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This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. With only limited high-level evidence for management of nasal and paranasal sinus cancers owing to low incidence and diverse histology, this paper provides recommendations on the work up and management based on the existing evidence base. Recommendations • Sinonasal tumours are best treated de novo and unusual polyps should be imaged and biopsied prior to definitive surgery. (G) • Treatment of sinonasal malignancy should be carefully planned and discussed at a specialist skull base multidisciplinary team meeting with all relevant expertise. (G) • Complete surgical resection is the mainstay of treatment for inverted papilloma and juvenile angiofibroma. (R) • Essential equipment is necessary and must be available prior to commencing endonasal resection of skull base malignancy. (G) • Endoscopic skull base surgery may be facilitated by two surgeons working simultaneously, utilising both sides of the nose. (G) • To ensure the optimum oncological results, the primary tumour must be completely removed and margins checked by frozen section if necessary. (G) • The most common management approach is surgery followed by post-operative radiotherapy, ideally within six weeks. (R) • Radiation is given first if a response to radiation may lead to organ preservation. (G) • Radiotherapy should be delivered within an accredited department using megavoltage photons from a linear accelerator (typical energies 4-6 MV) as an unbroken course. (R).

Background: Melanomas account for 4% of sinonasal malignancies. We present the largest single institution series reported thus far and analyze the outcome with reference to lymph node involvement, radiotherapy and endoscopic resection., Methodology: Survival and recurrence data were analyzed on sinonasal melanoma cases collected from 1963-2010 to compare treatment strategies and to ascertain factors predicting outcome., Results: 115 cases (mean age 65.9) were treated at our institution during this period. All underwent surgical resection of the tumour, 31 (27%) endoscopically, and 51 (44%) also received radiotherapy. Five year overall survival was 28% and disease-free survival was 23.7%. Local control was achieved for a median of 21 months, 5-year disease control rate of 27.7%. Endoscopically resected cases showed a significant overall survival advantage up to 5 years. Radiotherapy did not improve local control or survival. Cervical metastases conferred a dramatically worse outcome., Conclusions: Endoscopic resection of sinonasal melanoma does not prejudice outcome. The role of radiotherapy is unproven.

The following report describes the treatment carried out by a UK high street dental technician on an elderly patient with a large malignancy invading the oral cavity through the hard palate from the nose. The lesion remained undiagnosed during treatment for three months. The consequences of this error, and the future role of the clinical dental technician are discussed.

Inverted papilloma is the most common benign tumour of the nose and paranasal sinuses, and usually arises in the lateral wall of the nasal cavity and the middle meatus. The diagnosis is suggested on computed tomography (CT) when there is a mass continuous from the middle meatus into the adjacent maxillary antrum, through an expanded maxillary ostium. The mass may contain areas of high density or calcification, and there may be sclerosis of the wall of the affected sinus. The main advantage of magnetic resonance imaging (MRI) is in defining the extent of the tumour, and in differentiating it from adjacent inflammatory tissue, but there are no certain signal intensity or enhancement characteristics to help differentiate inverted papilloma from sinus malignancy. In the differential diagnosis, antro-choanal polyp, malignant sinus tumours and chronic rhinosinusitis and fungal disease need to be excluded. The combination of bone deformity and sclerosis with the typical antro-meatal mass suggests a slow-growing tumour such as inverted papilloma.

The herbicide acetochlor, and its analogue alachlor, have similar toxicological properties, the most significant being the induction of nasal adenomas in rats in 2-year feeding studies. Previous investigations have proposed a mode of action involving metabolism to a quinone-imine, the formation of protein adducts, cell death, and compensatory hyperplasia leading to the observed adenomas. Comparisons between rats and humans of the metabolic cascade leading to the quinone-imine indicate that these chemicals do not pose a threat to humans. Further investigations with acetochlor, presented here, have revealed an additional activation pathway in which a sulfoxide metabolite of acetochlor plays a key role. The sulfoxide was found to be the major plasma metabolite in rats dosed with acetochlor. Whole-body autoradiography studies established that this metabolite selectively accumulates and persists in the olfactory epithelium of rats. Radiolabeling of the sulfoxide molecule in the phenyl ring and in the sulfoxide side-chain demonstrated that the metabolite accumulating in nasal tissues retains the sulfoxide side-chain. The formation of a quinone-imine from the sulfoxide was facilitated by hydroxylation of the phenyl ring by a cytochrome P450 isoenzyme which was specific to the nasal epithelium in the rat. This metabolic conversion could not be detected in 33 fresh human nasal tissue samples, supporting the earlier view that the acetochlor-induced rat nasal tumors do not represent a hazard for humans., (Copyright 2000 Academic Press.)

Surgery offers the optimum modality of treatment for inverted papilloma although a considerable range of operative approaches have been described. The results are presented in a cohort of 37 cases treated by both endoscopic and combined endoscopic and external approaches with a recurrence rate of eight and 21 per cent respectively. This series is compared with those in the literature and demonstrates that it is extent of disease which primarily determines the choice of surgical approach, with previous treatment, individual patient factors and surgical expertise as secondary determinants.

The midfacial degloving approach has been available for twenty five years and is slowly increasing in popularity in the management of extensive benign lesions of the sinonasal region, for selected malignancy in this area and to afford access to the nasopharynx and infra-temporal fossa. The advantages, applications and low complication rate are presented in a cohort of 86 patients, ranging from three to 79 years of age with a mean follow-up of 5.5 years. Seventy-seven per cent of the group had benign pathology of which juvenile angiofibroma was the commonest (40 cases). The 20 cases of malignant disease were a heterogeneous group histopathologically including adenoid cystic carcinoma (four cases), malignant schwannoma (two cases), rhabdomyosarcoma (two cases) and squamous cell carcinoma (two cases). Five underwent bilateral radical maxillectomies combined with orbital clearance in one patient. Complications include oro-antral fistula (three cases) and epiphora (three cases) all of which were successfully treated.

Objectives/methods: To determine whether surgery combined with radiotherapy confers any survival benefit on radical local excision alone in the management of mucosal malignant melanoma of the nose and sinuses., Study Design: Retrospective review., Methods: From a cohort of 72 patients treated between 1963 and 1996 within a single unit, complete data were available for 58 individuals who were examined to determine whether there was any significant statistical difference in local control and/or survival between those receiving surgery and those receiving combined surgery and radiotherapy., Results: There were 30 men and 28 women. Their ages ranged from 39 to 90 years (mean, 64 y). Twenty-nine patients underwent surgery alone; 23 patients underwent surgery and radiotherapy; 6 patients received surgery and chemotherapy; and 3 patients received surgery, chemotherapy, and radiotherapy. Primary surgery included lateral rhinotomy (42 cases), maxillectomy (8 cases [orbital clearance in 3 cases]), craniofacial resection (3 cases), total rhinectomy (3 cases), and endoscopic clearance (2 cases). Survival ranged from 1 to 228 months with rapid patient loss due to local (and/or systemic) disease during the first 36 months, irrespective of the treatment modality. Overall 5-year actuarial survival was 28%, and overall 10-year actuarial survival 20%, with a median survival of 21 months. There was no statistical difference in local control or survival between patients receiving surgery alone and those receiving surgery and radiotherapy, irrespective of whether this treatment was given in the early part of the series (i.e., before 1983) or thereafter. The addition of chemotherapy had no impact on survival, nor did the site of the tumor, the surgical procedure, the presence of lymph node metastases or the age of the patient., Conclusion: In this large cohort of sinonasal melanoma, overall survival was poor and did not appear to be improved by the addition of radiotherapy.

Background: The rarity of sinonasal tumors has precluded long-term follow-up of large series of craniofacial resections until now., Methods: A series of 209 patients suffering from a wide range of histologies who had undergone craniofacial resection for sinonasal neoplasia with up to 17 years' follow-up were analyzed., Results: An overall actuarial survival of 51% at 5 years and 41% at 10 years was found for the cohort as a whole. For malignant tumors, the 5-year actuarial survival was 44%, falling to 32% at 10 years. For benign pathology, the actuarial survival was 75% at both 5 and 10 years. Statistical analysis identified three factors which significantly affect outcome and survival: malignant histology, brain involvement, and orbital involvement. Few complications are associated with the surgery, with the mean post-operative stay being 16 days., Conclusions: The improved survival and minimal morbidity and mortality associated with craniofacial resection make it the optimum approach to sinonasal tumors.

Twenty cases of olfactory neuroblastoma were available for clinical and histopathological evaluation. The usefulness of immunohistochemistry in the diagnosis of this tumour was investigated and was best achieved using a panel of monoclonal and polyclonal antibodies, notably neuron-specific enolase, PGP 9.5, S-100 protein, synaptophysin and chromogranin A. This study confirmed that immunohistochemistry is a useful adjunct in cases where conventional histology is equivocal.

Sinonasal malignancy is a rare disease in which a number of aetiological factors have been implicated. Incidence, site and histological type can vary in different geographical areas which may be due to occupational, social and genetic factors. Relative risk rates have been determined for a number of occupations such as workers with wood, nickel, chrome, chemicals, shoes and textiles though the exact causative agents and mode of action is not entirely clarified. Some non-occupational agents and pathological conditions may also play a role in certain cases. A group of 350 patients with sinonasal malignancy have been reviewed with regard to aetiological factors and more detailed information was obtained in 50 of these patients by questionnaire and interview. Significant exposure to a wide range of known carcinogens was revealed suggesting a possible causative relationship in several unusual histological types.

Formaldehyde is a well known nasal carcinogen in rodents, but so far there has been no convincing evidence that workers occupationally exposed to formaldehyde have an increased risk of nasal cancer. In this study three cases of malignant melanoma of the nasal mucosa in persons occupationally exposed to formaldehyde for a long time are presented. The occurrence of such a rare tumour in patients with significant exposure to a known carcinogen warrants further investigation.

The combined approach for resection of tumors of the nose and paranasal sinuses is well established. The technique has been considerably modified, resulting in an operation that combines good access, sound oncologic resection with excellent cosmesis, and a low postoperative morbidity rate for conditions that have been associated hitherto with an extremely poor prognosis. A 9 year experience with 92 patients is presented. Long follow-up confirmed the initial results, suggesting an improved survival rate in patients with potentially curable disease. An increasing number of large benign tumors, which would previously have been considered inaccessible, are now being resected. Herein, the role and accuracy of preoperative investigations such as computerized tomography and magnetic resonance imaging are evaluated, and the cosmetic implications associated with long-term survival, particularly in children, is considered. The many advantages of craniofacial resection recommend it as the treatment of choice for tumors of the nose and paranasal sinuses, and the versatility of the technique allows its application to tumors arising in adjacent areas.

The experience with 220 consecutive cases of malignant tumours of the nasal cavity and paranasal sinuses seen over a period of 20 years by 1 person is presented. Squamous cell carcinoma (64 cases) constituted the commonest tumour though a wide range of pathologies was encountered. Combined treatment with surgery and radiotherapy produced the best results. 3- and 5-year survival was 44 and 30%, respectively. Local control of disease is very important in improving survival, and long-term follow-up is essential.

Inverted papilloma is an uncommon benign tumour of the nose and paranasal sinuses which has a characteristic histological pattern, high recurrence rate after surgery and may undergo malignant change. The X-ray features are reviewed in 60 patients with histologically confirmed tumours. Plain X-ray appearances were negative or non-specific in nearly half the patients. The changes shown on hypocycloidal tomography and on CT scan are more specific. A mass in the middle meatus of the nasal cavity extending into the adjacent maxillary antrum is highly suggestive of the tumour. Other features not hitherto reported are the presence of calcified areas within the tumour mass demonstrated by CT, and sclerosis and deformity of the walls of the sinuses involved by tumour.

The craniofacial approach for resection of tumors of the nose and paranasal sinuses is well established, as are its advantages over previous methods of treatment. The technique has been considerably modified, resulting in an operation that combines excellent access, a sound oncologic resection with excellent cosmesis, and low postoperative morbidity for conditions associated hitherto with an extremely poor prognosis. The 7-yr experience of 60 patients is presented. Results suggest improved survival in a group of patients who are potentially curable by this procedure, while in those with extensive disease good palliation is achieved. In addition, large benign tumors that would previously have been considered inaccessible can be resected. Its many advantages recommend it as the treatment of choice for tumors of the nose and paranasal sinuses.

The craniofacial resection operation was developed for the treatment of advanced nasal, paranasal and orbital malignancies. It has been refined in recent years, giving increased cure rates and better palliation when cure is not possible. When used to treat extensive benign lesions involving the anterior skull base, this procedure allows more complete and safer resection with better access for repair and avoidance of major complications of brain damage, cerebrospinal fluid leak and haemorrhage. Presented here is a technique for craniofacial resection. The study demonstrates its effectiveness and low morbidity in treating 10 patients with extensive benign disease.

Adenoid cystic carcinoma of the nasal cavity and paranasal sinuses has a unique natural history. It has a propensity for frequent local recurrence and early perineural and hematogenous spread. These factors, together with a complex anatomic situation, make adequate oncologic surgery extremely difficult. The incidence of local recurrence is lower in those patients receiving more radical primary surgery, but the choice between conservative and radical management may not alter prognosis. Indeed, it is doubtful if any patients are cured of this disease.