xRead - Nasal Obstruction (September 2024) Full Articles

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as orbital clearance, is defined by complete removal of the orbital contents up to the orbital apex and, when appropriate, removal of the eyelid skin or bones of the orbit. 342,344,345 Lastly, approaches for limited resection, which falls under orbital preservation surgery, include either resection of involved periorbita with a visual margin or limited resection of extraconal orbital contents. These approaches have been studied in relation to OS and DFS, as they often balance functional outcomes with macroscopic tumor clearance. In the late 1990s, McCary et al. and Carrau et al. described some of the foundational literature on selec tive orbital preservation versus exenteration for cases of SNM involving the orbit. 323,325 Through a retrospective, single-institutional case review on malignant sinonasal neoplasms with orbital involvement, McCary et al. found that selective periorbital resection with adjuvant chemora diation was an acceptable alternative to orbital exentera tion with respect to local control (i.e., orbital recurrence) rates, even in cases where there is orbital bony ero sion on imaging. 325 With regard to OS, Carrau et al. found that orbital exenteration does not increase survival odds in malignant sinonasal tumors without full-thickness involvement of the periorbita based on an institutional case series. 323 Since these discoveries, other retrospec tive case series have confirmed and expanded on these original findings on indications when orbital preserva tion may be more appropriate. 164,165,220,339 Of note, selec tive periorbita resection is often a defining element in orbital preservation surgery and, if attainable based on pathology, allows for oncologic control with functional visual outcomes. 164,220,325,337–339 Importantly, both Imola et al. and Essig et al. found that patients who under went orbital preservation surgery in cases of orbital bone and/or periorbita involvement (without orbital fat or EOM involvement) demonstrated stable visual acuity in the majority of cases. 337,338 Specifically, in Imola et al. and Essig et al., 91% (49/54) and 97% (35/36) of patients, respectively, who undergo orbital preservation surgery maintain a functional, seeing eye postoperatively. 337,338 Conversely, other studies have confirmed indications for more aggressive orbital interventions, such that patients with tumors involving the EOMs, optic nerve, or intraconal space have improved OS and DSS when orbital exenteration is performed compared to orbital preservation. 164,165,220,324,339,343 Although much of the available literature and recom mendations are based on level 4 evidence, with the major ity of studies being retrospective case series, two systematic reviews and several literature reviews exist on the topic of management of orbital involvement in SNM. 342 Based on the two studies with the highest LOE, orbital preser vation can be considered in cases of purely periorbital

TABLE XI.1 Proposed grading systems for staging orbital involvement by sinonasal tumors. Study Year Grading scheme McCary et al. 325 1996 Grade A: Tumor adjacent to orbit, no bony erosion Grade B: Tumor erosion of the orbital wall without ocular bulb displacement

Grade C: Tumor infiltration of the orbital wall without periorbital invasion Grade D: Tumor with invasion of the periorbita Grade 1: Erosion or destruction of medial orbital bone Grade 2: Extraconal invasion of periorbital fat Grade 3: Invasion of extraocular muscle (EOM), optic nerve, or eyelid skin Grade 1: Tumor adjacent to orbit, no significant periorbital involvement Grade 2: Tumor invasion of the periorbital layer Grade 3: Invasion of the extrinsic ocular muscles, optic nerve, ocular bulb Grade 4: Tumor invasion of the nasolacrimal sac, eyelids Grade 5: Tumor invasion of the cavernous sinus, optic canal, or intracranial extension Grade 1: Orbital bone erosion Grade 2: Invasion of the periorbital layer and/or periorbital fat Grade 3: Invasion of the extrinsic extraocular muscles, optic nerve, or ocular bulb Grade 4: Involvement of the orbital apex

Iannetti

2005

et al. 324

Neel

2017

et al. 341

Turri

2019

Zanoni et al. 165

B Orbital preservation versus orbital exenteration In the era of multimodal therapy and minimally invasive surgical corridors, there is a push to improve perioperative patient morbidity while maintaining oncologic outcomes. Given the significant morbidity from either orbital exen teration or a nonfunctional preserved eye, there has been extensive study on the long-term outcomes of patients undergoing orbital preservation, orbital exenteration, or limited periorbital or orbital resection when sinonasal tumors involve the orbit (Table XI.2). 164,165,220,323–326,335–344 Orbital preservation is defined as maintaining the globe with the goal of preserving a functional eye and asso ciated orbital contents. Orbital exenteration, also known