92 THE NOSE AND PARANASAL SINUSES
tumour. Biopsy should be performed under general anaesthesia to allow a
more thorough investigation of the site of the tumour and the extent of its
spread.
While malignant disease of the sinuses usually occurs in those over the age
of fifty, it must be remembered that children and young adults may also
suffer, particularly from sarcoma.
TREATMENT. This is a distressing condition to treat because in general the
tumour has advanced so considerably before advice is sought. Briefly, the
patient should be given first a course of irradiation by the linear accelerator or
the cobalt beam. The purpose of this is to reduce the bulk of the tumour, and
if this is successful surgical excision of the growth may be attempted. There
are two approaches: (i) a radical removal of the hard palate, the alveolus and
the lateral nasal wall which affords an entry into the maxillo-ethmoidal area;
and (ii) a lateral rhinotomy in which the incision starts below the inner end of
the eyebrow and continues down the lateral side of the nose close to the cheek
to the ala nasi. This offers a wide exposure for resection of the maxilla and the
ethmoidal cells. In either case a prosthesis will ultimately be required. If the
cervical glands are involved they are resected in the usual way. In the majority
of cases enucleation of the eye will be necessary.
Considerable experience is required to select cases for radical surgery.
Many are too far advanced when first seen, and their lot may be made worse
by surgery if there is extension of the tumour into the nasopharynx or the base
of the skull, or if there is gross involvement of the cervical lymph nodes, or in
those cases with distant metastases. Such patients should be treated by
palliative irradiation and local excision of the growth in the nasal and buccal
cavities.
Chemotherapy by cytotoxic drugs may be employed in these advanced cases.
There are a number of such drugs available, and their action depends upon the
vulnerability of tumour cells at the time of mitotic activity. Unfortunately, the
drugs have a similar effect on normal tissue by suppression of the bone
marrow so that therapy must be controlled by frequent blood counts. In
sinus tumours intra-arterial infusions of methotrexate are used giving 50 mg
in 24 hours through a plastic cannula which is introduced into the external
carotid artery through the superior thyroid artery. Folinic acid may have to be
injected intramuscularly in doses of 6 mg every 6 hours to combat the drop in
the numbers of white blood cells and platelets. Recently some antibiotic drugs
have been used, notably bleomycin, which may be injected intravenously or
intramuscularly. It is claimed that better results are obtained if radiotherapy
follows the administration of cytotoxic drugs.
PROGNOSIS. The outlook is grave in children and young adults and in the
more lethal types of tumour in adults. It is better in tumours of low malignancy
especially if these arise in the antero-inferior half of the maxillary sinus. Any
- spread to the nasopharynx or the base of the skull, or a gross involvement of
the cervical glands denotes a poor prognosis. In general, and in the best hands,
there is a 33 per cent survival rate 5 years after diagnosis of the tumour.
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