity and paranasal sinuses will start with a surgical cut (incision) on the face. This is usually described as open surgery. In some cases, the incisions may be hidden inside the mouth or nose. Some types of nasal cavity and paranasal sinus cancer also use endoscopic surgery.

Endoscopic surgery uses a rigid tube with a light and lens on the end (called an endoscope) to look at structures or organs or to remove tissue. The surgeon places the endoscope in the body through 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, to the skin or to large areas of surrounding bone.

Endoscopic surgery uses small incisions, so it has fewer complications than open surgery and causes less damage to healthy tissue, such as blood vessels and nerves. It also gives the surgeon a better view of the inside of the nasal cavity and paranasal sinuses. People who have endoscopic surgery also tend to recover faster and their appearance is changed less compared to those who have open surgery.

The following types of surgery are commonly used to treat nasal cavity and paranasal sinus cancer. You may also have other treatments before or after surgery.

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, bone 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 upper jawbone (maxilla). It is also used to remove some nasal cavity tumours. During a maxillectomy, the surgeon removes all or part of the maxilla on one or both sides of the head. If maxillary cancer spreads outside of the maxilla, the surgeon removes the maxilla as well as surrounding tissues and upper teeth. If the tumour has grown into the eye, the eye may need to be removed as well.

Reconstruction of the maxilla may be done by using bone from another part of the body or by using a prosthesis or denture.

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 (the area just below where the brain sits). It is similar to a maxillectomy except that the surgeon may also remove upper parts of the eye socket and the front base of the skull. If the tumour has grown into the eye, the surgeon will also remove the eye.

A craniofacial resection 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 using skin grafts or flaps will also be done to rebuild the face, but there may be significant changes to your 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.

A selective neck dissection removes some of the lymph nodes on the same side of the neck as the tumour.

A modified radical neck dissection removes most of the lymph nodes from one side of the neck between the jawbone and collar bone. The surgeon may also remove some muscle and nerve tissue.

A radical neck dissection removes nearly all of the lymph nodes from one side of the neck as well as more muscles, nerves and veins.

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.

Find out more about neck dissection.

Surgery for nasal cavity and paranasal sinus cancer may damage the structure of the nose and face. This can affect the way you look, speak and swallow. Reconstructive surgery may be needed to repair damage after surgery, to improve how you look or to help you speak and swallow as normally as possible. Reconstructive surgery often uses tissues from other parts of your body to rebuild structures of the nose and may also include the use of artificial structures called prosthetics.

Most reconstructive surgery for nasal cavity and paranasal sinus cancer is done at the same time as surgery to remove the cancer.

A skin graft is a piece of healthy skin taken from one part of the body, usually the upper leg, and placed over the surgical wound.

A flap is a thick piece of tissue with its own blood supply. Like a skin graft, a flap covers the area where the cancer was removed. It can be used to repair large wounds on the face. A flap can contain components of skin, muscle and bone.

The surgeon takes the flap, which includes skin, fat and sometimes muscle or bone, from either the forearms, legs, back, chest or abdomen. The flap sometimes remains partly attached to its original location and blood vessels are still connected. In most cases, the flap is completely removed (called a free flap) and the blood vessels of the flap need to be connected to vessels at the new site. The flap is positioned over the wound and stitched in place. Plates and screws are often used to connect the bony parts of the flap to the bone of the face.

A bone graft may also be used to reconstruct the nose, cheekbone or other bones in the face that are removed during surgery. The shoulder blade, the hip bone or a bone from the lower leg (called the fibula) are used as a bone graft. 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.

Side effects can happen with any type of treatment for nasal cavity and paranasal sinus cancer, but everyone's experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery, the effect of other treatments (for example, tissue treated with radiation therapy may not heal well after surgery) and your overall health.

Surgery for nasal cavity and paranasal sinus cancer may cause these side effects:

• pain
• bleeding
• swelling and bruising
• infection
• breathing problems
• blood clots
• changes to your sense of smell
• hearing problems
• vision changes
• difficulty chewing, swallowing and speaking
• changes to your physical appearance
• nerve damage
• difficulty opening the jaw (called trismus)
• stiff neck
• trouble moving the shoulders
• inflammation of the covering of the brain and spinal cord (called meningitis)
• the fluid surrounding the brain (called cerebrospinal fluid, or CSF) leaking into the sinuses and draining from the nose
• brain damage (rare)

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.