xRead - Nasal Obstruction (September 2024) Full Articles

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who were not. 2131 Both Upadhyay et al. and Jalessi et al. found that NSFs were associated with temporary olfactory loss, but that this improved by 3–6 months. 2132,2133 While a detailed discussion is beyond the scope of this review, SNM frequently presents with regional lymph node metastases requiring upfront neck dissec tion and/or radiation to the neck. Common adverse effects of neck radiation include neck tightness, fibro sis, pharyngoesophageal stenosis, hypothyroidism, and weakness of neck muscles. 2134 Common adverse effects of neck dissection include neck and shoulder discom fort, skin numbness, lymphedema, and reduced shoulder mobility. 2135,2136 Neck morbidity has been assessed with multiple different tools including the Disabilities of the Arm, Shoulder and Hand scale (DASH), Neck Disabil ity Index (NDI), and Shoulder Disability Questionnaire (SDQ). 2137–2139 Studies have found high rates of neck and shoulder disability following surgical and/or radiation treatment of the neck, and that neck and shoulder dis ability is linked to inferior QOL. 2140 Additional literature review related to morbidity following endoscopic surgical treatment of skull base pathologies is covered in ICSB 2019 (Section XI.C). 5 Morbidity following surgical treatment

Policy level

Recommendation to attempt endoscopic surgical approach when feasible in order to preserve QOL.

Recommendation to anticipate the QOL implications of surgical treatment when treating SNM. Intervention Endoscopic surgical resection of SNM is

associated with decreased postoperative QOL, particularly in sinonasal domains. Open surgical resection is associated with higher rates of serious postoperative complications. QOL tends to improve with time after surgery and returns to baseline in many studies.

C Morbidity following radiation treatment

NCCN guidelines dictate the use of RT in the adjuvant setting for all but the lowest risk tumors after surgery or as an alternative for definitive treatment for T3/T4a or T4b tumors, commonly integrating chemotherapy. 196 Older studies examined the impact of traditional exter nal beam radiation therapy (EBRT), finding the potential for severe toxicity. 1213,2141,2142 With the advent of IMRT, there has been better sparing of normal tissue compared to conventional two-dimensional or three-dimensional con formal RT techniques. 2143 Acute toxicities of sinonasal RT include fatigue, dermatitis, dysgeusia, xerostomia, nasal and orbital irritation, and mucositis, while late side effects typically involve ocular and neurologic toxicities, perma nent dry mouth, hearing loss typically when given with cisplatin chemotherapy, and hypopituitarism. 476,2144,2145 Patel et al. examined a cohort of 129 patients undergo ing RT for SNM and found that 21% had acute grade 3 or more toxicity, most commonly dermatologic side effects or dysphagia, findings that are replicated in other simi lar studies. 2145,476,550 The vast majority of studies confirm worse sinonasal QOL and symptom burden in patients receiving adjuvant RT versus no adjuvant treatment, though confounded by the fact that the addition of adju vant RT is associated with more extensive and aggressive tumors. 2085,2089,2093,2120,2127,2130 Severe late side effects, such as blindness and brain necrosis, are found much less com monly, and their incidence is proportional to the tissue volume receiving high-dose RT. 490,2144,2146 In the previously irradiated setting, the morbidities of RT can be further intensified. Bahig et al. examined longitudi nal QOL via the MDASI and the ASBQ questionnaires in a cohort of SNM patients undergoing re-irradiation. They found initial decreases in QOL at the end of treatment, but most scores returned to normal by the end of the 12-month evaluation period. 443 In line with these findings, Fan et al.

Aggregate level of evidence

C (Level 2: one study; Level 3: 12 studies; Level 4: five studies) Endoscopic surgical approaches are associated with decreased postoperative complications and faster recovery compared to open surgical approaches. Surgical treatment of SNM has been found to cause long-term sinonasal symptoms and decreased sinonasal-specific QOL. Sinonasal symptoms are worst in the first month after surgery but improve with time, back to or exceeding the presurgical baseline. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms. Surgical treatment of SNM is associated with long-term side effects and morbidity. While overall serious complications and morbidity are lower with the endoscopic approach, the endoscopic approach does cause increased sinonasal morbidity, which has been shown to affect sinonasal-specific and general QOL.

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Harm

Cost

Benefits–harm assessment

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judgments

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