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Non-bacterial thrombotic endocarditis.

melanomas occur less frequently; and rare varieties include lymphosarcomas and other sarcomas, gliomas, plasmacytomas, and mucoepidermoid carcinomas. The most common malignant tumour seen in the nose is a late secondary extension of carcinoma of the maxillary sinuses, the treatment being that of the primary tumour. Both innocent and malignant neoplasms may cause a purulent nasal discharge. Pain or bleeding will also occur if a tumour of either type destroys bone by pressure absorption. In general, tumours confined to the nasal passages produce nasal obstruction and epistaxis rapidly while those that invade the nasal cavity secondarily (such as carcinomas of the paranasal sinuses) produce symptoms late in the course of the disease; often the diagnosis is not apparent until the tumour has penetrated the surrounding bony walls, causing swelling of the face, proptosis, and epistaxis. Swelling of the palate, pain, or loosening of the teeth may send the patient to a dental surgeon, and proptosis or unilateral epiphora to an ophthalmologist. Since the clinical differentiation between a simple and a malignant neoplasm of the nose may be difficult, all such cases should be referred promptly to a rhinologist, whose investigations are likely to include anterior and posterior rhinoscopy, x-ray examination of the nose and paranasal sinuses, and biopsy of the swelling-absolutely essential for accurate diagnosis. Simple tumours are removed intranasally under general anaesthesia, preferably augmented by instillation of a cocaine solution to control haemorrhage. If a haemangioma is present the base is cauterised to prevent recurrence. Squamous cell papillomas of the nasal vestibule are quite common; again the base of the tumour should be cauterised, otherwise a squamous carcinoma may develop at the site of repeated excisions. The pleomorphic adenoma or mixed tumour is rare and until the series recently reported by Compagno and Wong, no single investigator had been able to collect enough cases for evaluation. Compagno and Wong have studied 40 cases and have follow-up data on 34 of these for over seven years. Most of these neoplasms originate from the mucous membrane of the bony or cartilaginous septum but they may also occur on the lateral nasal wall. They are seen in all age groups but are most common in white people in the third to sixth decade. The symptoms are of nasal obstruction and a mass in the nasal cavity and the lesions are seen as polypoid, broad-based swellings. Local but adequate excision is the treatment of choice, and most patients in the American series were treated by local or wide excision in the form of septectomv, turbinectomy via a lateral rhinotomy, or a Caldwell Luc procedure. Thirty-one of the 34 patients followed up did not have a recurrence of the tumour. Those that did recur either had not been completely removed or recurred locally and were removed again without further recurrence. Squamous carcinoma of the skin of the nose may extend into the vestibule or nasal septum and may be treated by excision or radiotherapy. Basal-cell carcinoma may affect both the nose and the paranasal sinuses. Early lesions respond well to radiotherapy, but wide surgical excision is necessary if the tumour has reached the underlying bone. Malignant melanoma of the nasal passages is uncommon; bleeding occurs early in the disease and the tumour may metastasise to cervical lymph nodes. Wide surgical excision is essential-the response to radiotherapy is poor-and chemotherapy combined with surgery is the most successful form of treatment.