Step 1 of 14
Presentation & Pattern Recognition
Local sinonasal · regional · orbital · otologic · neurological symptom clusters
Sinonasal malignancy hides behind common symptoms and presents late. The local sinonasal cluster — unilateral nasal obstruction, persistent or blood-stained rhinorrhoea, recurrent unilateral epistaxis, facial pain or pressure, hyposmia or anosmia, and headache — is the most frequent and the most easily dismissed as rhinosinusitis or a polyp. The discriminator is unilaterality and persistence despite medical treatment.
Spread beyond the sinonasal box produces telling clusters. Regional disease causes cheek swelling, facial deformity, loose maxillary teeth, palatal swelling or anaesthesia, and infraorbital (V2) numbness. Orbital invasion presents with proptosis, diplopia, epiphora, ophthalmoplegia, or visual loss. An otologic presentation — unilateral Eustachian-tube dysfunction or a persistent unilateral middle-ear effusion in an adult — points to the nasopharynx or skull base. Neurological features — cranial neuropathies, facial numbness, trismus, and skull-base pain — signal advanced perineural or skull-base disease. Recognising the cluster, not the individual symptom, is what brings the diagnosis forward.
- Local — unilateral obstruction, blood-stained rhinorrhoea, recurrent unilateral epistaxis, facial pain, hyposmia
- Regional — cheek swelling, facial deformity, loose maxillary teeth, palatal swelling/anaesthesia, V2 numbness
- Orbital — proptosis, diplopia, epiphora, ophthalmoplegia, visual deterioration
- Otologic — unilateral Eustachian dysfunction, adult unilateral middle-ear effusion
- Neurological — cranial neuropathies, facial numbness, trismus, skull-base pain
Key statistics
Sinonasal cancer — incidence
~0.5–1.0 / 100,000/yr
Population-based SEER data show sinonasal malignancies are rare — an annual incidence around 0.5–1.0 per 100,000 — with only modest survival gains over recent decades, underscoring late presentation.
★ High-yield pearls (chapter-wide)
- A unilateral nasal mass, unilateral obstruction, or recurrent unilateral epistaxis in an adult is sinonasal malignancy until proven otherwise — never settle for 'polyp' on one side.
- An adult with a persistent unilateral middle-ear effusion has a nasopharyngeal or skull-base tumour until imaging and endoscopy say otherwise.
- Image before you biopsy — a vascular tumour (juvenile angiofibroma, haemangiopericytoma) or a meningoencephalocele biopsied in clinic can bleed catastrophically or open the subarachnoid space.
- CT reads bone (erosion, remodelling, hyperostosis, calcification); MRI separates tumour from trapped secretions and defines orbital, dural, brain, and perineural spread — you need both.
- Perineural spread along V2 to the foramen rotundum, the vidian canal, and the cavernous sinus is the signature of adenoid cystic carcinoma — hunt for it on MRI before planning resection.
- Histology dictates strategy: SNUC and olfactory neuroblastoma favour induction or multimodality therapy; mucosal melanoma is surgery-led; sinonasal lymphoma is not a surgical disease at all.
- Every case goes through a skull-base multidisciplinary tumour board before treatment — rhinologist, skull-base and head-and-neck surgeons, radiation and medical oncology, neuroradiology, pathology, neurosurgery, ophthalmology, and prosthodontics.
- Send fresh tissue and request flow cytometry whenever lymphoma is on the differential — formalin alone can lose the diagnosis.
- Endoscopic resection matches open craniofacial resection for selected nasoethmoidal tumours with experienced hands — but frontal sinus, lateral maxillary, hard-palate, lacrimal, or massive intracranial disease still drives an open approach.
- The vascularised nasoseptal flap transformed anterior skull-base reconstruction — plan flap availability before resection, because prior surgery or tumour may have destroyed the pedicle.
Evidence base
4 sources- HIGH
Llorente JL, López F, Suárez C · Nat Rev Clin Oncol · 2014ReviewPMID 24935016
Comprehensive review anchoring epidemiology, risk factors, histologic/molecular classification, and treatment principles across the chapter.
- HIGH
Kuan EC, Wang EW, Adappa ND · Int Forum Allergy Rhinol · 2024International consensus statementPMID 37658764
ICAR multidisciplinary consensus on sinonasal tumours — the contemporary reference standard for evaluation, staging, and management across histologies.
- MOD
Dulguerov P, Jacobsen MS, Allal AS · Cancer · 2001Outcomes series + systematic reviewPMID 11753979
Large series and systematic review anchoring histologic distribution and outcome by subsite and stage.
- MOD
Turner JH & Reh DD · Head Neck · 2012Population-based analysis (SEER)PMID 22127982
SEER analysis anchoring the rarity (~0.5–1.0/100,000) and modest survival trends of sinonasal malignancy.
Decision tree
The triage screen is the first gate. Classification routes the stable patient to one of the aetiology-keyed pathways below. Cross-cut cards capture the chapter's must-not-miss rules.