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Rhinectomy


Introduction

The nose is the most prominent part of the face defining an individual’s unique identity. It plays an important role functionally and aesthetically. However, the prominent position of the nose also accounts for its constant exposure to sunlight and thus for its predisposition to the development of cancer of the overlying skin. Thus surgical resection of the nose, rhinectomy, presents a difficult problem for both the patient and the surgeon. Rhinectomy is defined as the removal of the vast majority of the nasal framework and soft tissue. Rhinectomy involves not only surgical resection with adequate tumor margins but also reconstruction of the nose for satisfactory cosmesis. Surgical resection of the nose can be classified as a partial or total rhinectomy based on the extent of the excision. In head and neck surgery, the classical assumption of a wide surgical resection with control of margins is usually preferred; however, this may not be applicable for rhinectomy, due to anatomic limitations such as the orbit, skull base, and brain. Additionally, extensive resection may result in an unacceptable cosmetic defect that may cause rejection, depression, and other psychosocial problems.

The anterior nasal cavity is bounded by the bony pyriform aperture, hard palate, and external framework of the nose. The external nose is composed of bone and cartilage. The nasal septum divides the nasal cavity and connects with the nasal bones. It is continuous with the upper lateral cartilages anteriorly and medial crura of the alar cartilages inferiorly. The anterior nasal septum, lower lateral cartilages, and columella form the nasal vestibule. The nasal cavity is lined by ciliated mucosa and the nasal vestibule with stratified squamous epithelium.

Malignant tumors of the nose are quite rare and can be classified as internal and external cutaneous tumors. The majority of nasal tumors comprise external cutaneous cancers including basal cell carcinoma, squamous cell carcinoma, and melanoma, which commonly occur along the ala and dorsum of the nose. Most cancers of the nasal cavity are squamous cell carcinoma and adenocarcinoma. Among these cancers, squamous cell carcinoma is the most frequently encountered pathology that requires rhinectomy.

Rhinectomy is indicated only for extensive, aggressive, and recurrent cancers, including multicentric or large cancer, radiotherapy failures, or recurrent squamous cell carcinoma, or for palliative reasons such as in metastatic disease. In contrast to other locations, cancers originating from the columella or nasal vestibule behave aggressively. Because of the thin subcutaneous tissue along the columella and the vestibule, there is little soft tissue resistance against tumor spread. Therefore, cancers can easily invade bone and cartilage through periosteum or perichondrium and spread into the skin of the face. Infiltration of surrounding structures such as the upper lip, cheeks, and medial canthal regions may increase the risk of recurrence. Tumor eradication is much more complex, particularly in the medial canthal area due to the risk of orbital invasion. On the other hand, regional lymphatic metastasis is uncommon for both internal and external cancers of the nose. Neck dissection is only considered in clinically or radiographically evident lymph node involvement, except for cutaneous melanomas in which sentinel lymph node biopsy should be performed.

Key Operative Learning Points

  • Rhinectomy is not technically difficult, but reconstruction of the nasal framework is challenging.

  • The procedure is usually reserved for extensive or recurrent cancers of the nose, particularly in multicentric or large tumors, radiation failures, recurrent cancer, or for palliation in metastatic cancer.

  • Soft tissue invasion of the medial canthal region is challenging, due to the close proximity of the orbital structures.

  • Intraoperative assessment of the surgical margins by frozen sections is critical in the prevention of recurrence.

  • The patient should be informed preoperatively about the anticipated postrhinectomy defect and plans for reconstruction.

  • Neck dissection is not a routine part of the procedure. However, possible metastasis to cervical lymph nodes should be evaluated carefully preoperatively and in postoperative follow-up, particularly in squamous cell carcinomas.

Preoperative Period

The important functions of the nose, including olfaction, respiration, humidification, and filtration, as well as aesthetics, when compromised may give rise to psychologic and functional problems. The decision to proceed with rhinectomy should be taken only after the patient is informed regarding the extent of the excision and the types of reconstruction available. History of the presenting problems, physical examination, and imaging is essential to accurately plan the surgery. Invasion of the following structures should also be evaluated prior to surgical resection:

  • Adjacent structures of the nose: The hard palate, medial canthus, orbit, maxillary sinus, and skull base that broadens the extent of the dissection and results in extended rhinectomy

  • Regional lymph node metastasis: Though regional lymph node metastasis is rarely reported, examination must be done carefully. Examination should include all levels of the neck as well as the parotid lymph nodes. Depending on the presence of lymph node involvement, unilateral or bilateral neck dissection must be added to the primary surgery. This depends on the tumor type, which is particularly important in squamous cell carcinoma.

  • Distant metastasis: Positron emission tomography (PET)-CT is helpful to define the presence of regional lymphatic metastasis and rule out distant metastasis.

Once a rhinectomy has been performed, the greatest challenge is providing an acceptable nasal reconstruction plan. Preoperative planning for the type of the reconstruction is very important. Either reconstruction with a nasal prosthesis or flaps may be indicated.

History

  • History of present illness

    • Risk factors:

      • Tobacco and alcohol consumption

      • Radiation exposure

      • Occupational exposure to chemicals and particulates, such as nickel, wood dust, radium, mustard gas, and asbestos

      • Drug abuse

    • Symptoms and signs:

      • The otolaryngologist must be cognizant of the potential for a nasal malignancy in patients presenting with chronic symptoms, which may also present in benign and inflammatory diseases of the nose. These symptoms include nasal congestion, nasal obstruction, nasal discharge, epistaxis, nasal crusting, intermittent bleeding, septal perforation, epiphora, headache, and erythema of the skin.

      • Other more obvious symptoms or signs include a visible nasal mass, ulceration, loss of vision, swelling of the palate, and problems with denture fit.

  • Past medical history

    • In recurrent cancer, details of the previous treatment modality should be determined, including the extent and duration of surgery as well as treatment with chemoradiotherapy.

    • Comorbid diseases including systemic diseases and hemorrhagic diatheses

    • Family history

    • Medications, herbal products, and supplements taken by the patient

Physical Examination

  • Face

    Inspection of the face, particularly for extension of the cancer from the nose to surrounding structures such as the medial canthus or upper lip

  • Nose

    Palpation of the nose is critical because even with normal appearing skin, there may be tenderness or induration that may indicate a more insidious process.

    Anterior rhinoscopy and bilateral nasal endoscopy are important for a comprehensive evaluation of the patient presenting with a nasal mass.

    Before nasal endoscopy, appropriate decongestion and application of a topical anesthetic should be performed to provide optimal examination of the nasal cavity, nasopharynx, and sinus outflow tracts.

  • Oral cavity

    Examination may reveal a soft tissue submucosal mass, ulceration, or erosion of the bone of the hard palate.

    Inspection of the teeth and detection of dental disease are important for the patient being considered for adjuvant radiotherapy.

  • Neck

    Palpation of the neck for detection of lymph node metastasis is of vital importance.

Imaging

  • 1.

    Computed tomography (CT) scan with and without contrast

    • A dedicated maxillofacial CT should be performed to evaluate the bony structures of the nose and involvement of the paranasal sinuses.

    • Used to detect tumor extension to the cartilage and bone

    • CT scan of the neck is necessary to evaluate whether there is cervical lymph node metastasis.

  • 2.

    Magnetic resonance imaging (MRI)

    • Should be performed in all cases and is complementary to the information that the CT scan provides

    • Can help determine tumor extension to the soft tissues

    • Evaluate for intracranial extension

    • Evaluate for perineural invasion

    • Differentiate inflammatory tissue from the cancer

    • Complementary to CT for evaluation of lymph nodes in the neck

  • 3.

    Chest radiograph

    • Important for preoperative assessment

    • Detection of pulmonary metastases or primary cancer of the lung

  • 4.

    PET-CT

    • Not performed in all cases

    • To detect distant metastases in recurrent cases, radiotherapy failure, and aggressive primary tumors with extensive regional involvement

Indications

  • Extensive skin cancers of the external nasal framework ( Fig. 101.1 )

    • The most common cutaneous basal cell and squamous cell carcinomas and rarely melanomas, adnexal tumors, and Merkel cell carcinomas

    Fig. 101.1, Extensive skin cancer of the nose extending through the cheek and the upper lip.

  • Extensive malignant tumors such as SCCs and adenocarcinomas of the nasal cavity, columella, nasal vestibule, septum, or the lateral nasal wall

  • Recurrent or multifocal cancers after surgery or radiation therapy ( Fig. 101.2 )

    Fig. 101.2, Recurrent tumoral defect on the lateral side of the nose.

  • Palliative treatment, including cases in which there are distant metastases to the nose from a distant site

Contraindications

  • Distant metastasis (Relative) It may be appropriate for palliation for patients who have bleeding or severe pain in the primary site.

  • Comorbid diseases with unacceptable risk for general anesthesia

  • Patient preference for nonsurgical therapy

Preoperative Preparation

  • Incisional or punch biopsy to confirm the diagnosis

  • Routine laboratory tests and preparation for transfusion, if necessary

  • Cessation of antiplatelet/anticoagulant drugs, supplements, and herbal products

  • The patient with cervical lymph node metastasis should be counseled regarding the need for neck dissection, alternatives, and expectations after the surgical resection and neck dissection.

  • Consultation with an experienced maxillofacial prosthodontist for immediate reconstruction, with a prosthesis

  • The patient should be counseled regarding the expected cosmetic deformity.

  • The patient should discontinue smoking tobacco if a flap reconstruction is planned.

The decision of the reconstruction method depends on many factors:

  • A prosthesis may be preferred in the following situations.

    • Age: Younger patients may find that a prosthetic has more acceptable aesthetic results. Older patients who may have significant comorbidities would benefit from shorter surgery duration and avoid the need for multistage procedures.

    • Size of defect: Cases without sufficient tissue to restore a large facial defect, especially in recurrent tumors or in cases with a compromised local vascular bed

    • Patients with poor prognosis, including the need for palliative surgery

    • Aggressive cancers, such as squamous cell carcinomas of the columella, which require close oncologic examination of the surgical bed, or in patients with planned postoperative radiation therapy

    • Patients who have compromise in vasculature due to comorbid conditions and/or continued tobacco use, which increases the risk of flap failure

    • Patient’s preferences

    • Experience of the surgical team

  • Flap reconstruction may be preferred in the following situations:

    • Patients with psychiatric illness who may not be able to tolerate a prosthesis

    • Patients who cannot manage the daily care of a prosthesis

    • Patients with previous prosthesis-related complications

    • Patient’s preferences

    • Experience of the surgical team

Nasal Prosthetics

  • There are many methods for placement of the prosthesis to the nasal region:

    • Medical adhesives, mainly of silicone-based adhesives, are used to attach the prosthesis to the skin.

    • Anatomic undercuts are natural anatomic indents in the surgical area for physical retention of the prosthetic. In the presence of stable tissue support, an anatomic undercut is the most suitable choice for the patient. It is a noninvasive, easy-to-use, low-cost, and tissue-tolerant method.

    • Eyeglass frames are used for retention of the prosthesis. The prosthesis is fixed to an eyeglass frame, and they should be used together. The primary disadvantage is that the patient cannot remove the eyeglasses without also removing the attached prosthesis.

    • Osseointegrated implants are used to attach the prosthesis to span the nasal defect. Implants can be placed along the zygoma, floor of the nose, glabella, orbital rim, and maxilla. Implant failure is more common at the orbital rim and maxilla due to poor quantity and quality of bone and in patients with previous radiation therapy treatment. Preoperative CT scans are useful to determine whether there is sufficient bone (at least 3 mm) for implant placement. Implants are contraindicated in locations with the potential for persistent tumor involvement.

Advantages

  • Better surveillance of the wound bed for recurrence

  • A staged procedure is still possible with flap reconstruction performed after prosthesis placement

  • Technically easier to perform than a flap reconstruction

  • Inexpensive care

    • Anatomic undercuts, adhesives, and eyeglasses are preferred by the patients because of their low cost. However, a prosthesis with osseointegrated implants costs are much higher and may be comparable to the cost of free flap reconstruction. Therefore there may be some cost differences between institutions or countries.

  • Avoid additional surgical procedures and corresponding potential morbidity.

  • Minimize psychologic distress to the patient if placed intraoperatively, which can mitigate the aesthetic repercussions of the surgery

  • Shorter surgery duration

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