The sinuses are air filled cavities in the skull which connect with the nose. There are a lot more sinuses in the skull than most of us realise. The biggest are the maxillary sinuses under the cheekbones. The frontal sinuses are under the forehead. The ethmoid sinuses are between your eyes. The sphenoid sinus is deep behind the nose in the centre of your head. These sinuses are all related to your brain and form part of your skull base. The skull base is a crowded and complicated area with different openings that the spinal cord, many blood vessels, and nerves all pass through.
Most people are not aware that they can develop a cancer of the nose or sinuses (sinonasal cancer). Symptoms such as a blocked nose, excessive mucus, decreased sense of smell, pain and even bleeding may occur with a cold or inflammation of the sinuses (sinusitis). So it is important that if these symptoms persist or worsen that review by an ENT head and neck surgeon should be organised rule out one of these rare cancers.
There are two different surgical approaches to the sinuses. The first is endoscopic, a minimally invasive surgery (MIS) technique where a rigid telescope with a light and camera is used to access the sinuses through the nose. Endoscopic sinus surgery does not involve cutting the skin as it is performed entirely through the nostrils. The second approach is called an open or external approach which involves accessing the sinuses via skin incisions. This is particularly important in cancers of the maxillary sinus under the cheek, cancers that spread to involve the eye and cancers of the nasal septum (centre part of the nose).
Treatment and Diagnosis
Sinus and nose cancers, like all other head and neck cancers, should be reviewed by a Head and Neck Multidisciplinary Team which includes Otolaryngology Head and Neck surgeons, surgical oncologists, medical oncologists, radiation oncologists and pathologists. Before we can decide on the right treatment for any individual patient we have to determine how far the tumour has spread. This is done using scans and other tests and is called cancer staging.
Most sinus tumours and cancers can now be treated by endoscopic approaches. The term “endoscopic” refers to the use of small rigid telescopes that allow all of the surgery to be performed through the nostrils, without the need for any skin incisions. Endoscopic surgery for sinus and nose tumours can work well in some specific circumstances. If the tumour is advanced and has spread into adjoining bones or structures then endoscopic surgery may be too conservative to stop the spread of the tumour.
If the tumour is very advanced an external approach may be required. I am one of only a small number of surgeons trained specifically in both open and endoscopic approaches to sinus and nasal cancers.
I spent a year completing hands on advanced surgical training in endoscopic sinus surgery in 1997-1998 at the University of Virginia Hospitals in the United States. Over the past twenty years I have performed thousands of Functional Endoscopic Sinus Surgeries (FESS) before recently deciding to shift the majority of my practice to head and neck surgery.
I get very concerned when I hear about sinus and nose cancer patients are not reviewed by a Head and Neck Cancer Multidisciplinary Team (MDT). Even more alarming is when poor decisions regarding appropriate surgery are made because the specialists involved are not appropriately trained in external sinus surgery. This means that patients may undergo endoscopic treatment resulting in incomplete removal of the cancer which leads to poor results.
Working with other surgical disciplines
The position of these cancers, some deep within the skull, means that I may need the expertise of surgeons from other surgical specialities to operate with me on the same patient in the same surgical session. These surgeons are referred to as co-surgeons. They may include neurosurgeons and plastic and reconstruction surgeons. All the co-surgeons I work with at St Vincent’s are excellent, not just in terms of their surgical expertise but also in regards to post operative care. This includes the period while you are recovering in hospital and ongoing treatment and review after you have been discharged.