xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

whereas grade II was defined as invasion of extraconal fat and grade III as involvement of extraocular muscles, globe, orbital apex, or optic nerve. Management of the orbit in ONB

tive margin resections and completed adjuvant RT. Four patients had chemotherapy. The University of Pennsylva nia Smell Identification Test (UPSIT), performed at a mean of 37.3 months, demonstrated that six patients (43%) had residual smell function; two patients (14%) had normal or mildly reduced smell function. There were no recurrences with a mean follow-up of 51.3 months. In a study by Van Gompel et al., the authors evalu ated the ability of five board-certified skull base surgeons to determine the degree of involvement of the olfac tory bulbs or tracts based on preoperative imaging. 1362 The authors analyzed 26 patients histopathologically and reported the olfactory bulb or tract was involved in 85% of cases, with unilateral or no involvement in 65% of cases. The authors reported that the surgeons could predict or overcall bulb/tract involvement 96% of the time based on preoperative imaging. We note, however, that the absolute surgeon prediction accuracy was significantly lower. In a relevant anatomical study by Gomez Galarce et al., the authors examined 17 cadaveric specimens (34 sides) and elucidated the anatomical distribution and density of olfactory fila. 1363 Interestingly, 88% of specimens had olfac tory fila that crossed midline. In specimens with crossing olfactory fila, 20% of the fila crossed the nasal septum at the midline. The authors suggest that in some patients with unilateral tumors with septal involvement, it may not be cogent to preserve the contralateral olfactory epithelium, even when clinically and radiographically clear. 1363 The primary goal of surgery for ONB is an oncologic resection and any attempt for a unilateral resection and smell preservation should not compromise this goal. The LOE is not sufficient to support unilateral resection for smell preservation as a recommendation. In select cases, this approach might be an option. Unilateral resection and smell preservation in ONB

Aggregate grade of evidence

C (Level 2: one study; Level 4: three studies)

Benefit

Potential for orbital preservation with induction chemotherapy approaches. Orbital invasion is associated with decreased OS.

Harm

Cost

Not evaluated in current studies. Balance of benefits and harms.

Benefits–harm assessment

Value

There are some data to suggest that orbital preservation may be feasible in select cases.

judgments

Policy level Option. Intervention Consider induction chemotherapy for

advanced cases with significant local or orbital invasion, especially if high-grade tumors. Further studies are necessary to determine the balance between orbital exenteration and orbital preservation approaches for ONB.

5 Unilateral resection and smell preservation

Inherent to an oncologic resection of an ONB is olfac tory loss. Traditional open and endoscopic approaches remove the cribriform plate bilaterally, resulting in post operative anosmia. Given the morbidity of olfactory loss, there has been some interest in unilateral resection of ONB, whenever oncologically feasible, with the aim of smell preservation (Table XXIV.5). 1359–1361 Nakagawa et al. reported 12 patients from 10 tertiary referral hospitals in Japan between 2008 and 2016 who underwent unilateral ONB resection with the intent of olfactory preservation. 1360 Six patients had Dulguerov stage T1, three had T2, and three had T3 disease. They achieved negative margin resections in all patients. In this study, olfaction was assessed via interview and retained in 11 patients (92%), nine of whom received RT. The 12th patient could smell after surgery; however, they devel oped smell loss after RT. With a mean follow-up of 43.8 months, there were no recurrences reported. Tajudeen et al. reported a multi-institutional retrospective review of 14 patients who underwent unilateral endoscopic ONB resection with preservation of one olfactory bulb between 2003 and 2015. 1361 Six patients had Kadish B, six had Kadish C, and two had Kadish stage D. All patients had nega

Aggregate grade of evidence

D (Level 4: three studies)

Benefit

Potential for some smell preservation if unilateral structures are preserved. Not achieving an R0 resection given more limited approach. Possibility of smell loss regardless of unilateral approach given contralateral intracranial dissection, or RT side effect. There are no studies investigating cost. Preponderance of benefits over harms if negative margins can be obtained through unilateral resection. Smell preservation must not compromise oncologic resection.

Harm

Cost

Benefits–Harms Assessment

Value

judgments

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