xRead - Nasal Obstruction (September 2024) Full Articles

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ranged from 0% to 12.5% for maxillary IP tumors. The most common approach was endoscopic medial maxillec tomy with or without trans-septal access and transection of the nasolacrimal duct. Liu et al., Dean et al., Wang et al., and Wu et al. each reported small series of IP cases, together totaling 118 patients treated with endo scopic medal maxillectomy with only three recurrences (2.5%) during the duration of study. 302–305 Reported com plications were rare (range 0%–17%) and included dry nose, epistaxis, numbness of the front maxillary teeth, and epiphora. Other common maxillary tumor approaches include endoscopic modified Denker maxillectomy and prelacrimal approaches. Both allow the surgeon to gain better access to the anterior maxillary wall and the anterior inferior and anterior lateral disease. Additionally, these approaches provide improved angles for accessing the pterygopalatine and infratemporal fossa in endoscopic surgery. In this review, we are unable to draw clear conclu sions about the advantage of one approach over the other for maxillary sinus tumors. Lee et al., Pagella et al., and Stavrakas et al. all reported on the endoscopic modified Denker approach. 306–308 In the combined 59 patients, two patients developed recurrent tumors during the course of study. The permanent complications reported after modified endoscopic Denker included bleeding requiring surgical treatment ( n = 1), epiphora ( n = 2), and facial numbness ( n = 3). Data on the prelacrimal approach also demonstrate low rates of tumor recurrence and complications. Yu et al. describe a case series of 71 patients with Krouse stage T3 IP resected via the prelacrimal approach, with a 7% recurrence rate and 7% of patients experiencing facial numbness or mild alar collapse. 309 Suzuki et al. also reported similar favorable outcomes with the prelacrimal approach for IP with a 2% recurrence rate and 14% incidence of transient upper lip numbness. 310 The available literature is limited by significant hetero geneity of the population, tumor type/extent, and surgical approach. This is compounded by the lack of prospective data, variable follow-up timeframe, and inconsistency of variables collected by the researchers. Moreover, most of the studies looking at clinical outcomes after maxillary sur gical approaches occur in benign tumors, which may not be translatable to malignant tumors in the same location. Therefore, only the most basic of conclusions can be drawn about surgical outcomes from areas of consistency across many studies. In conclusion, endoscopic maxillary sinus approaches appear to have similar or better rates of recurrence in IP and other benign tumors to the recurrence rates for open approaches. It is not possible to advocate for one approach over another. It is also not clear whether the experience in

benign tumors translates to a similar experience in more aggressive malignancies. For instance, the presence of maxillary sinus floor infiltration (involving mucosa/bone) is a known negative prognosticator for primary maxil lary sinus malignancies. 311 Thus, this is currently up to the discretion of the surgeon to tailor the surgery to the tumor pathology, location, and extent to ensure the best patient outcomes. Furthermore, this review highlights multiple gaps in the literature where prospective cohort studies and randomized controlled trials to compare surgi cal approaches could lead to better understanding of when to employ specific open and endoscopic maxillary surgical approaches. Extended endoscopic approaches to the maxillary sinus

Aggregate grade of evidence

C (Level 4: 12 studies)

Benefit

Compared to open maxillary surgical approaches, endoscopic maxillary surgical approaches generally yield improved morbidity and shorter recovery times with comparable or even improved outcomes based on the IP literature. Failure to achieve GTR with negative margins in extensive or high-stage tumors, particularly those with bony maxillary wall and/or palatal invasion, which could result in tumor progression or surrounding structure invasion. Reduction in cost is possible with EEA related to reduced operative times, shorter hospital LOS, and reduced morbidity. Preponderance of benefits over harms. unclear how these data will translate to treatment of other primary maxillary neoplasms, including malignancies, especially those with bony invasion. Moreover, many studies have small sample sizes and cannot adjust for patient comorbidities, covariates, or tumor stage. Larger prospective cohort studies are needed to develop clear recommendations for maxillary surgical approach in malignancies. Recommendation for EEA for IP and other benign lesions. Option for EEA for malignant tumors based upon anatomical involvement and at the discretion and comfort of the surgeon. Current conclusions are primarily based on limited data focused on IP resection. It is

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level

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