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Nose and Sinus Cancers

If an adult in your life has sinonasal cancer, you may want to learn more about it. This page has information about sinonasal cancer, its types and what to expect.

First, you should understand what cancer is. Cancer is a disease of unhealthy cells. Our bodies are made of cells so tiny you need a microscope to see them. Cancer cells don’t look or act like normal cells, and they grow much more quickly. There are many different types of cancer that can grow anywhere in the body.

Cancers on the outside skin of the nose are typically skin cancers, so see that section if you’re interested in learning more about cancers on the outside of the nose. This section covers cancers inside the nose (the nasal cavity) and the paranasal sinuses (air-filled spaces in the head around the nasal cavity). These are called sinonasal cancers.

Of all sinonasal cancers, maxillary sinus cancers are the most common, followed closely by cancers of the nasal cavity and ethmoid sinus cancer. Sphenoid and frontal sinus cancers are very rare.1Dulguerov P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra T. Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review. Cancer. 2001Dec 15;92(12):3012-29. Most cancers in the inside of the nose are squamous cell cancers. However, a number of tumors in this are benign (non-cancerous), including:

  • Papilloma
  • Pyogenic granuloma
  • Adenoma
  • Dermoid
  • Glioma
  • Fibroma
  • Osteoma
  • Chrondroma
  • Hemangioma
  • Neurofibroma
  • Lymphangioma

Technology has helped us diagnose these cancers better. Doctors can use nasal endoscopy (telescopes and cameras inside the nose) to see areas we can’t just by looking in the front of the nose. Also, advances in MRI and CT scanning help us look at the anatomy inside the head much better. Finally, tests like PET scans may also help with diagnosis and understanding the extent of cancers in this area. We also have many more tools to treat cancers in this complex area, which has several important structures nearby.

Here are some facts about sinonasal cancers:

  • Are less than 1 percent of all cancers
  • Are approximately 3 percent of head and neck cancers
  • Usually affect adults older than 45 years old
  • Affect caucasians more than other races
  • Affect males more than females

Your loved one may have noticed a problem in his or her nose or sinuses and then went to the doctor to get it checked. Not every lump or pain is cancer, but it is a good idea to ask a doctor when you are not sure. The earlier cancer is found, the better the outcome can be.

Understanding the anatomy

To understand sinonasal cancer, you need a basic understanding of the anatomy (parts) of your head and neck.

The inside of the nose is called the nasal cavity. It is actually bigger than many people think and has many structures inside it. Basically, there is a left and right nasal cavity. The sides are divided by the nasal septum. The nasal cavity on each side opens into the nasopharynx through the choana.

43_nasalcavity

The paranasal sinuses are air-filled spaces in the head. The sinuses are closely related to some major structures. They are near the brain, the eyes, the carotid artery, the teeth and important nerves in the head and neck area.

44_sinuses

Causes of sinonasal cancer

You may want to know what caused the sinonasal cancer. The short answer is that we don’t know. You can be sure that you did nothing to cause it. Also, it is not contagious (you can’t catch it).

In most cases, it’s a combination of genetics (inherited traits) and the environment.

Tobacco use may increase a person’s risk of developing sinonasal cancer. Researchers also now believe that exposure to certain chemicals in the workplace may increase the risk as well. Workers who may be at increased risk include2, Leclerc A, Martinez Cortes M, Gérin M, Luce D, Brugère J. Sinonasal cancer and wood dust exposure: results from a case-control study. Am J Epidemiol. 1994 Aug 15;140(4):340-9.3, Brinton LA, Blot WJ, Becker JA, Winn DM, Browder JP, Farmer Jr JC, Fraumeni Jr JF. A case-control study of cancers of the nasal cavity and paranasal sinuses. Am J Epidemiol. 1984 Jun;119(6):896-906.4Battista G, Comba P, Orsi D, Norpoth K, Maier A . Nasal cancer in leather workers: an occupational disease.J Cancer Res ClinOncol. 1995;121(1):1-6.:

  • Nickel workers (including nickel refineries, cutlery factories and battery manufacturing)
  • Chromium workers (including chrome plating and chromium production)
  • Leather workers
  • Woodworkers

 

Signs and symptoms of sinonasal cancer

Sinonasal cancer can appear in many different ways, depending on where the cancer is located. For early cancers, there might not be any symptoms, or symptoms may seem like allergies, sinusitis or nasal polyps. Generally, if a nasal polyp or something unusual is seen on only one side of the nose, the doctor might be more worried that it could be cancer and should be further evaluated by a biopsy (testing).

Some common symptoms include:

  • Nasal obstruction (feels like something is in the way)
  • Sinus pain, pressure and infections
  • Change or loss of sense of smell
  • Bleeding from the nose, particularly if only on one side (known as epistaxis)
  • Hearing loss due to fluid in the middle ear

When cancers in this area get larger, the symptoms will depend on what nearby structures are involved.

  • A tumor growing out of the nose
  • Change in vision or double vision
  • Pain
  • Recurrent sinus infections
  • Numbness in part of the face
  • Growth in the roof of the mouth from cancer growing downwards
  • Brain infection

These symptoms sound scary, but don’t jump to conclusions. The person could have one or more of these symptoms but NOT have sinonasal cancer. There are several non-cancerous causes of the same symptoms. That’s why they need to see a specialist.

What will happen at the doctor visit

Step 1: History

First, the doctor will listen to the patient talk about his or her health. The doctor will probably ask many questions, too.

The doctor might ask some of these questions:

  • How long has the problem been there?
  • Is it getting worse, better or staying the same?
  • Does it come and go?
  • Have you tried anything to make it better?
  • Is it painful?
  • Do you have numbness or tingling anywhere in your face or mouth?
  • Do you have any changes in your vision or hearing?
  • Do you have a change in your sense of smell?
  • Do you have any lumps or bumps in your neck?
  • Are you losing weight?
  • Do you have any other medical conditions?
  • Have you had any surgeries in the past?
  • What medications do you take? And do you have any allergies?
  • Have you ever been exposed to radiation in the head and neck?
  • What do you (or did you) do for a living?
  • Do you have a family history of cancer?

Step 2: Physical Exam

Next, the doctor will look at and feel the patient’s head and neck. The nasal cavity and sinuses typically require a specialist to examine them because they are hard for a general doctor to see and feel. In general, the specialist might do some of the following:

  • Look and feel inside the mouth
  • Feel the neck extensively and carefully to check for any lumps or bumps
  • Look inside the ears
  • Look inside the front of the nose
  • Check the cranial nerves, do some simple hearing tests and test sense of touch all over the face

The doctor may also perform some special examinations using a sinonasal endoscope. Sinonasal endoscopy is a way to look far inside and around the nose and into the openings of the different sinuses. This method uses a tiny camera on the end of a long flexible tube. The camera is inserted into one of the nostrils and can go deep into the nasal passages and the sinus cavities.

Step 3: Reviewing Tests

After getting background information and doing a physical exam, the doctor will look at the results of any tests the patient has already had.

Step 4: Suggestions

Finally, the doctor will make suggestions about next steps. This will probably include more tests and doctor visits.

Diagnosing sinonasal cancer

If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less worried that the lesion is cancer, the doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

However, if the doctor is concerned, he or she may choose one or more of the following diagnostic tests.

Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside the head and neck. In general, imaging might not be necessary for small tumors that can be easily seen by the doctor. For larger tumors, or tumors in locations difficult to examine, the doctor will probably order some sort of imaging to get more information about the tumor location to see if the tumor has spread to nearby lymph nodes. An important reason to get a scan for sinonasal tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment the doctor recommends.

Some surgeons also say getting imaging (pictures of the inside of the head and neck) will lower the chance of surprises in the operating room. Imaging will also give some clues about whether the tumor is really cancer. This will prepare the patient and the surgeon for what to expect during surgery.

There are many different kinds of imaging scans. The doctor may recommend more than one kind of scan to see a better picture of the tumor.

The two main types of imaging used in the U.S. are CT scans and MRI scans.

CT SCAN MRI
 CT Scan  MRI
Advantages A computed tomography (CT) scan is a quick test that shows a great deal of useful information. A CT scan can show the size of the tumor and how far it has spread. It can help a surgeon plan an operation. Magnetic resonance imaging (MRI) is better at showing how the tumor has spread to body parts around it. The patient will not be exposed to radiation during an MRI.
Disadvantages A CT scan uses radiation, which can be dangerous. The pictures might not be clear if the patient moves or has a lot of dental work. Also, a CT doesn’t show damage to nearby body parts as clearly unless the damage is moderate to severe. An MRI takes a lot longer than a CT scan. It requires the patient to lie perfectly still for almost an hour. The patient can’t have an MRI if he or she has metal implants.

For most head and neck cancers, if imaging is required, the doctor will likely start with a CT scan with contrast. Other tests might include an MRI and/or a positron emission tomography (PET) scan.

Biopsy

A biopsy is the best way to find out if a growth is cancer. For a biopsy, the doctor takes out a small piece of the lump or the entire tumor. Another doctor, called a pathologist, then looks at the sample under a microscope to see if it is cancer. Doctors often do biopsies because they can usually be done quickly and safely. The doctor can sometimes do a biopsy during the first visit, and there is a very low chance of anything going wrong.

Fortunately, many sinonasal lesions can be biopsied in the office with a little numbing medicine (either a spray or a tiny injection or both). It usually takes just a few minutes to do the biopsy.

In some cases, however, the doctor may want to do the biopsy in the operating room, especially if there is concern that the tumor has spread to the neck or throat.

Sinonasal biopsies can sometimes be performed with forceps inserted into the nose. They can also be done with an endoscope, which is a long flexible camera that can be inserted deeper into the nasal passages or sinus cavities. If there is also a lump in the neck, the doctor may decide to take a sample of that as well to see if cancer has spread to the lymph nodes in the neck. This can be done with a needle (called fine needle aspiration biopsy or FNAB) or during open surgery.

As good as biopsies sound, there are a few problems. First, biopsies are not 100 percent accurate. A biopsy could show that a growth is NOT cancer when it really is; this is called a false-negative biopsy. A false positive is also possible when the biopsy seems to show that a growth is cancer but more testing shows it isn’t. Experienced pathologists are far less likely to give a false positive or negative result as long as they have an adequate sample of tissue. Sometimes doctors can’t be completely sure a tumor is cancerous from a biopsy.7Marcus DM, Marcus RP, Prabhu RS, Owonikoko TK, Lawson DH, Switchenko J, Beitler JJ. Rising incidence of mucosal melanoma of the head and neck in the United States. J Skin Cancer. 2012;2012:231693.

Determining the type of sinonasal cancer

Only after a pathologist analyzes some cells or actual pieces of tissue from the lesion will the doctor be able to tell if it is cancer. The doctor may also want a second opinion from a specialist to be sure. Remember, not all lumps and bumps inside the nose and sinuses are cancer. Most growths are benign (non-cancerous), and some tumors are on the border between benign and malignant (cancerous).

In many cases, borderline growths should be removed with surgery. Examples of these types of tumors are:

  • Schneiderian papillomas: These might be related to human papillomavirus (HPV) infections, and they can be found on the front part of the nasal septum (fungiform-type) or on the lateral nasal wall (inverted and cylindrical types). There is a chance of squamous cell carcinoma within some of these papillomas, so they should be surgically removed.

Other borderline tumors include:

  • Angiofibroma
  • Ameloblastoma
  • Fibrous dysplasia
  • Ossifying fibroma
  • Giant cell tumor
  • Myxoma

However, some lesions in the nasal and sinus cavities are in fact cancer. The best way to categorize these types of tumors is based on the cell type from which the cancer started.1, Dulguerov P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra T. Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review. Cancer. 2001Dec 15;92(12):3012-29.5Katz TS, Mendenhall WM, Morris CG, Amdur RJ, Hinerman RW, Villaret DB. Malignant tumors of the nasal cavity and paranasal sinuses. Head Neck. 2002Sep;24(9):821-9.

Epithelial-based cancers start in the surface layer of skin or the lining of organs and glands. They include:

  • Squamous cell carcinoma: These are cancers that start in the lining of the nasal cavity and sinuses. There are a few subtypes of squamous cell carcinomas, some more aggressive than others. Examples include verrucous squamous cell carcinomas (which have less tendency to invade deeply), basaloid squamous cell carcinoma and well-to-poorly differentiated squamous cell carcinomas.6Wieneke JA, Thompson LD, Wenig BM. Basaloid squamous cell carcinoma of the sinonasal tract. Cancer. 1999 Feb 15;85(4):841-54.
  • Minor salivary gland cancers: These cancers affect minor salivary glands located in the nasal cavity and sinuses. Cancer types in this area include:
    • Adenocarcinoma (see below)
    • Adenoid cystic carcinoma
    • Mucoepidermoid carcinoma
  • Adenocarcinoma: This type of minor salivary gland cancer arises from gland-like elements in the lining of the sinonasal tract or from salivary glands in the nasal cavity. Adenocarcinoma is the second most common type of sinonasal cancer.
  • Melanoma: These cancers come from skin cells that give skin its color. In rare cases, melanoma can be found in the lining of the mouth, nose and/or throat; this is called mucosal melanoma.7Marcus DM, Marcus RP, Prabhu RS, Owonikoko TK, Lawson DH, Switchenko J, Beitler JJ. Rising incidence of mucosal melanoma of the head and neck in the United States. J Skin Cancer. 2012;2012:231693. Actually, approximately two-thirds of all mucosal melanomas start in the nasal cavity and paranasal sinuses (another one-third begin in the oral cavity, and the rest are in various mucosal sites of the head and neck, such as the throat).8Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010.Chapter 9: Mucosal Melanoma of the Head and Neck. These are aggressive cancers, even when small.
  • Olfactory neuroblastoma (esthesioneuroblastoma): This very rare cancer is thought to begin from the tissue lining in the roof of the nose that is responsible for smell.
  • Sinonasal undifferentiated carcinoma (SNUC): This is a rare but very aggressive cancer. It is unclear what the cell of origin is. It often involves multiple sites.9Ejaz A, Wenig BM. Sinonasal undifferentiated carcinoma: clinical and pathologic features and a discussion on classification, cellular differentiation, and differential diagnosis. Adv AnatPathol. 2005May;12(3):134-43.
  • Neuroendocrine carcinoma: This is a type of cancer that begins in special cells that are a cross between endocrine cells (which produce hormones) and nerve cells. Neuroendocrine carcinoma can be found anywhere in the body, including the gastrointestinal tract, brain or lungs.10Perez-Ordonez B, Caruana SM, Huvos AG, Shah JP. Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses. Hum Pathol. 1998 Aug;29(8):826-32.

Non-epithelial-based sinonasal cancers include11Spiro JD, Soo KC, Spiro RH. Nonsquamous cell malignant neoplasms of the nasal cavities and paranasal sinuses. Head Neck. 1995;17:114-118.:

  • Sarcoma: These soft tissue tumors start in different types of tissues, including fibrous tissue, cartilage, bone, muscles and blood vessels, to name a few. Some examples of sarcomas found in the sinonasal area include:
    • Fibrosarcoma
    • Hemangiopericytoma
    • Angiosarcoma
    • Kaposi’s sarcoma
    • Rhabdomyosarcoma
    • Malignant fibrous histiocytoma
    • Chrondrosarcoma
    • Osteogenic sarcoma
  • Lymphoma: Lymphoid tissue is located all over the body, so lymphoma might appear as a lump in the sinonasal area.
  • Chordoma: This rare bone tumor occurs along the spine. Even more rarely, spread of cancers from other sites could show up in this area as a metastasis. This includes spread of lung, kidney, breast or ovarian cancer.

Even more rarely, spread of cancers from other sites could show up in this area. This includes spread of lung, kidney, breast or ovarian cancer.

The doctor will determine the treatment for the cancer based on the category (type), grade (abnormality) and stage (severity) of the tumor.

Determining the grade of the tumor

Pathologists will typically report on the grade of the tumor. This is the pathologist’s interpretation of how much the cancerous cells resemble normal tissue from that site. There are a number of different grading systems that might be used. The most common is as follows:

  • GX: Grade cannot be assessed
  • G1: Well differentiated
  • G2: Moderately differentiated
  • G3: Poorly differentiated
  • G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumor or lesion resemble normal cells from the healthy tissue surrounding the tumor. “Well differentiated” means that the cells look similar to normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumor’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this particular cancer type.

Determining the stage of the cancer

The final step before treatment is identifying the stage or the extent of the cancer. This will be determined by the physical exam, imaging studies, laboratory work and biopsies.

As with all cancers of the head and neck, doctors in the U.S. use the AJCC Cancer Staging Manual (7th Ed) to figure out the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

Note that there are different staging systems for maxillary sinus cancers versus ethmoid and nasal cavity cancers. Those staging systems apply to all forms of carcinoma (hence, they do not apply to mucosal melanoma, lymphomas and sarcomas). Mucosal melanomas of the head and neck have their own staging system as well.

You may hear people refer to your loved one’s cancer by a stage number. In general, Stage I cancer is limited to one tumor site and has not spread beyond that location. Stage IV usually refers to cancer that has spread to distant sites elsewhere in the body. Treatment of cancer that is caught in lower stages generally has a better outcome than cancer found after it has progressed to later stages.

Deciding on a treatment plan

Like with all cancers in the head and neck, there are three general treatment options, which may be used alone, together, or one after the other:

The latest National Comprehensive Cancer Network (NCCN®) Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers will help the doctor suggest the best treatment.12Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. Let’s look at the types of treatments available.

Surgery

The main treatment for almost all sinonasal cancers is complete surgical removal of the tumor. The surgeon will remove the tumor plus a little bit of normal tissue around it to be sure to get all the cancer. Another doctor, called a pathologist, will look at the entire tumor under a microscope to identify a more exact stage for the tumor. This report, called the pathologic stage, can help the doctor decide if radiation and/or chemotherapy are needed.

Radiation

Radiation therapy kills cancer cells with high-energy radiation such as X-rays or gamma rays.11Spiro JD, Soo KC, Spiro RH. Nonsquamous cell malignant neoplasms of the nasal cavities and paranasal sinuses. Head Neck. 1995;17:114-118. Radiation may be used as a main treatment for tumors that cannot be easily removed. The surgeon will use radiation alone or radiation with chemotherapy, depending on the characteristics of the tumor. Radiation is also often used after surgery to lower the chances that the tumor will come back.

Chemotherapy

Chemotherapy, or “chemo,” uses drugs to kill cancer cells. It can be used alone or with radiation.

Determining the prognosis

The prognosis is a prediction of how the treatment will turn out. How likely is it that a person with cancer will be cured? Will the cancer come back? How will life change? These are the big questions on most people’s minds when they find out that someone they love has sinonasal cancer.

The following characteristics of the cancer may affect the chances of a cure.

Factors That Can Affect the Chances of Being Cured
Stage This is the most important factor that affects the chances of being cured. Cancers in earlier stages usually have better outcomes.
Type and Grade The type and grade of tumor show how aggressive a tumor is.
Spread to Lymph Nodes If there is spread to lymph nodes in the neck, there is a lower chance of a cure.
The Tumor Margins (edges) Some say the ability to completely remove the tumor is the single most important factor in whether a person will be cured.
Spread into Nearby Body Parts Spread into large nerves, skin and bone has been shown to indicate a worse prognosis.

In general, it is very difficult to discuss prognosis (outcomes) without understanding all the details of the cancer; to give a percentage chance of a cure is difficult because cancer research looks at all types of cancers and may include patients from long ago.

What to expect after treatment is completed

When the person in your life who has cancer has completed treatment, he or she will need to follow up closely with the doctor. Follow-up doctor visits and testing are to make sure the cancer doesn’t come back or to catch it quickly if it does. In general, a person who has completed treatment for head and neck cancer should have regularly scheduled doctor’s visits every one to three months for the first year, every two to six months in the second year and every four to eight months in the third to fifth year. In addition, the doctor will order scans to help in the monitoring process. After making it past the first five years, the person can then see the doctor once a year.12Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

Navigating sinonasal cancers

To learn more about a particular type of nose or sinus cancer, choose an article below.

Nasal Cancer

Nasal cancer begins inside the nose, in the nasal cavity. Explore this page to learn more about nasal cancer.

Sinus Cancer

Sinus cancer begins in the paranasal sinuses, the air-filled spaces inside the head. Explore this page to learn more about sinus cancer.


References

1 Dulguerov P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra T. Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review. Cancer. 2001Dec 15;92(12):3012-29.

2 Leclerc A, Martinez Cortes M, Gérin M, Luce D, Brugère J. Sinonasal cancer and wood dust exposure: results from a case-control study. Am J Epidemiol. 1994 Aug 15;140(4):340-9.

3 Brinton LA, Blot WJ, Becker JA, Winn DM, Browder JP, Farmer Jr JC, Fraumeni Jr JF. A case-control study of cancers of the nasal cavity and paranasal sinuses. Am J Epidemiol. 1984 Jun;119(6):896-906.

4 Battista G, Comba P, Orsi D, Norpoth K, Maier A . Nasal cancer in leather workers: an occupational disease.J Cancer Res ClinOncol. 1995;121(1):1-6.

5 Katz TS, Mendenhall WM, Morris CG, Amdur RJ, Hinerman RW, Villaret DB. Malignant tumors of the nasal cavity and paranasal sinuses. Head Neck. 2002Sep;24(9):821-9.

6 Wieneke JA, Thompson LD, Wenig BM. Basaloid squamous cell carcinoma of the sinonasal tract. Cancer. 1999 Feb 15;85(4):841-54.

7 Marcus DM, Marcus RP, Prabhu RS, Owonikoko TK, Lawson DH, Switchenko J, Beitler JJ. Rising incidence of mucosal melanoma of the head and neck in the United States. J Skin Cancer. 2012;2012:231693.

8 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010.Chapter 9: Mucosal Melanoma of the Head and Neck.

9 Ejaz A, Wenig BM. Sinonasal undifferentiated carcinoma: clinical and pathologic features and a discussion on classification, cellular differentiation, and differential diagnosis. Adv AnatPathol. 2005May;12(3):134-43.

10 Perez-Ordonez B, Caruana SM, Huvos AG, Shah JP. Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses. Hum Pathol. 1998 Aug;29(8):826-32.

11 Spiro JD, Soo KC, Spiro RH. Nonsquamous cell malignant neoplasms of the nasal cavities and paranasal sinuses. Head Neck. 1995;17:114-118.

12 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.