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KUANetal.

TABLE XI.4 Evidence surrounding advancements in endoscopic orbital approaches and role for open orbital approaches.

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusion

Tilak et al. 359

1. No intraoperative or postoperative orbital complications were encountered with normal vision postop 2. Complete removal was obtained in all cases of tumor resection

1. Orbital/visual outcomes 2. Successful removal of targeted lesion or skull base recon struction 1. Orbital/visual outcomes 2. Successful tumor resection 1. Orbital/visual outcomes 2. Successful removal of targeted lesion

2022 4

Retrospective case series

All patients underwent endoscopic endonasal surgery with endonasal periorbital suspension for access to pathology of the lateral frontal sinus ( n = 30) All patients ( n = 45) underwent combined endonasal and TONES for sinonasal tumors All patients ( n = 24) underwent an endoscopic endonasal surgery with endonasal orbital transposition for access to the far-lateral frontal sinus

Ramakrishna et al. 355

2016 4

Retrospective case series

1. TONES associated with minimal morbidity including low risk of visual loss or diplopia postoperatively 2. High success for complete tumor resection 1. Complete tumor removal was obtained in all cases of IP and fibro-osseous lesions, and all mucoceles resolved 2. No intraoperative or postoperative orbital complications were encountered with normal visual outcomes

Karligkiotis et al. 358

2015 4

Retrospective case series

Abbreviation: TONES, transorbital neuroendoscopic surgery.

A Techniques Some authors prefer to sample margins prior to tumor resection, while others complete margin sampling after resection. 140,382,383 In an example of the former, follow ing identification of the tumor attachment site, Nakamura et al. favor a 6- to 8-point biopsy of tissue 1 cm from the macroscopic tumor margin for malignant tumors. 140 Once negative margins are confirmed, mucosal incisions for resection of the tumor are made in pathologically con firmed tumor-negative areas. 140 Typically, these margins are sent for intraoperative frozen section analysis. Aside from the attachment site, margins must be cleared circum ferentially around the tumor as dictated by the tumor’s three-dimensional anatomy. Alternatively, margins are taken from the periphery of the tumor resection site following identification of the tumor attachment. Chiu et al. resected tumors with a 1-cm margin of normal mucosa around the tumor attachment. 280 There is a paucity of information regard ing the specific size of margins for SNM. While there is no consensus for adequate margins, some authors define adequate margins as ≥ 5 mm. 140,272,384,385 This appears to be extrapolated from the head and neck literature. 140,386–388 Complicating the consensus on what constitutes an ade-

resections. However, studies have demonstrated endo scopic tumor resection to be oncologically equivalent to open en bloc resections, without any significant differences in survival metrics or the ability to obtain neg ative margins (Table XII.2). 135,182,254,268,272,297,312,361,379,380 Additionally, endoscopic surgery allows for excellent visualization of the sinonasal region, a limitation with open approaches due to the inherent anatomy of the paranasal sinuses, skull base, and orbit. The endoscope not only provides magnified visualization, but also better illumination and range of motion than the operating microscope. 182,316,381 Further, endoscopic approaches have been shown to have lower morbidity and hospitalization time than open approaches. 278,280,297,314 Endoscopic endonasal resection of sinonasal tumors typically begins with tumor debulking. This, alongside dissection of uninvolved sinuses, allows for visualization to assess the extent of the tumor. 140,316,382 Some authors recommend a centripetal dissection moving from the periphery or free edge of the tumor toward the epicen ter/origin site. 316 Ideally, circumferential exposure around the site of tumor origin or attachment can be achieved, allowing for clear visualization of the gross tumor mar gins, key anatomical landmarks, and improved planning of resection margins.