There is a rich blood supply to the nose from the nasal, facial and palatine arteries, which branch off the large “external carotid” arteries which supply the face. The “internal carotid” arteries are deeper and the main source of blood for the brain. Blood is also drained by similarly named veins into the large “jugular veins”, which return it to the heart. Thus the bloodstream can be a route for disease spread, called “hematogenous dissemination”. There is also a network of “lymph channels” which
collect the tissue fluid (which has seeped out of blood vessels to bathe individual cells), and this fluid is sent to local pea-sized bean shaped “lymph nodes”. These nodes, also called “glands”, swell up when invaded by germs, allergens or cancer. This swelling is called “lymphadenopathy”, and is most commonly observed in the lymph nodes of the neck. The lymph nodes, which are filled with white blood cells, interconnect (there are about 700 of them in the head and neck) and act as filters to purify the blood serum [note-- serum is the liquid portion of the blood, as distinguished from the blood cells]. . Eventually the purified blood serum is returned to rejoin the bloodstream in the region of the heart. However, this lymph system can also act as a conduit for the spread of cancers or infections, a process called “lymphogenous dissemination”. Prior to spread by the bloodstream or lymph system, nasal diseases, including cancer, tend to grow large in their local area, but occasionally the first symptoms seen are due to more distant spread of disease.

What is Nasal Cavity Cancer?

Fortunately, most conditions affecting the nasal cavity are not cancer, but rather “benign” afflictions. This includes infection of the nose (“rhinitis”), a continuously runny nose (“rhinorrhea”) and stuffiness due to allergies (“allergic rhinitis”). Also, since there are many small “capillaries” in the nose (where the smallest arteries join the smallest veins) nosebleeds (“epistaxis”) are common. Bleeding can be initiated by irritation, dry air, trauma, excessive sneeing, high blood pressure, infections or cancer and are harder to control when they occur deep within the back portion of the nose. In general, cancer is the LEAST likely cause of nasal problems.

Cells in the nose are subjected to lots of injury from heat and abrasion, dust and germs breathed in, and thus must divide frequently to replace those lost due to injury and old age. Normally, cells divide quickly as we develop in the womb and through infancy, and then the rate slows down considerably, just to replace cells that die. The division of cells in the nose and elsewhere is under very tight control, regulated by the “genes” within the cells. When this control is lost, the cells may start to divide in a haphazard, uncontrolled manner, and grow to form a swelling of abnormal cells, called a “tumor”. A “benign” tumor only grows within it’s local area, it does not spread to distant organs, and it is not cancer. In contrast, a “malignant” tumor can spread to any area of the body, it is cancer. It is this ability to spread, or “metastasize”, to vital organs which makes a cancer so dangerous. Nasal cancers tend to grow large locally before spreading, but any cancer can spread at any time.

How Common is Nasal Cavity Cancer?

Nasal cancer is relatively rare. Each year in the United States there are about 1000 new cases of nasal and paranasal sinus cancer leading to about 300 deaths annually from this disease. Men are affected twice as often as women. Overall, nasal cancer represents less than ) 0.5% of all new cancers each year, affecting one out of 100,000 Americans. and it is more common in blacks than whites, and in those of “lower socioeconomic status” (poor people). The average patient is 60 years old. However, some rarer subtypes of nasal cancer (esthesioneuroblastoma and nasal lymphoma) occur primarily in patients under between 20 and 40 years old. The disease is more common in Asia Minor and China than the Western Countries, and worldwide appears to be slowly increasing-- probably owing to better detection.

What Causes, or Increases the Risk, for Nasal Cancer?

Like any cancer, the reason why one person develops Nasal Cancer and another does not remains unknown. However, by studying groups of patients for common features, we have established certain “risk factors” that , if present, raise the risk:

1) Tobacco usage-- This is the single strongest risk factor for developing cancers of the head and neck. Any form of tobacco taken through the mouth, whether smoked or chewed, increases the risk over time. The more tobacco that is used, for a longer period of time, the higher the chance is to get cancer. Likewise, when use is stopped, the risk declines to normal over a 5 to 10 year period.

2) Infections such as syphilis and some viruses can lead to cancer over time, these cause sores which heal poorly. The constant attempt to heal leads to "chronic cell division" and thus more chance for cancer. Viruses can also get into the cells of the nose themselves and change the genes in them to form a cancer cell. This elaborate process is called "Oncogene Activation". Another process called “Suppressor Gene Inactivation” can allow a damaged cell (which should not divide) to go about division anyway. The most common virus noted to do this in the upper respiratory tract is the Human Papillomavirus (HPV). Some people seem genetically predisposed to getting cancer from viruses.

3) Lowered Immunity such as from AIDS or transplant anti-rejection drugs will increase the risk for many cancers, including those of the "aero-digestive tract" (i.e. the area from the nose and mouth to the lungs and stomach). This will be especially important in combination with the other risk factors noted.

4) History of Cancer of the aero-digestive tract can mean as much as 5% chance of a separate already present (“simultaneous”) cancer, and a 25% chance of developing another (“metachronous”) cancer in this area over time (especially if risks like smoking are continued).

5) Breathing sawdust and smoke from certain fires increases the risk for nasal, nasopharynx and sinus cancers, probably from chronic irritation. This is believed one reason why these cancers are more common in the Far East, where people still use many open-smoke fires to cook food.

A “symptom” is something that the patient feels, such as a headache or fatigue, while a “sign” is something that can be measured by the doctor, such as weight loss or lymph gland swelling. A cancer must grow to 1 billion cells to be just 1 cm. (about 1/2") across, so a very early cancer will have no symptoms and likely to go undetected. As it grows, it produces symptoms in it's local area, and eventually in distant areas as it spreads. A nasal cancer may actually be noticed before other cancers of the sinuses or nasopharynx, since it tends to cause a blocked nose early. However, this may just be attributed to allergy or “sinus infection”. The way a patient appears when they first come to their doctor is called the “presentation”. The most common presenting symptoms and signs of nasal cancer noted by patients are:

1) Nasal obstruction, nasal discharge, smell loss, and sinus congestion, are so commonly associated with non-cancerous conditions that they are frequently neglected until the disease is advanced. Bleeding (“epistaxis”) may occur. The cancer may erode through the palate into the mouth, and first be noted by a dentist.

2) Breathing problems, frequent headaches, a lump in the nose or neck, pain or ringing in the ear, speech difficulty, or trouble hearing. Swallowing and eating may be mechanically obstructed as the cancer grows down into the throat.

3) Local pain is possible as the tumor enlarges, especially if it invades nerves. The nose shares nerves with the ear, mouth and throat, so some deep nasal cancers cause pain in these areas ('referred pain') Interestingly, the further back in the nose the cancer, the deeper in the ear the pain appears.

4) Swelling in the Neck or Face is possible as the lymph nodes are invaded. The nose has a rich blood and lymph supply (in contrast to the sinuses which have a poor supply), and 15% of patients will have involvement of the lymph glands in the neck when they first “present” for medical attention. An additional 15% will develop neck lymph gland swelling further along in their disease. This swelling is usually firm and painless. Neck lymph nodes can also swell up from non-cancerous conditions such as infection, so swelling alone does not prove cancer. However, larger, harder and more persistent swellings are more likely to be cancerous. Also, as a cancer advances, it is likely for the area to become infected by germs in the area, so lymph nodes can be swollen from both cancer and infection at the same time. Other lymph nodes which may swell are in the cheeks (“buccinator nodes”), under the chin (“submental nodes”) and at the back of the neck (“occipital nodes). If the cancer invades into the nasopharynx, the chance of lymph node swelling is over 80%.

5) Nerve Problems in the eyes, face and neck occur as the cancer invades into the cavernous sinus nearby the brain ("Jacod's syndrome") or into lymph glands that press against the nerves exiting the base of the skull ("Villaret's syndrome"). These nerve problems present as double vision (“diplopia”), deviation of the eyes (so they do not turn together (“conjugation”), weakness of the muscles of the face, and/or difficulty with swallowing, turning the head, or lifting a shoulder.

6) Signs of Distant Spread, to lung, liver, bone, and brain with advanced disease.

The behavior of a disease in the average patient is called it's "natural history". Recall that cancer starts in a single cell, which divides in an uncontrolled manner to make millions and billions of copies of itself. It generally starts on the surface of of the nasal cavity (the “mucosa”) and gradually penetrates deeper. As it goes deeper, it can invade lymphatic channels and spread to local lymph nodes in the neck. It may invade nerves and cause pain, and into underlying bone to destroy it. Commonly, an untreated nasal cancer will grow larger and larger in it's local area ultimately become a huge, infected and bleeding “mass”. The extent of the mass may not be appreciated merely by looking up into the nose, since it can have “local extension” which is unapparent to the naked eye. It may then protrude through the skin to form a gaping and seeping wound, and spread via the bloodstream to distant organs. Ultimately, Nasal cancer kills by anemia, infection, malnutrition, dehydration and general debility.

How is Nasal Cancer Diagnosed and Evaluated?

If a patients comes to their physician with symptoms and signs suggestive of a nasal cancer problem, they are commonly referred to a specialist called an “Ear, Nose and Throat” (“ENT”) doctor or “Otolaryngologist”. While some of these “ENT”s confine their practice to lesser problems like allergies and ear infections, they are all by training “Head and Neck Surgeons” and some sub-specialize in treating cancers. The most experienced “Head and Neck Surgeon Otolaryngologists” are found at Academic University Hospitals.

Examination of the a patient with a new neck lump (“mass”) should include inspection of the ears, nasal cavities, mouth and entire throat [nasopharynx, oropharynx, hypopharynx, and larynx (voice box), palatine tonsils, and base of the tongue], as well as the thyroid and salivary glands. The only way to absolutely diagnose any cancer is to get a piece of it ("biopsy") and analyze it under the microscope. A special instrument (called a nasoscope) may be put into the nose to see into the nasopharynx and back of the nasal cavities. If an originating site ("primary site") cannot be found the any area of cancer spread may be sucked up ("aspirated") with a fine needle for further evaluation to locate a precise site. These fine needle aspirations are 85% accurate at confirming or denying cancer in a suspicious swelling (“lesion”). Sometimes patients with cancer in lymph nodes of the neck have no evident “primary site” and then are diagnosed with a “Cancer of Unknown Primary Site”-- but these can usually be successfully treated in the Head and Neck. As long as we have something to biopsy, a “pathologist” will be called in to examine the biopsy specimen. This is a physician who specializes in making diagnoses from tissue samples. The usual steps in evaluation of a suspected Nasal Cavity cancer include:

1) Physical Examination is done carefully and includes a meticulous description of the tumor, including it's location, size, color, texture, and whether it is "fixed" to underlying tissue or can be moved about. the doctor looks for white patches ("leukoplakia") and reddish patches ("erythroplasia") which may be precancerous areas. A through exam of the neck is always done, noting any enlarged glands which may represent the cancer spreading to lymph nodes. the back of the throat is examined, and a mirror is used to visualize the vocal cords ("indirect laryngoscopy"). The nerves which arise from the brain (12 of the called "cranial nerves") supplying the face, eyes, ears, nose and throat are tested to look for signs of nerve invasion or compression by cancerous lymph nodes. Naturally, it is also appropriate to do a complete exam of the rest of the body to assess general health and look for signs of distant cancer spread.

2) Endoscopic Examination means placing a visualization tube under light local anesthesia into the nose and down the throat. the preferred procedure is a "triple endoscopy", which looks at the nose, esophagus and larynx (voice box). Clear Endoscopic visualization of the larynx is called "direct laryngoscopy". A biopsy is taken of any suspicious area, and sometimes "blind biopsies" are taken of areas most likely to develop cancer (such as the tonsil, nasopharynx, pyriform sinus and bse of the tongue). This is also done since, as mentioned 5% of patients will have a "second primary" when they come to medical attention-- that means another simultaneous cancer. Endoscopy is a very safe procedure, and is the clearest way to actually look at tissues of the aero-digestive tract, and take samples for pathologist evaluation (the endoscope has a cutting scissors at its end to take biopsies).

3) Blood and Urine Tests are standard preoperative ones to assess general health; there are no special blood tests ("tumor markers") yet to detect spread of squamous cell cancer as there are for some other cancers. Routine tests include Complete Blood Count ("CBC") to look for anemia and infection. A Blood Chemistry Panel ("SMA") measures sodium, potassium, calcium, phosphorus, blood sugar, cholesterol and liver and kidney function. If a major surgery is contemplated , blood tests for clotting ability (PT, PTT and bleeding time) are standard. A Urinalysis (UA) to check for protein, blood, or infection completes the lab tests.

4) Imaging Tests are done in the radiology department and standardly include a Chest X-ray to look for signs of infection or lung tumors. Special imaging of the head and neck is obtained; a "panorex" is a series of jaw X-rays which is excellent for detecting spread of cancer to local bone. A CT scan in "thin slices" of the “sinonasal” area helps define the extent of the tumor. It can tell whether normally unexaminable lymph nodes (such as the “retropharyngeal” or “parapharyngeal” nodes are enlarged). Slices should be 3 mm. or less, 5 mm. (standard at some institutions) is NOT acceptable for nasal cancers. CT scan with Contrast (given by vein) is almost always used since it is valuable in detecting spread into the sinuses or brain. Insist on “omnipaque” or equivalent contrast, it is more expensive but also more comfortable and less likely to cause an allergic reaction or kidney damage. The more expensive Magnetic Resonance Imaging (MRI) scan has become increasingly popular. MRI, which uses magnetism instead of radiation, allows the area to be viewed in three dimensions. It is great for looking at the tumor as well as checking local muscle, cartilage and nerves for signs of invasion by cancer. In general, it is superior to CT scan for checking soft tissues of the head and neck.

An MRI with Contrast can be given with an different agent called “gadolinium”, which highlights blood vessels and increases the ease of reading the scan. Lymph nodes of the neck are not routinely studied with Nasal cancer unless the cancer has spread to the nasopharynx, facial lymph nodes, or if there is evident (“clinical”) swelling of neck lymph nodes. Other more exotic tests are only obtained in the presence of suspicious symptoms. For instance, a Bone Scan is gotten if there is new bone pain. A CT of the Chest and Abdomen is obtained if the plain Chest X-ray appears to show tumor in the lung, and a CT of the Brain is gotten if new neurological symptoms occur. Ultrasound is not useful for head and neck cancer. “Angiography” means injecting some contrast dye into a face or neck artery and taking rapid pictures, it plays a small role for tumors with lots of blood vessels (“highly vascular”)-- but much of the same information can be gotten today on a contrast MRI (“MRA”) scan. There are special tests which can be ordered to look at just about any area of the body-- but only if necessary. In general, a test should only be ordered if the therapy may be changed based upon its results!

5) Biopsy of the tumor is crucial, since only by examining an actual piece of the tumor under the microscope can a diagnosis of cancer be made, and the particular type known with certainty. For a small tumor, the whole of it may be removed along with a "safety margin" of surrounding normal tissue, and sent fro evaluation ("Excisional Biopsy"). For a larger tumor, a cut is made into it so some tissue can be removed for examination ("Incisional Biopsy"). Sometimes a swollen gland in the face or neck may be the easiest (or even only) area to biopsy. It usually takes several days (of anxious waiting) for the pathology report to come back.

The nose is a brilliantly designed organ which functions in breathing, germ killing, smell, and appearance. It is formed of a small protrusion of bone from the skull, called the nasion, upon which cartilage is molded to form it's shape. The area where the nose attatches to the highest part of the throat is called the "nasopharynx", and this is considered a different area as far as cancers are concerned. Cancer is rare in the nose proper, and is usually an extension of skin cancer going up into the nose.

It is crucial to get proper diagnosis and prompt treatment for a nose cancer problem. Selecting the right treatment can make the difference between getting or not getting acceptable cosmetic results, or even the difference between life and death. Understanding your options for a Nasal Cavity Cancer problem will give you the peace of mind of knowing you have done everything possible for a happy outcome.

Cancers of the lungs, throat, nasal cavity and other asbestos related cancers are very harmful, though they are preventable. Mesothelioma has a very low survival rate, so contact a mesothelioma attorney if you think you've been diagnosed.