xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

5 Techniques for hemostasis Achieving hemostasis is a critical goal in the perioperative management of JNA. In the preoperative setting, emboliza tion of external carotid artery branches has become a mainstay in the multimodal management of JNA. 5,777 While branches of the ICA may be embolized, the risk of stroke and retinal artery embolization with subsequent blindness precludes safe ICA embolization. Typically, angiography with embolization is performed 24–72 h prior to surgery. A variety of embolic agents are employed, frequently including polyvinyl alcohol, gelatin sponge, microcoils, and radiopaque liquid embolic agents (e.g., Onyx, ethylene vinyl alcohol copolymer). 5,777,795–799 Numerous studies have shown that preoperative emboliza tion is associated with reduction in intraoperative blood loss, though some studies suggest this benefit is lim ited to the advanced-stage cases. 5,777,796,797,800 Choi et al. queried the Kids’ Inpatient Database and reviewed 473 cases of patients with JNA. They found that preoperative embolization was associated with an additional cost of $36,500 to patients; however, this additional cost trended down when examined over time. 801 While embolization is typically performed in a trans-arterial fashion, experi ence is emerging with embolization with direct tumoral puncture. 802 Intraoperatively, many techniques and devices have been tested to assist with hemostasis including tradi tional electrocautery, lasers, and radiofrequency plasma ablation. 5,777,803 However, there are no RCTs that directly compare methods for intraoperative hemostasis, and tech niques are likely best chosen by the surgeon based on comfort, availability of resources, and specific clinical scenarios (Table XVII.A.5). Techniques for hemostasis in JNA

Benefit–harm assessment

The procedural risks of embolization are significantly less than the perioperative benefit of reduced bleeding and improved visualization; the procedural cost may be offset by reduced LOS and need for blood products. Choices for or against specific embolic agents or instruments for intraoperative hemostasis should be guided by surgeon/interventionalist experience and preference.

Value

judgments

Policy level Recommendation. Intervention For advanced tumors, and possibly for locally

limited tumors, preoperative embolization of ECA feeder vessels reduces perioperative bleeding, may reduce LOS and need for transfusion, and should be considered.

6 Role of nonsurgical therapy RT has been used in the management of JNA, but its use is, in general, controversial given the benign nature of the dis ease and the young population affected by JNA. Early work investigated the use of RT as definitive treatment with local control rates ranging from 80% to 92%. 804,805 More commonly, RT is used in the adjuvant setting to treat resid ual/persistent tumor in proximity to critical structures not amenable to surgical resection (e.g., cavernous sinus, ICA, orbital apex) or for management of large-volume intracranial disease. 806 A variety of chemotherapeutics have been employed to try and treat JNA, including classic, cytotoxic agents (dox orubicin, Adriamycin, vincristine), hormonal agents (flu tamide, given that JNA cells are prostate-specific antigen receptor positive), and immunomodulating therapies (e.g., anti-VEGF, steroids). 807–811 There have been no significant advances since the last ICSB document.

Aggregate grade of evidence

C (Level 4: eight studies)

B Vascular malformations, hemangiomas, and paragangliomas 1 Hemangioma

Benefit

Preoperative embolization reduces intraoperative bleeding and may reduce LOS, surgical duration, and need for perioperative blood transfusion. Risk of inadvertent embolization of ICA-supplied structures via internal–external anastomosis, puncture site hematoma, and contrast exposure. Possible additional cost of ∼ $36,500 and need for prehospitalization for procedural planning.

Hemangiomas are the most common vascular lesion of the head and neck; however, sinonasal hemangiomas are rare. 815 Hemangiomas are categorized into capil lary and cavernous types, depending on the size of the involved vessels. 816 Historically, capillary hemangiomas were termed pyogenic granuloma, but it was recognized that this was a misnomer and lobular capillary heman gioma became the preferred descriptor as it most accu rately describes the histopathologic characteristics of this

Harm

Cost

(Continued)