xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

approach. 2050 They found an overall complication rate of 36.8%, with severity reaching 13.6% in cases. The only fac tor associated with a higher perioperative risk of surgical complications was advanced T stage, often represented by orbital or intracranial invasion, although, in univariate analysis, these factors alone were not statistically signifi cant for increased risk of surgical complications. A large multicenter review conducted by Ganly et al. evaluated 1193 patients, who underwent open CFR of malignant sinonasal tumors with skull base involvement. 2056 They reported an overall complication rate of 36.3%, with the most frequent being those related to the surgical wound (19.8%), followed by CNS complications (e.g., CSF leak, meningitis, pneumocephalus) in 16.2% of cases. On mul tivariate analysis, the presence of comorbidities, previous RT, and dural or cerebral invasion were the only predictors for surgical complications. In the same study, the pres ence of comorbidity was the only significant risk factor for perioperative mortality (RR 1.9, p = 0.05). Beswick et al. prospectively followed 142 patients undergoing resection of malignant sinonasal tumors, 69% by endoscopic access and 31% by open or combined approach. 14 They concluded that factors such as age, sex, comorbidity status, T stage, and chemotherapy before or after surgery were not asso ciated with a higher risk of early or late complications. However, adjuvant RT was associated with a higher risk of complications ( p = 0.013) in patients undergoing open or combined resection. The introduction of vascularized nasoseptal flaps by Hadad et al. for reconstruction of surgical defects in accesses to the skull base has been effective to reduce the risk of postoperative CSF leak. 244 In cases where the use of the nasoseptal flaps is not possible, lateral nasal wall or pericranium flaps may be an option. 141 The rate of postoperative CSF leak is particularly frequent in large anterior cranial fossa defects and tumors with posterior fossa involvement. 2057 Overweight and obese patients tend to be more likely to develop postoperative leaks when compared to patients with body mass index < 25 kg/m 2 . 2058 Factors that lead to increased ICP, such as patients with intracranial hypertension, are associated with a decreased success rate in CSF leak repair. In these patients, external CSF diversion (e.g., lumbar drainage) could be considered for reducing ICP. 2059 For a com prehensive discussion of the evidence surrounding skull base reconstruction, please refer to ICSB 2019 sections X (Reconstruction) and XI.A (Risk Factors for Postopera tive CSF Leaks) and associated updated reviews on this topic. 5,2060 Aggregate grade of evidence : C (Level 2: one study; Level 3: five studies)

cussion at multidisciplinary tumor conferences and should receive comprehensive care and multimodal therapy when feasible.

SECTION IV: MORBIDITY, QUALITY OF LIFE, AND SURVEILLANCE XXIX RISK FACTORS FOR SURGICAL COMPLICATIONS A Primary surgery Surgery is part of the standard treatment for sinonasal tumors and is also an option for salvage in cases of recur rence. The most common surgical complications encoun tered during sinonasal tumor surgery include bleeding, infection, CSF leak, meningitis, diplopia and other visual disturbance, orbital and intracranial injury, ORN, and sec ondary CRS. 14,68,313,2054 Most studies involving sinonasal tumors and its treatment outcomes are retrospective. Research of this topic is challenging because of the low incidence of these tumors and heterogeneous histologic subtypes. In many cases, the use of suitable surgical instru ments and binarial access is recommended for better execution of the procedures and allows for improved surgi cal performance. Both practices may reduce the incidence of complications, especially in cases where conventional techniques may not afford for adequate resection. 68 Benign lesions, such as IP, have been preferentially resected with endoscopic techniques with generally low complication rate. Most complications encountered are minor and include epistaxis, epiphora, or temporary max illary nerve paresthesia. Less frequently, major compli cations, such as CSF leak and orbital injury, are related to tumor invasion of the orbit and skull base. 674 Surgi cal management of vascularized tumors, particularly JNA, has intraoperative massive blood loss as the major surgical complication. Preoperative angiography allows for eval uation of tumor blood supply and possible embolization to decrease intraoperative bleeding. According to Boghani et al. 767 in a systematic review that included 85 arti cles and 1047 patients who underwent primary resection of JNA, preoperative embolization significantly reduced intraoperative bleeding in cases operated by endoscopic or combined approach. Another review with meta-analysis published by Overdevest et al. analyzed 828 cases of JNA submitted to embolization and found blood supply orig inating from the ICA system in 35.6% of patients and bilateral supply in 30.8%, both associated with a significant increase in intraoperative bleeding. 2055 Dodhia et al. analyzed 448 patients who underwent surgery for sinonasal tumors, of which 404 had an open