Nose Cancer (Nasal, Sinus Cancer)

What is the Nasal Cavity and Paranasal Sinuses?

The nasal cavity is the large, air-filled space behind the nose. Paranasal sinuses are small air-filled spaces at the front of the skull, and surrounding the nasal cavity. They are found on the cheeks (the maxillary sinuses), above the eyes (the frontal sinuses), between the eyes (the ethmoidal air cells or sinuses) and behind the ethmoidal aircells (sphenoid sinuses).

What do the Nasal Cavity and Paranasal Sinuses do?

The nasal cavity warms and moistens the air we breathe and helps filter out dust and other harmful bits in the air. It runs back from the nostrils, above the roof of the mouth and curves down to connect with the mouth at the back of the throat.

The paranasal sinus air cavities give your voice its clarity and tone and lighten the weight of the skull.

The nasal cavity is the main sensory organ responsible for the human sense of smell. It consists of specific receptors (olfactory) which are responsible for transmitting odours into neural impulses.

What causes Nose Cancer?

Doctors can’t always explain why a person gets cancer. But we do know what makes some cancers more likely.

The main causes of nose and paranasal sinus cancers are:

• Smoking (cigarettes, cigars or pipes) or using ‘smokeless’ tobacco (snuff and chewing tobacco) If a person smokes or has smoked in the past, they have a higher risk of getting nasal and paranasal sinus cancer than someone who has never smoked. Get information about quitting smoking.
• Drinking alcohol — If a person drinks a lot of alcohol over many years, they have a higher risk of getting nasal and paranasal sinus cancer, especially combined with smoking. Get information about reducing how much alcohol you drink.
• Breathing in certain chemicals or dust that may cause cancer including wood dust (hard and soft wood), leather dust (e.g. shoe making), chromium, nickel, heavy metal exposure, formaldehyde, cloth fibres (e.g. textile manufacturing) and mineral oils (used in metal work and printing.

Other factors that may increase the risk of nose and paranasal sinus cancer are:

• Being male – in Australia nasal and paranasal sinus cancers are twice as common in men compared to women
• Age — most nasal and para nasal sinus cancers are common in people aged 45 years and over

The signs and symptoms of Nose Cancers depend on where the cancer is, its size and how far it has spread in the body.

Common signs and symptoms include:

• decreased or loss of sense of smell
• blocked or congested nose that does not clear
• pressure or pain behind the nose around the upper teeth
• nosebleeds (particularly if only on one side)
• a lump or sore inside the nose or mouth or on the face.

Other symptoms may include:

• frequent headaches or pain in the sinus areas
• numbness or tingling in the face
• swelling or trouble with the eyes, such as double vision, complete or partial loss of sight, or a bulging or watery eye
• painful or loose teeth (or dentures)
• pain or pressure in the ear

Some people with nasal or paranasal sinus cancers may not experience any symptoms at all. However if you have any of these symptoms for more than a few weeks, talk to your doctor as early as possible. They may be able to help diagnose and treat you.

What are the Tests for Nose Cancer?

It is important that your doctor establishes the diagnosis of Nose Cancer, assesses the size of the cancer and whether it has spread to the lymph nodes in the neck or elsewhere in the body. To answer these questions your doctor will need do the following things:

• talk with you about your medical history. This includes signs you may have noticed, any health conditions, medications that you are taking, and whether you smoke or drink alcohol
• perform a physical examination by feeling and looking inside the nose, face and neck
• order diagnostic tests, which may include scans.

Not everyone will need to have every test for Nose Cancer. Your doctor will recommend tests that are right for you.

Common tests include:

Following a diagnosis of Nose Cancer your cancer care team will discuss treatment options including the possibility of participating in a clinical trial that is suitable for you. This is also a good time to consider if you would like a second opinion.

The most suitable treatment for Nose Cancer depends on many things including:

• type of Nasal or Para Nasal Cancer
• size and location of the cancer
• whether the cancer has spread
• personal factors (e.g. age, general health and treatment history)
• types of treatment available (and whether any clinical trials are available)
• ​your preferences for treatment.

Nose Cancers are generally treated with surgery, radiation therapy, or a combination of both. Radiation therapy may be in combination with chemotherapy (adjuvant concurrent chemoradiation)

Surgery involves taking the cancer out of the nasal cavity and para nasal sinuses and for some people, the lymph glands in the neck. Some people may need extra treatment after surgery to reduce the risk of the cancer coming back.

This can be either radiation therapy alone (adjuvant radiation therapy) or radiation therapy in combination with chemotherapy (this is called adjuvant concurrent chemoradiation).

Surgery for Nose Cancer

There are a number of different operations that can be used to remove Nose Cancer. The operation used will depend on the size, the type nasal cancer and location of the tumour.

How can I prepare for the surgery?

Your doctor will explain details of the surgery, general risks and side effects of surgery. Ask your doctor if you have questions. They may recommend:

• stopping blood thinners (e.g. aspirin) before surgery to reduce the risk of bleeding
• special stockings to reduce the risk of blood clots
• early mobilisation (i.e not staying in bed) to reduce the risk of blood clots and chest infection
• antibiotics to lower the risk of wound infection.

If you smoke, it is important that you consider stopping smoking before starting treatment to help reduce the risk of infection and help you recover after your treatment.

Surgical procedures include:

Radiation Therapy for Nose Cancer

The most common radiation therapy approach for Nose Cancer is called external beam radiation. This type of radiation therapy applies radiation from outside the body.

Radiation therapy can be used in the following ways:

Definitive
This is the main treatment for Nasal and Para Nasal Sinus Cancer. It is used without surgery to cure Nasal and Para Nasal Sinus Cancers.

Definitive radiation therapy can also be given in combination with chemotherapy (called concurrent chemoradiation). The decision to give radiation therapy, alone or in combination with chemotherapy depends on the type of tumour, how big it is and how fit and strong you are. Typically radiation therapy is delivered one each week day (not on weekends) over 7 weeks.

Neo-adjuvant
This is when radiation therapy is given before surgery to help shrink large cancers so they are easier to remove during surgery. Sometimes chemotherapy is added to radiation therapy (chemoradiation) to make it more effective.

Adjuvant
This is when radiation therapy is given after surgery. It is used as an additional treatment to kill cancer cells that may not have been removed during surgery. This typically starts about 4 weeks after surgery to give you time to recover from the surgery. The radiation therapy usually lasts for about 6 weeks. Sometimes chemotherapy is added to the adjuvant radiation therapy (chemoradiation) to make it more effective.

The decision to give radiation therapy, either alone or in combination with chemotherapy, is based on the pathology results after surgery and how fit and strong you are to cope with the treatment. The aim is to lower the risk of the cancer coming back again in the nose, sinuses or neck, however not all patients need this.

Palliative
In cases where a cure is not possible, radiation therapy is used to relieve symptoms of advanced nasal and para nasal sinus cancer. Symptoms that may require palliative radiation therapy include pain, bleeding and pressure symptoms pressing on vital structures (e.g. visual disturbance and headaches).

How do I prepare for Radiation Therapy?

Radiation Therapy Mask-Making and Simulation

• Radiation therapy is a precise treatment. In order to make sure, that the cancer is covered by the treatment, you will need to be very still during the treatment, usually for about five minutes. A radiation therapy mask that is made to fit perfectly to your shape, will be put on you during each treatment to help the machine target where the cancer is.
• You will have a planning CT scan (and sometimes other scans) with the mask on. Your radiation oncologist and radiation therapists will use these scans with all your other clinical information to develop a radiation therapy plan just for you (a personalised plan). Your plan will be checked by the radiation therapy and radiation oncology physics team before it is ready to be used for your treatment. This whole process can take approximately 2-3 weeks.
  
  

Teeth and Mouth Care

You might need to have some of your teeth taken out, this will depend on the area being treated and the dose of radiation therapy. It is important to take out any broken or infected teeth before radiation therapy. Taking out unhealthy teeth after radiation therapy can cause problems with the jaw bone. Further information about removing teeth and what to expect before and after the operation is available here.

Diet and Nutrition

Your cancer and its treatment can make it hard to eat and drink. Your doctor will recommend you see a dietitian to maximise your nutrition during treatment as well as while you are recovering. Sometime feeding tubes may be recommended depending on the area being treated and the dose of radiation therapy.
There are two common types of feeding tubes:

• Gastrostomy tube (sometimes called a PEG tube): this type of tube is inserted through your abdominal wall into your stomach, with part of the tube staying outside the stomach. A syringe can be attached to the tube to give you food this way if needed. The tube is inserted using a camera through the mouth into the stomach (gastroscopy) or using a CT scanner to guide insertion directly through the skin. If a PEG tube is needed, your doctor will organise this before starting your radiation therapy
  
  
• Nasogastric tube: this type of tube goes through the nose down into the stomach and is usually used for short periods (days or weeks). A nasogastric tube can be inserted at any time (before, during or after treatment).

Speech, Voice, Swallowing

Your cancer and its treatment can make swallowing and speech difficult. Your doctor will recommend you see a speech pathologist, who can help you with ways to manage swallowing and communication difficulties, during and after treatment.

There are many other aspects of supportive care that are available, ask your doctor if you have any specific needs.

The side-effects of radiation therapy start around two weeks into treatment and progress through treatment to peak in the last week or just after treatment ends. The side effects start to improve 2-3 weeks after the end of treatment.

Side effects associated with radiation therapy depend on:

• the dose of radiation therapy
• the area being treated
• whether or not chemotherapy is added to the radiation.

Each person responds to radiation therapy differently. Some people may experience a few side effects while others may not experience any at all. The following are some common side effects of radiation therapy.

Common side effects of radiation therapy include:

• tiredness
• skin irritation in the treated area e.g. redness, dryness and itching, weeping skin, scaling or sometimes skin breakdown (sores)
• nasal irritation, blockage and crusting
• dry mouth and throat due to lack of saliva (called xerostomia)
• altered taste, which is usually a loss of taste or sometimes an unpleasant taste in the mouth
• pain on swallowing or difficulty with swallowing.

Most side effects are short lived and may go away within 4–6 weeks of finishing radiation therapy. Some side effects may last for months after you finish radiation therapy and some may be permanent.

Rare side effects from nerve damage (called cranial neuropathy) may occur following treatment of very advanced cancers. These include difficulty speaking, swallowing, impaired and double vision. The nasal and paranasal cavity is very close to a number of important structures such as the spinal cord, brain and nerves involved with vision, hearing and balance. Your radiation oncologist will be very careful to avoid these structures by using very precise radiation therapy techniques but sometimes rare side effects may occur from the radiation therapy. You can talk to your radiation oncologist to find out if these concerns apply to your situation and to find out more about these rare side effects.

Once your radiation therapy ends, you may continue to have follow-up appointments so that your doctor can check your recovery and monitor any side effects that you may have. Sometimes your doctor may arrange for a PET scan about 12 weeks after finishing radiation therapy to make sure the cancer has completely gone.

Your doctor may recommend that you receive specific supportive care to help during your treatment and recovery.

Chemotherapy for Nose Cancer

Chemotherapy works by destroying or damaging cancer cells. For Nasal and Para Nasal Sinus Cancers, it is usually given into a vein through a needle with a cannula (tube) attached.

There are a number of ways that chemotherapy may be used to treat Nose Cancer including:

Definitive
Sometimes chemotherapy is added to definitive radiation therapy (chemoradiation). This may be given once every 3 weeks or once a week throughout the duration of radiation therapy. This makes the radiation more effective at killing cancer cells but also leads to more side effects in most people.

Adjuvant
This is when chemotherapy is given after surgery and is usually combined with radiation therapy (called concurrent chemoradiation). This may be given once every 3 weeks or once a week throughout the duration of radiation therapy. This makes the radiation more effective at killing cancer cells but also leads to more side effects in most people. Unlike chemotherapy for many other cancers, most people do not lose their hair or have severe nausea and vomiting.

Neo-adjuvant
This is when chemotherapy is given before surgery or radiation therapy. It works to shrink large cancers so they are easier to remove during surgery or target with radiation therapy

Palliative
This is used when the cancer is incurable. The cancer may be too large or has spread too much to be removed by surgery. Palliative chemotherapy helps to slow the growth of cancer and reduce symptoms. It is important to remember that palliative chemotherapy is not as intense as other types and is much less likely to have significant side effects.

Before you start treatment, your medical oncologist will choose one or more chemotherapy medications that will be best to treat the type of cancer you have.

The chemotherapy medications your doctor chooses may depend on:

• whether the treatment is curative or palliative
• when it is used
• your medical history.

Side Effects

The side effects of chemotherapy depend on the medication used and and how much you are given by your doctor (the dose). The most common medications used are called cisplatin, carboplatin and cetuximab.

Each person responds to chemotherapy differently. Some people may experience a few side effects while others may not experience any at all.

The following are common side effects of chemotherapy:

• nausea and vomiting
• more side effects of radiation, if you have chemotherapy at the same time as radiation
• loss of feeling in the fingers and toes
• some medications may cause kidney damage
• hearing loss/thinning
• ringing in the ears
• rash
• higher risk of infection (if the chemotherapy reduces the number of white cells in the blood).

Most of these side effects are short lived and may go away once you finish chemotherapy. . Some side effects can take months or years to improve or may be permanent

Once your treatments end, you will have regular follow-up appointments so that your doctor can check your recovery, make sure the cancer has not returned and monitor and treat any side effects that you may have.

Your doctor may recommend that you receive some specific supportive care to help during your recovery.