xRead - Nasal Obstruction (September 2024) Full Articles

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sites and many tend to behave differently. Many of these pathologies tend to recur locally as opposed to regionally, though this is highly dependent on tumor biology and local recurrence of benign disease, notably IP, is also possi ble. Furthermore, sinonasal inflammation can persist long after treatment, leading to increased FDG avidity and alter ing the accuracy of FDG-PET/CT. 2193 Given the variability in pathology and the differences in biology of the sinonasal mucosa, the general principles applied to head and neck malignancies should not be universally applied. Ideally, the posttreatment examination and surveillance practice should be tailored to the specific tumor. There are no studies evaluating the ideal tim ing for clinical follow-up in patients with sinonasal tumors; however, many authors report their follow-up protocols. 216,369,373,402,418,419,431,1153,1161,2194,2195 Despite being institutionally dependent, there are a few themes that may be highlighted. Regardless of tumor biology, most authors utilize clinical examination with nasal endoscopy every 1–6 (median 3) months in the first year with varying de escalation of intervals in the subsequent years. Depending on the tumor type, posttreatment imaging is performed between 2 and 12 months following completion of therapy with FDG-PET/CT being used for SNM and CT or MRI being used for benign disease. In order to develop recommendations on timing, it is important to consider tumor biology and recurrence patterns. Of the 35 included studies, 22 studies reported RFS and time to recurrence. For all tumors, the mean time to recurrence ranged from 8 to 138.1 months, with the majority of the recurrences occurring within the first 5 years. ,216,369,373,402,418,419,431,701,720,721,741,1086,1135,1153,1161,1166, 1397,1417,1931,2194–2201 Notably this group consists of benign and malignant tumors, including ACC and ONB, known for late recurrence. Notably, ACC and ONB pose risks for recurrence as up to 10 years following primary treat ment and this should be taken into consideration when developing a surveillance protocol. 419,430,1417 Furthermore, for benign neoplasms (e.g., IP), the mean time to recur rence ranges from 8.0 to 45.5 months with a maximum of 253.2 months, suggesting that longer follow-up is necessary. 5,15,17,19–21,24,25,27,29,2202 While there are no studies investigating specific surveillance intervals and protocols, it is conceivable that follow-up duration should be at least 5 years, with certain disease etiologies (e.g., IP, ACC, ONB) requiring longer or even lifelong follow-up. B Role of assessment based on physical exam, signs, and symptoms Due to the anatomy of the paranasal sinuses, tumors of this region are often asymptomatic given the large poten

tial space, especially in a postoperative setting. Recurrent tumors have an opportunity to grow larger due to lack of defined tissue planes to prevent growth, resulting in advanced stage by the time symptoms are apparent. This is in contrast to the majority of head and neck malig nancies, where new symptoms are an early indicator of recurrence and recommendations for long-term imaging are based on physical exam findings and symptoms. 1,31,32 Three studies assessed the impact of patient symptoms on the diagnosis of recurrence (Table XXXIII.1). 7,11,12 Workman et al. assessed factors associated with recur rence in patients with recurrent SNM and determined that up to 49% of patients had symptoms at the time of recurrence diagnosis. 11 Furthermore, the majority of symptomatic recurrences were seen in stage IVB tumors and predicted worse survival, suggesting that development of symptoms is a late presentation in SNM recurrence. Zocchi et al. assessed risk factors associated with recur rence of SNM and reported that recurrence was diagnosed based on symptoms in only 6.3% of cases. 12 Of these cases, 25% were due to presence of distant metastases. Despite this, there was no significant difference in timing of diagnosis and OS between patients diagnosed symp tomatically compared to endoscopically or via advanced imaging. Conversely, Nyquist et al. demonstrated that, of 67 patients with recurrent SNM, 19 (28.4%) patients were symptomatic, which ultimately led to a diagnosis of recurrence in conjunction with further workup. 7 Diag nosis was ultimately made by endoscopy in 10 patients, physical exam in two patients, and imaging in seven patients. Given the unrestricted paths for tumor growth in the paranasal sinuses, tumors generally have room for expansion before symptoms become apparent, making diagnosis based on difficult. Symptoms are also gener ally nonspecific and may be limited only to epistaxis or nasal obstruction. 33 Furthermore, without the use of nasal endoscopy, physical exam is limited and generally only useful for detection of regional metastases. Despite the low yield in diagnosis, a comprehensive physical examina tion should be performed at each clinical visit following treatment. Despite this, Khalili et al. demonstrated that the presence of patient symptoms (e.g., intractable facial pain, recurrence epistaxis, severe headache, neck masses, cranial neuropathies) increases the PPV of both nasal endoscopy and imaging for detection of recurrence. 14 Additionally, in a cohort of SNM patients, Nyquist et al. demonstrated that physical exam detected recurrence in only 3.0% of cases; however, all of these patients were symptomatic. 7