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.