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345

ICAR SINONASAL TUMORS

TABLE XXXI.B.1 (Continued)

Clinical endpoints 1. Baseline symptoms 2. Long-term sequelae

Study

Year LOE Study design Study groups

Conclusions

1. Baseline symptoms included recurrent epistaxis (2), nasal obstruction (1), seizures (1), exophthalmos (1), proptosis (1), cranial nerve palsy (1), and headache (1) 2. Long-term sequelae included

Bisogno

2012 4

Retrospective case series

Nine patients with

et al. 2100

ONB, four of whom underwent surgical resection

chronic sinusitis (1), hyposmia (1), chronic headache (1), and facial bone hypoplasia (1) Abbreviations: ASB-QOL, Anterior Skull Base QOL; LKE, Lund–Kennedy endoscopy score; ONB, olfactory neuroblastoma; QOL, quality of life; SNM, sinonasal malignancy; SNOT, Sino-Nasal Outcome Test; VAS, visual analog scale.

decisions intend to balance the associated morbidity of surgery and other treatments against the risk of recurrence (Table XXXI.B.2). 166,2104 Surgical complications have been reported with both orbital exenteration and orbital preser vation. Traylor et al. studied 180 patients who underwent orbital exenteration for malignancies, 40 of which were for sinonasal primary tumors. 2105 The 30-day postoperative complication rate was 15%, with surgical site infections, CSF leak, and pneumonia being the most frequent. The most common Clavien–Dindo grade was II (9%), followed by IIIa (2%) and IVa (2%). Sugawara et al. evaluated 15 patients who underwent CFR with orbital exenteration for SNM involving the orbital apex; they reported a post operative infection rate of 33% but no new neurologic deficits in any patients postoperatively. 166 Spiegel and Var vares described a series of four patients with intracranial complications (three with large abscesses, one with symp tomatic epidural enhancement) after orbital exenteration who were successfully treated with free flap obliteration of the orbital cavity. 2104 Rajapurker et al. studied 19 patients who underwent resection of SNM with orbital preservation and found globe malposition ( n = 2), enophthalmos ( n = 3), and diplopia ( n = 2) among the postoperative sequelae. 511 Imola et al.’s analysis found a higher (63%) rate of globe malposition after orbital preservation surgery. 338 Stern et al. studied 18 patients who underwent orbital preservation surgery and found that resection of the orbital floor led to a 39% rate of ectropion compared to a rate of 20% with preservation of the floor. 2106 Li et al. reported a variety of complications after orbital exenteration or orbitotomy, including local wound infection, CSF leak requiring reop eration, intracranial abscess necessitating drainage, and intraorbital infection requiring orbital decompression. 164 However, Li’s study did not clearly delineate whether the complications were found in the orbitotomy or in the exenteration cohorts.

Multiple authors have described the ophthalmic func tional outcomes associated with orbital preservation strategies in the management of SNM. The treatment out comes in this population reflect either primary surgery, neoadjuvant or adjuvant therapies, or revision surgery for tumor recurrence. 164,220,336,338,511,2106 Because many orbital preservation patients receive multimodal therapy, it can be difficult to assess the relative contribution of each therapy to specific outcomes. These ocular and orbital sequelae can include visual loss, cataract formation, dry eye, keratitis, keratopathy, ectropion, enophthalmos, diplopia, epiphora, among others. Imola et al. found that 91% of patients who underwent orbital preservation surgery had a use ful seeing eye (range of follow-up: 2–10.5 months after surgery) and 74% had no change in vision. 338 However, 41% had one or more ocular symptoms, two patients had only light perception, and one had no light perception. Looking further, Ferrari et al. reported functional eye rates reaching 92.8% and 86.6% when measured 5 and 10 years after orbital preservation treatment, respectively. 220 Sim ilarly, Turri-Zanoni described a 4% rate of nonfunctional eye after orbital preservation. 165 In patients with ONB who had orbital invasion, Li et al. showed that 63% of patients treated with orbital preservation and RT had no visual impairment or grade 1 visual impairment, while 9% had grade 2, 11% grade 3, and 13% grade 4. 495 Looking specifi cally at outcomes after orbital floor resection, Stern found a variety of potential functional impairments, including ectropion, enophthalmos, diplopia, keratitis, and no light perception. 2106 Ferrari et al. found that tumor involve ment of extraconal fat was predictive of worse orbital dysfunction-free survival. 220 Despite these positive reports, it should be noted that these outcomes are reported retro spectively with the potential for significant selection bias in the patients offered this intervention. While there is a fairly well-defined body of literature on surgical complication rates and functional orbital out-