xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

There were no differences in surgical outcomes when comparing OCH and other benign orbital tumors by indi vidual CHEER stages. 915 With increased CHEER stage, preferences toward a binarial approach and using a two surgeon (three- or four-hand) dissection technique as well as increased likelihood of intraoperative reconstruction was reported. 911 Endoscopic resection of selected intraconal and medial orbital schwannomas of symptomatic patients can be achieved via purely EEA or assisted by small-incision medial orbitotomy, particularly when the tumor extends anterior to the meridian of the globe. Several studies reported that tumors ranging from 1.6 to 5.9 cm 3 were resected with no complications and with improved post operative visual symptoms. 356,916–920 On the other hand, optic nerve sheath meningiomas are complex to manage, and iatrogenic blindness is not rare. Several cases of endo scopic endonasal optic canal decompression and GTR were recently published with encouraging outcomes. However, the value of endoscopic surgery for these lesions remains unclear. 921–924 A multicenter international retrospective analysis of 110 consecutive tumors found that ORBIT class III tumors rep resented approximately half (45.9%) and class II tumors represented 18.4% of all tumors, followed by classes I, IV, and V tumors, which constituted 16.5%, 13.8%, and 5.5%, respectively. When comparing benign orbital tumors that were resected exclusively endoscopically (76.4%) to those that were addressed in a combined fashion (23.6%), the former tended to be OCHs and were smaller in size. The presentation included visual field deficits and decreased visual acuity in over half of all patients at presentation (58.2% and 57.3%, respectively). Proptosis was seen in 37.3% patients, and approximately a fifth of patients pre sented with diplopia (21.8%) or pain/headache (20.9%). A combined approach was more commonly used when the patient presented with diplopia (46.2%, p = 0.001) but tended to be less commonly used in cases of visual field deficit (42.3%, p = 0.06) on presentation. Medial rec tus muscle retraction was more commonly performed for tumors that were addressed via a combined approach, and two or more surgeons were more likely to be involved in those cases. Tumors that were exclusively endoscop ically approached tended to achieve GTR, although this may be confounded by smaller tumor size. Overall, GTR was achieved in 80.2% of tumors. When considering long term surgical outcomes using the ORBIT classification system, as with CHEER, there was also a significant trend away from GTR within an increasing class. Overall, the long-term outcomes were favorable compared to patients’ baseline presentation, with 99% of patients who had visual deficits at baseline (i.e., visual field deficits, decreased visual acuity, and/or impaired color vision) experienc

ing an improvement in their preoperative visual deficits, and 79.7% patients showing improvement or no change in diplopia, 92.3% in eye position, and 96.7% in reported pain/headache. 912 A cadaveric study investigated the prelacrimal corridor to orbital floor lesions located inferolateral to the optic nerve and found improved visualization and preservation of neurovascular structures by entry laterally to the infe rior rectus muscle after mobilization of the infraorbital nerve and drilling of the orbital floor. 925 This approach provided good access to the space between the orbital floor and the optic nerve. The prelacrimal approach may also facilitate access to select ORBIT III lesions and pre clude the need for septectomy or a transeptal approach, while ORBIT II lesions may be approached via a transeth moid approach, through the corridor between the medial rectus and superior oblique muscles after retraction of the medial rectus muscle. 925–928 Described methods for medial rectus muscle retraction include the placement of vessel loops around the medial rectus muscle insertion point at the globe, pulled through a transseptal corridor or transchoanal static retraction. Dynamic retraction options using various instruments have been associated with the greatest intraconal exposure and reduce the risk of ocu lomotor neuropraxia resulting from tonic retraction. 929–931 Injection of indocyanine green with the enhancement of vascular lesions 1–30 min after injection and use of suit able endoscope filters may facilitate differentiation of the vascular lesion from the muscular and surrounding soft structures and allow refined dissection. 932 Methods of direct tumor retraction may also include the placement of traction suture through the OCH capsule and use of a cryoprobe. 933–935 The benefit of medial orbital wall reconstruction is an area of active investigation, and while data are being accrued, the current literature remains scant, with variable risk of postoperative enophthalmos and diplopia based on tumor size, location, and degree of intraconal dissec tion. Some surgeons advocate using soft materials such as free mucosal grafts, pedicled flaps, or self-dissolving materials, while others have used rigid materials such as bone, titanium mesh, or porous polyethylene implants. The associated risk of orbital compartment syndrome due to postoperative edema, oozing, and fluid transudation in the setting of immediate rigid reconstruction is an area of continued investigation. 910,936–939 A meta-analysis of 60 patients from 24 studies reported that 56.7% of patients underwent orbital reconstruction fol lowing resection by pedicled flaps (44.1%), free mucosal grafts (32.4%), and rigid reconstruction (8.8%). The deci sion to perform reconstruction was linked with pre operative vision compromise—visual field defect (61.8% vs. 7.7%; p < 0.001), decreased visual acuity (73.5% vs.