xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

C Management of the nasolacrimal system and role of dacryocystorhinostomy Management of the nasolacrimal system, including the nasolacrimal duct (NLD) and consideration of dacryocys torhinostomy (DCR), is an important consideration when sinonasal masses affect the orbit and paranasal sinuses. A few important concepts arise when discussing the management strategies for the nasolacrimal system: (1) oncologic principles when tumor involves the NLD and lacrimal sac and (2) the role of a formal DCR or NLD stenting at the time of surgery to prevent postoperative dys function. Regarding sinonasal tumor involvement of this region, there are no well-controlled studies or retrospective reviews specifically on the role of resection of the naso lacrimal system in these cases, though oncologic principles should be applied regardless. To this end, complete resec tion of the NLD and/or the lacrimal sac may be performed depending on extent of tumor involvement. While there is a large body of literature detailing man agement of the nasolacrimal system in the setting of IP and when endoscopic medial maxillectomies (EMMs) are performed, there is a paucity of peer-reviewed publica tions examining outcomes of sinonasal tumors specifically involving the orbit (Table XI.3). 320,346–348 In fact, these have often been exclusionary criteria in many studies. As the number of EMMs performed has increased, and with increasing availability of powered endoscopic instru mentation, the literature has become more informative on the reality that sharp transection of the NLD during EMM for benign sinonasal tumors will generally result in duct patency, and most cases do not require a for mal DCR or stenting. 320,346–348 Additionally, while novel techniques like total duct preservation are of technical interest, the rate of posttreatment epiphora when perform ing EMM is sufficiently low to obviate performing such techniques, ranging from 0% to 15% following EMM in most reports. 310,346–349 One major caveat to this approach in the setting of SNM, however, is the potential for NLD scarring post-RT. Thus, if postoperative RT is planned or likely, this may factor into the decision-making with regard to DCR or stenting at the time of surgery, though further investigation is needed on this topic. Aggregate grade of evidence : C (Level 3: two studies; Level 4: two studies) D Advancements in endoscopic orbital approaches and role for open orbital approaches In the past decade, significant advances in EEA to the orbit have revolutionized the treatment paradigm when con

sidering orbital dissection. To date, multiple clinical and anatomic studies have been performed to better charac terize the endoscopic corridors in approaching both extra conal and intraconal orbital pathology. 328–332 Through the use of angled endoscopes and novel endonasal instru mentation, endoscopic dissection of periorbital tissue allows for improved visualization and delineation of the periorbita, EOMs, and intraconal neurovascular struc tures, facilitating tumor resection and orbital preserva tion surgery. 328–332 Importantly, bimanual dissection via the two-surgeon, endonasal approach, as employed for endoscopic skull base surgery, has also greatly impacted our ability to more effectively chase disease beyond the periorbita. With regard to comparing endoscopic versus open cran iofacial surgery, there have been several studies evalu ating the long-term outcomes and indications for endo scopic versus open surgery for SNM. 312,350,351 For sinonasal tumors with orbital invasion, there have been limited stud ies directly comparing endoscopic approaches versus open techniques. In most cases, the location of the tumor within the sinonasal cavity and extent of invasion with respect to the orbit and extraconal structures impact consideration for the feasibility of the endoscopic approach for orbital management. Based on descriptions provided above and orbital grading schema described by Turri-Zanoni et al., the authors propose that grade 1 orbital involvement is generally amenable to the endoscopic approach. 165 Grade 2 orbital invasion with periorbital tumor invasion or involvement of extraconal fat often requires resection of involved periorbital tissue and fat, which can be accom plished endoscopically, depending on the type of pathology and the experience of the surgeon with the endoscopic orbital approach. In contrast, grades 3 and 4 orbital inva sion generally will require open approaches given the potential need for orbital exenteration in many instances and dissection of the orbital apex in grade 4 orbital invasion. 165,324 Overall, when considering endoscopic ver sus open techniques, a robust multidisciplinary collab orative effort is strongly advocated for the management of sinonasal tumors with orbital involvement. Given the relative novelty and nuances in operative technique, endo scopic orbital approaches in orbital preservation surgery require detailed knowledge of the endoscopic corridor and experience with manipulating orbital structures through endonasal technique. 165,331,336,352 Lastly, with advancements in endoscopic instrumen tation and improved understanding of orbital anatomy with respect to endonasal approaches, transorbital endo scopic (TOE) approaches and transorbital neuroendo scopic surgery for the management of sinonasal and skull base pathology are now adopted by many centers and have continued to evolve (Table XI.4). 353–357 Though many