Nasal and sinus cancer

Behind the nose and around it lies a whole system of cavities: the nasal cavity itself and four pairs of air-filled sinuses — in the cheeks, in the forehead, between the eye sockets and deeper still, at the base of the skull. A tumour can grow there, and the disease is rare: roughly one case a year per hundred thousand people, usually after fifty and more often in men. What makes it distinctive is not its severity but the fact that for the first few months it looks like an ordinary head cold, which is why it is worth knowing how one nostril differs from two.

Why it goes unnoticed for so long

The tumour grows inside a closed bony box and for a while presses on nothing. What the person feels is exactly what half the population feels every autumn: blockage, dripping down the back of the throat, heaviness under the eye. Those complaints get put down to allergy, a deviated septum, sinusitis that will not clear or nasal polyps — and the explanation is nearly always right, because cancer here is thousands of times less common.

There is one difference, and it is very simple: ordinary nose conditions affect both sides, a tumour affects one. Allergy blocks both nostrils, so does a cold; but if for months only the right nostril will not breathe and only that one leaks blood-stained fluid, it is no longer "chronic catarrh", however many sprays have been tried. The second warning sign is that the complaint does not fluctuate: it does not settle with treatment, does not ease off in summer, does not vary with the weather, and slowly gets worse.

There is no screening programme that looks for this tumour in healthy people — it is far too rare to test everybody for. So everything rests on paying attention to a one-sided, persistent complaint.

Which signs should raise concern

While the tumour is still inside the nose it gives away very little:

• blockage of one side of the nose that does not clear for weeks or months;
• blood-stained discharge or repeated nosebleeds always from the same side;
• reduced or lost sense of smell;
• a feeling of constant dripping into the throat, sometimes streaked with blood.

Once it grows beyond the sinus, the signs become more obvious and depend on which way it has gone. Upwards and outwards, into the eye socket: the eye waters for no reason, double vision appears, the eye bulges or shifts, sight suffers. Downwards, into the upper jaw: the cheek or the side of the nose goes numb, the upper teeth loosen, a denture stops fitting, a swelling appears on the palate or the gum. Sideways: the mouth will not open fully, and one ear blocks and aches because the tumour is closing off the eustachian tube. Separately, there may be a firm, painless neck lump lasting more than three weeks.

None of these on its own means cancer: cheeks go numb after the dentist, ears block with an infection, noses bleed in dry air. What counts is the combination — one side, persistence and gradual progression.

What raises the risk

The best known and best proven link is occupational. Breathing wood dust for years, hardwood especially, clearly raises the risk of a tumour in the ethmoid sinus; joiners, furniture makers and floor layers are all exposed. Leather dust in tanneries and shoemaking works the same way. Then come nickel and chromium compounds, formaldehyde and isopropyl alcohol manufacture. Decades pass between the exposure and the illness, so most people fall ill long after leaving that job.

Smoking raises the risk here too, as it does in almost all head and neck tumours. Radiotherapy to the head in childhood also counts — for a retinoblastoma, for instance. The contribution of human papillomavirus is discussed, though it is far less well established than in throat tumours.

What can be done with all this. If there is dust at work, a respirator and extraction are not a formality but the only things that genuinely lower the risk, and they have to be used all year round, not on inspection days. Stopping smoking helps even after many years. And anyone who has spent years working with wood or leather should keep that history in mind and not brush off a one-sided blockage, however trivial it seems.

How the diagnosis is made

It all starts with an ear, nose and throat examination: the doctor looks at the nose, mouth and throat, checks sensation in the face and movement of the eye, and feels the neck. Then come the key tests.

• Nasal endoscopy. A thin flexible or rigid tube with a camera goes into the nasal cavity and shows what neither a speculum examination nor an ordinary image can. It is done under local anaesthetic and takes a few minutes.
• Biopsy. A piece of tissue is taken during the endoscopy itself and examined under the microscope. Only that makes the diagnosis and identifies the type of tumour, and everything about the treatment follows from it.
• CT scan shows the bone: whether the sinus wall has been eroded and whether the skull base is involved.
• MRI tells the tumour apart from the mucus trapped behind it — on CT the two look identical — and shows whether it has reached the eye socket or the coverings of the brain.
• Neck ultrasound, with a needle sample of a node if needed, checks whether cells have spread to the lymph nodes.

What will not find this tumour. A plain sinus X-ray is useless here: it shows an opacity, and a run-of-the-mill sinusitis produces exactly the same opacity. Blood tests settle nothing either, because this disease has no marker of its own, and normal results do not remove the need to look inside the nose. And there is one more rule worth knowing: every polyp that is removed goes to the laboratory, and a one-sided polyp in an adult must be sent without exception, because some of these tumours look precisely like that.

Biopsy results usually take one to two weeks. A delay does not mean bad news has been found: most often the sample simply needs extra staining.

How it is treated

The plan is not made by one doctor but by a team: an ENT surgeon, an oncologist, a radiation oncologist and, where needed, a neurosurgeon, an ophthalmologist and a maxillofacial surgeon. The choice depends on the type of tumour, its size, which way it has grown and the person's general health.

Surgery is the mainstay. Many tumours are now removed endoscopically through the nose, with no cuts on the face; wider spread calls for an open approach, sometimes with a neurosurgeon if the skull base is involved. A margin of healthy tissue is taken along with the tumour, otherwise the risk of it returning stays high. If part of the upper jaw or palate has had to go, the defect is repaired — with the person's own tissue, a titanium plate, or a removable obturator prosthesis that restores normal speech and eating. Facial scars are not inevitable, and they fade over time.

Radiotherapy is given after surgery to cut the chance of the tumour returning, or as the main treatment when surgery is not possible or when the tumour was caught early and responds well to irradiation. Chemotherapy is used to shrink a tumour before an operation, alongside radiotherapy in locally advanced disease, or to hold the disease back once it has spread beyond the head and neck.

If the tumour cannot be cured, treatment does not stop; it changes its aim to holding growth back, controlling pain, restoring breathing and supporting nutrition. That is the work of the palliative care team, and there is every reason to involve them early rather than at the very end.

After treatment: what to expect

After surgery and radiotherapy the nose works differently. The lining dries out, crusts form, and the sense of smell may not come back at all — and with it the taste of food changes, because most of taste rests on smell. Regular saline rinses become a daily habit: they clear the crusts and make breathing noticeably easier. The doctor will show you how to do them properly.

Irradiation around the eye socket can leave a dry eye or, conversely, constant watering because the tear duct has narrowed; both are manageable and are discussed with an ophthalmologist. When the upper jaw has been irradiated, the teeth get particular attention: they are put in order before treatment starts, because afterwards an extraction in the irradiated area heals badly.

Follow-up is built around endoscopic examination and goes on for years. A recurrence is usually picked up that way, before any symptoms appear. Between appointments the rule of thumb is simple: any new one-sided blockage, bleeding, pain or numbness is a reason to ring your team rather than wait for the scheduled date. Stopping smoking after treatment lowers the risk both of recurrence and of a second tumour.

When urgent help is needed

Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single European number is 112) if:

• a heavy nosebleed starts that pinching the soft part of the nose for ten to fifteen minutes will not stop, or blood is pouring down the throat;
• vision in one eye is suddenly lost or worsens, the eye becomes painful and will not move, or double vision persists;
• a severe headache comes with a high temperature, an inability to touch the chin to the chest, vomiting or confusion;
• breathing becomes difficult.

See a doctor the same day if an eyelid or cheek swells and reddens suddenly, a temperature comes on and the eye moves less well. Book an appointment without delay if one side of the nose has not breathed for more than a few weeks, if blood comes repeatedly from one nostril, if the cheek goes numb, the upper teeth loosen, or a firm lump persists in the neck. None of this means you have cancer: in most people something else, and something quite treatable, will be found. But it needs checking by a doctor, not by a search engine.

Online consultation with a doctor

A remote appointment is useful at the first step, when it is unclear whether this is an ordinary cold or something else. The doctor will go through it in order: one side or both, how long it has lasted, whether there has been blood, whether smell has changed, what has already been tried and with what result, what you have done for a living. From those answers they will say whether family practice care is enough or whether an ENT specialist with an endoscope is needed, and how quickly.

Online is also a convenient place to work through what is already under way: what the CT or MRI report means, what to expect from the planned operation, what to ask the surgeon, how to look after the nose after treatment, what to do about dryness, crusting and loss of smell. The limits are obvious: looking inside the nose and taking a biopsy cannot be done through a screen, and heavy bleeding or sudden loss of vision calls for an ambulance rather than a conversation.

This material is for information only and does not replace medical advice.