xRead - Nasal Obstruction (September 2024) Full Articles

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34.6%; p = 0.003), and color vision deficits (41.2% vs. 0%; p < 0.001)—and a trend toward intraconal location, whereas the patients for whom reconstruction was for gone were presented with preoperative proptosis (69.2% vs. 17.6%; p < 0.001), larger tumor size ( p < 0.001), a uninar ial approach ( p = 0.01), and operative exposure of orbital fat ( p < 0.001) and extraocular muscles ( p = 0.035). In patients with intraconal tumors, there was a lower rate of short-term postoperative diplopia when reconstruction was performed (7.4% vs. 31.3%; p = 0.041). Nevertheless, at an average of 2 years postoperatively, this potential ben efit of reconstruction did not persist, and the diplopia either improved or remained unchanged for all patients for whom reconstruction was foregone. 940 A trend toward reconstruction for higher CHEER stages was reported in numerous studies. 911,915,940 Endoscopic resection of intraconal orbital lesions

( < 14 days) overall postoperative complication rate of 30%, including diplopia (15.2%), cranial nerve palsy (II, III, V 1 , VI) (8.6%), and visual acuity and field defects ( < 4%). This complication rate was substantially lower than the previously reported 50% complication rate reported with external approaches. 915,941 Among the 110 patients who were operated by endo scopic or combined approaches, the 26 patients who underwent a combined approach were more likely to expe rience an immediate cranial nerve palsy after surgery (11.5% vs. 1.2%, p = 0.04) and had a trend toward increased periorbital ecchymosis ( p = 0.09). However, this difference did not sustain in the long term ( > 14 days). The remain der of immediate complications (visual field defect, visual acuity defect, diplopia, epistaxis, infection, new enophthal mos, severe edema, uncontrolled pain, and others) were similar between both groups. 912 IgG4-related ophthalmic disease (IgG4-ROD) was first sus pected as a cause of autoimmune pancreatitis in 2001 and, in 2012, IgG4-related disease was formally defined as a multisystem immune-mediated inflammatory condition characterized by the abnormal infiltration of IgG4-positive plasma cells leading to pathologic formation of tumefac tive masses and hypertrophic lesions (Table XIX.B.1). 942 Though largely associated with pancreatic lesions, the orbit was in fact the first reported extra-pancreatic site. 943 Therefore, IgG4-ROD is considered to be a subset of IgG4-related disease and was traditionally known as orbital pseudotumor (OP), also known as idiopathic orbital inflammation (IOI). Unlike many autoimmune disorders, IgG4-ROD has a near-equal distribution between males and females. 944 The presentation of IgG4-ROD is classically insidious, is often bilateral, and is associated with painless eye lid swelling and proptosis. Symptoms vary depending on the involved periorbital tissues and include epiphora, erythema, and visual deficits. Pain is uncommon. The most commonly affected periorbital site is the lacrimal gland, although involvement of periocular nerves (includ ing the optic and trigeminal nerves), adnexa, and soft tissue has been reported. 945 Salivary gland involvement is common. 945,946 Absence of pain, bilateral involve ment, a prolonged waxing and waning history, and concomitant salivary gland involvement may help to clinically distinguish IgG4-ROD from other causes of orbital inflammation. 947,948 Though not pathognomonic, radiographic lacrimal gland involvement in IgG4-ROD B Other benign orbital lesions 1 IgG4-related ophthalmic disease

Aggregate grade of evidence

C (Level 2: two studies; Level 4: nine studies)

Benefit

Higher rates of GTR with reduced local morbidity relative to open approaches among patients with lesions medial to optic nerve and/or inferior to POR. Risk of diplopia related to necessity for translaminar approach.

Harm

Cost

Associated costs with surgery and preoperative evaluations. Balance of benefits and harms.

Benefits–harm assessment

Value

No study to date has compared endoscopic and open approaches directly. However, in appropriately selected patients (e.g., tumor medial to the optic nerve and/or inferior to POR), endoscopic orbital surgery was preferred to traditional open approaches with reduced external morbidity. Not all patients are candidates for an endoscopic orbital approach, with tumors lateral and superior to POR and/or concern for invasion of local structures.

judgments

Policy level Option. Intervention Endoscopic orbital surgery approach may be

offered in lieu of open surgery by trained multidisciplinary orbital teams following appropriate workup and candidacy determination.

2 Complications Increased risk of complications was associated with higher tumor stage. 911 The meta-analyses revealed a short-term