xRead - Nasal Obstruction (September 2024) Full Articles

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comes, the literature on sinonasal outcomes associated with orbitotomy and orbital resection is more limited. To prevent nasal obstruction associated with free flap recon struction after orbital exenteration, Rauchenwald et al. performed nasal splinting for 4 weeks after surgery. 2107 Postoperatively, one patient had mild nasal obstruction based on the NOSE questionnaire, and the second patient had moderate nasal obstruction. Both had patent nasal cavities on postoperative endoscopy. SNOT-22 line-item responses for nasal obstruction and need to blow nose ranged from “none” to “moderate.” Aggregate level of evidence : C (Level 3: three studies; Level 4: eight studies) 4 Morbidity related to intradural resection Morbidity from intradural resection can include olfac tory dysfunction, neurocognitive symptoms (anxiety, emo tional burden, memory deficits, visual motor speed, frontal lobe executive function), cerebrovascular com plications, intracranial infections, central endocrine dys function, and visual symptoms (e.g., vision changes, diplopia) (Table XXXI.B.3). 2098 Mehta et al. reviewed 252 patients with SNM involving the skull base (89% of which required durotomy) and found an overall perioperative complication rate of 28%, including 18% who had major complications (Clavien–Dindo grades IIIb–V). 179 Compli cations included symptomatic pneumocephalus, epidural hematoma, CSF leak, diplopia, wound complications, and infection. Yeung et al. evaluated 17 patients with T4b SNM with intracranial extension who underwent salvage resection and calculated a 35% perioperative complication rate, including CSF leak (18%), free flap congestion (6%), subcortical infarct without sequelae (6%), and death (6%, n = 1). 2108 Ziai et al. showed statistically similar rates of complications between 21 patients who underwent dural resection and 16 patients who had no dural resection. 2109 Complications included meningitis ( n = 1), abscess ( n = 1), other infection ( n = 6), and pneumocephalus ( n = 1). Various patient-reported outcome measures have been used to characterize the QOL impact of transdu ral/intradural surgery. Tyler et al. showed no difference in postoperative QOL between extradural ( n = 29) and transdural ( n = 9) resection of SNM, based on the global EQ-5D visual analog scale. 2110 Patients with extradural versus intradural surgery had similar scores on the disease-specific MD Anderson Symptom Inventory-Head and Neck (MDASI-22), and Anterior Skull Base Ques tionnaire (ASBQ) when measured a median of 65 months after treatment. Advanced T-stage tumors, however, were associated with worse ASBQ total scores. 2110 Based on the MDASI-22, diminished taste (25%) and mucus in throat

(20%) were cited by patients as two of their most severe symptoms. In the ASBQ, symptoms reported as being most severe included those involving sense of smell (40% of patients), nasal secretions (39%), and taste (39%). However, none of these instruments are designed or able to measure frontal lobe function and to date, no neuropsychiatric or neurocognitive studies of this patient population exist. Furthermore, the multimodality therapies deployed in this T4 disease again muddy the impact of surgery and RT on morbidity. Postoperative hyposmia/anosmia is a specific concern in the treatment of ONB. 374,1361,2111 Sun et al. studied SNOT-22 scores in patients with Kadish stage C esthesioneuroblas toma a median of 42.3 months after endoscopic resection and found worsened olfactory scores compared to pre operative baseline. 2111 Tajudeen et al. administered the UPSIT to 14 patients with ONB who underwent endoscopic unilateral resection with preservation of one contralat eral olfactory bulb, followed by a full course of adjuvant RT. 1361 After a mean of 37.3 months after treatment, six (43%) of patients had residual smell function, two (14%) of whom had normal or only mildly reduced smell func tion. Schreiber et al. demonstrated that patients who underwent transnasal craniectomy with unilateral resec tion had higher rates of subjective olfactory preservation (46% vs. 0%), compared to those who underwent bilat eral resection. 374 However, by objective UPSIT testing, 82% of the unilateral resection group patients had anosmia, whereas 18% had severe hyposmia. The median UPSIT score for the unilateral resection group was 12 (range 5– 27), while scores in the bilateral resection group were not reported. In the pediatric population, Maggiore et al. showed in a case report that preservation of the contralat eral olfactory bulb enabled normal postoperative olfactory function, with a postoperative UPSIT of 38. 2112 Aggregate level of evidence : C (Level 3: three studies; Level 4: four studies)

XXXII

QOL AFTER MULTIMODALITY

TREATMENT FOR SINONASAL MALIGNANCIES

As treatment outcomes of SNM continue to improve, there is increasing focus on the long-term treatment side effects and QOL of survivors. This shift is occurring through out oncology but is particularly important in SNM due to the proximity of the treatment field to critical structures (i.e., optic apparatus, cranial nerves, brain). Newer modal ities including proton beam therapy and immunotherapy attempt to optimize oncologic outcomes while minimiz ing morbidity associated with traditional therapies, which has increasingly led to the inclusion of QOL and functional