Diseases Of The Nose Throat And Ear

90 THE NOSE AND PARANASAL SINUSES

is complained of in the affected side of the nose. There is often epistaxis, and
there may be pain either over the affected sinus or referred to the forehead.
The pain is due to the expansion of the walls of the sinus. On anterior
rhinoscopy the nasal cavity contains a pinkish-white, friable mass of wart-like
growth which bleeds readily on being probed. Radiography will demonstrate
the extent of involvement of the maxillary and ethmoidal sinuses. The tumour
mass should be removed through a wide Caldwell-Luc approach. The mass is
followed upwards and removed from the ethmoidal cells and from the nasal
cavity, and a large counter-opening is made. The use of radium, either as an
implant or as radiotherapy, has been advocated. The tumour mass must be
examined histologically at every removal for evidence of malignant degenera-
tion, although this is uncommon.

Fibroma. Fibroma is rarely found within the sinuses as a soft, pedunculated
tumour which recurs after removal, and is liable to become sarcomatous. In
view of this it should be treated as a malignant tumour when the histological
report is available, and a course of radiotherapy given.
Angioma. Angioma uncommonly involves the ethmoidal cells and gives rise to
profuse epistaxis. It may be amenable to cryosurgery or to the injection of
sclerosing solutions, but very often diathermy removal after an external
approach is required, followed by radiotherapy or radium implantation.

MALIGNANT TUMOURS

Malignant tumours which develop primarily in the sinuses usually originate
in the maxillary or ethmoidal sinuses.

PATHOLOGY. The most common tumour is the squamous-celled carcinoma,
which accounts for 80 per cent of the cases. Adenocarcinoma, transitional-
celled carcinoma, sarcomata of various types—round-celled sarcoma,
myxosarcoma, fibrosarcoma, chondrosarcoma and lymphosarcoma—and the
melanomata such as melanosarcoma and melano-epithelioma may all be
found. The melanoma, sarcomata and carcinoma of the immature-celled type
are the most highly malignant.

SITE OF ORIGIN. Malignant tumours arise in the maxillary sinus, ethmoidal
sinuses, sphenoidal sinus and frontal sinus in that order of frequency, the
latter two being very rarely involved. It is often extremely difficult to determine
the exact site of origin as patients are not usually seen until the disease is
advanced and the tumour has spread beyond the original site. The one
exception is the adenocarcinoma which is found in the ethmoidal cells of
woodworkers in whom the disease may be discovered early because in certain
areas these workers are examined at regular intervals specifically for the
tumour.

CLASSIFICATION. Various classifications have been used over the years from
the point of view of prognosis. In general, a better prognosis is likely if the
tumour can be shown to arise from the antero-inferior part of the maxillary
sinus, while the outlook is poorer if the growth has its origin in the postero-
superior part of the antrum or in the ethmoidal sinuses.

SYMPTOMS. There are few early symptoms, which may explain why so many
cases are seen after considerable spread has occurred. When the tumour has
invaded the nasal cavity there is increasing unilateral nasal obstruction, a
bloodstained nasal discharge which is often foetid, pain in the cheek or teeth,