xRead - Nasal Obstruction (September 2024) Full Articles

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tissues is favored. 900 The entire defect must be circum ferentially identified and accessible for instrumentation and ablation, which for midline congenital nasal masses often includes exposure of the anterior ethmoid skull base and the cribriform adjacent to the foramen cecum. 907 Skull base repair for endonasal approaches is often done concurrently to diminish the risk of intracranial complica tions and postoperative CSF leaks and usually necessitates a multilayered closure. 900,908 Details of repair are sur geon specific, but may involve a combination of inlay (intracranial, extradural) or onlay (extracranial) grafts that can be made from autologous or synthetic materials. 907 Larger defects, especially with an intraoperative CSF leak, are usually managed with a combination of “gasket-seal” repair to achieve watertight closure of the anterior cra nial base and vascular pedicle flaps, such as the nasoseptal mucosal flap. 244,908 In conclusion, congenital midline nasal masses arise from embryologic errors of development of the nasofrontal region and require a thorough, prompt workup and a high index of suspicion. Neuroimaging is essential in the eval uation to characterize the lesion and identify the presence and extent of intracranial involvement and should include a CT and an MRI. Timely and complete surgical resec tion with approaches tailored to the patient and tumor characteristics is recommended to prevent postoperative complications and recurrence. Resection should be done through an endonasal endoscopic approach whenever possible and appropriate. Aggregate grade of evidence : C (Level 2: two studies; Level 4: nine studies) A Benign orbital lesions—intraconal Traditionally, orbital lesions have been surgically addressed by ophthalmologists and neurosurgeons via open approaches such as frontotemporal craniotomies with orbitozygomatic osteotomy, transcutaneous or transconjunctival orbitotomy, and lateral orbitotomy. 909 Seeking to improve tumor resection efficacy and reduce morbidity, endoscopic approaches for orbital lesions evolved during the last decade as a natu ral evolution of endoscopic sinonasal and skull base surgery. 910 Since the ICSB 2019 document (Section VI.B), several studies have been published describing surgical tech niques, reporting outcomes, and adding to the nascent field of endoscopic resection of benign orbital tumors. 5 Two new classification systems were developed to improve XIX BENIGN ORBITAL TUMORS AND LESIONS

F Management Treatment of CMNMs involves complete surgical excision, which allows for formal histologic diagnosis and prevents future complications and recurrence. Early surgical exci sion is important to prevent potential complications such as local infection, craniofacial deformity, and intracranial complications and has also been associated with improved patient outcomes (Table XVIII.2). 883,891 Complete removal is imperative—incision and drainage, aspiration, or STR without complete removal results in historical recurrence rates ranging from 50% to 100%. 881,897 Multiple surgical approaches have been developed for extirpation of these lesions, including local excision, rhino plasty techniques, endoscopic endonasal, open craniofa cial, and combined approaches. Ultimately, excision must be tailored to a patient’s unique combination of pathol ogy, location and size of the lesion, and individual patient characteristics. 898 In cases where there is concern for intracranial extension, a combined approach with neu rosurgery is frequently necessary. For nasal dermoids, combined intracranial–extracranial excision is utilized in approximately 20% of cases. 883 Similarly, when there is extension of the sinus tract deep to the nasal bones, nasal bone osteotomies may be required to obtain appropriate access. The use of frozen pathology to rule out intracranial extension in dermoids has not been well studied, but some authors have reported success in using frozen sections of the superior margin of the specimen to ensure that there is no intracranial extension. 878,883,898,899 If complete resec tion is able to be achieved, the overall 7-year recurrence rates appear to be very low (12%). 883 Anterior skull base encephaloceles in children have been historically repaired through open approaches due to narrow anatomy that may prevent endoscopic repair in very young children and concern for STR. 891 Continued advances in endoscopic techniques have made minimally invasive extracranial approaches possible and are known to be associated with decreased patient morbidity. 900 Endoscopic techniques have already essentially become the standard of care for repair of encephaloceles in adults, with reported 90% successful closure rate. 901,902 Endo scopic approaches appear to be associated with decreased mortality, LOS, and duration of follow-up compared to open approaches. 903 A number of studies in the pediatric population suggest that endoscopic resection and repair are feasible for some masses and appear to have a more favorable complication profile than open approaches, even in children as young as 8 months old. 904–906 Multiple endonasal endoscopic approaches have been described, all tailored to the pathology, location, and size of the lesion, but in general, a technique that grants adequate exposure of the skull base and minimizes trauma to surrounding