Psychological Manifestation of Patients with Sinonasal Tumors: An Obscured and Commonly Neglected Aspect of the Disease

The nose and paranasal sinuses occupy the mid portion of the face and are closely related to vital structures like orbit, skull base, cranial nerves, blood vessels etc. (Figure 1) Sinonasal carcinoma is the commonest malignancy of these structures [1,2] and accounts for about 3% of all head and neck malignancies. The hidden nature of the mucosal covering of these structures affected by this tumor contributes to its late clinical manifestation. In most cases, early symptoms are subtle and non-specific; hence, diagnosis is usually made at late stage of the disease [3,4]. Brent et al. [5] documented six month as the average duration between first symptom and diagnosis of sinonasal malignancy [5]. The delay is definitely much longer in developing countries where further delay is caused by poor cancer awareness, traditional and religious believes, poverty, limited and uneven distribution of health resources, and a huge population that over burdens the available diagnostic facilities. Late disease stage presentation characterized most of the patients with sinonasal malignancies in developing countries [4].

Figure 1: Facial appearance of a patient with sinonasal malignant tumor.

Sinonasal malignancy like other head and neck cancers is associated with significant disability, which has a major impact not only on the affected patients but also on their family members or caregivers [4]. These disabilities of functional and cosmetic impairment may include loss of sight, difficulty with feeding, breathing, phonation and facial disfigurement. Facial disfigurement which results either from the sinonasal tumor growing into the skin of the mid face or depression on the face as a result of surgical removal of sinonasal tumor may cause psychological trauma. However, most surgeons rarely include psychotherapy in the patients’ management plan.

In this observational study of 61 patients who were managed for malignant sinonasal tumors from 2006 to 2011 at the Department of Otorhinolaryngology, University College Hospital, Ibadan, Nigeria, there were 28(45.9%) males and 33(54.1 %) females. The mean age was 36.5 ± 19.2 years (range 5-72 years). There were 11(18%) children and 50(82%) adults. The common presentations were epistaxis, nasal obstruction and facial asymmetry. The site of origin of the tumor within the sinonasal region could not be determined because at presentation, the tumor had spread to involve more than one anatomic site of the paranasal sinuses and nose in all the cases. Histologic analysis revealed that 48 (78.7%) were epithelial tumors while 13 (21.3%) were nonepithelial tumors (Table 1).

Table 1: Histologic types of the Sinonasal malignancy

Twenty nine (47.5%) patients presented more than a year after the onset of clinical symptoms while 77.1% and 19.6% patients with squamous cell carcinomas were stage 3 and 4 respectively at presentation. The late stage disease presentation in the present study conforms to a previous study in the region [4]. This might be directly or indirectly related to their level of literacy and poverty which still prevail in our society. The late stage disease presentation contributes to poor management outcome of cancer patients.

Receiving the information on diagnosis of a sinonasal cancer brings about psychological traumatic, life-changing event in the affected individual and their caregivers. Unfortunately, the mental health effect of the disease is often obscured by attention to the physical disorder and inability to determine and differentiate “appropriate sadness” from clinical depression. Psychological/psychiatric manifestations (Aggression, anxiety disorder, depression and adjustment disorders) were seen in 23 (37.7%) patients. Gregurek et al. reported that ⅓rd of patients with cancer will experience psychological distress which requires psychiatric evaluation and treatment [6]. The new facial appearances of these patients have psychological effects on them and may significantly affect their quality of life.

Therefore, in the total care of patients with sinonasal tumor, it is important to involve psychiatrist/clinical psychologist early in their management. Reconstruction of the face with prosthesis in the Maxillectomy cavity can reduce facial depression post surgery, improve the facial appearance and reduce incidence of psychological manifestations.