xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23262, Wiley Online Library on [02/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

12

KUANetal.

Cost

Cost comparison analyses have not been undertaken.

Value

Attachment-oriented surgery is beneficial to the treatment of benign as well as malignant sinonasal tumors in select cases where adequate surgical margins can be obtained safely. In cases of locally advanced lesions, utilizing an attachment-oriented technique must be balanced with the risk of leaving residual disease or needing to convert to an open or combined approach.

judgments

Benefits–harm assessment

Balance of benefits and harms.

Value

No studies have demonstrated a clear benefit of either en bloc or piecemeal resection. Since no study has found worse outcomes for piecemeal resection and improved visualization is accomplished with piecemeal resection in endoscopic endonasal approach (EEA), it is reasonable to resect sinonasal tumors in a piecemeal fashion when necessary for tumor visualization. an option based on tumor extension and sites of involvement. The decision on whether to proceed with en bloc versus piecemeal resection of sinonasal tumors should be made on a case-by-case basis. En bloc resection of the site of attachment/tumor origin should be attempted whenever possible. C (Level 2: two studies; Level 3: one study; Level 4: three studies; Level 5: one study) Attachment-oriented surgery allows for accurate clearance of disease with successful oncologic outcomes while sparing uninvolved structures. Minimizing morbidity is an especially important consideration in benign sinonasal tumors. Additionally, this technique may allow for shorter operating times and facilitates observation and follow-up aimed at the pedicle attachment site. Not all tumors are amenable to attachment-oriented surgery and the decision must be done on a case-by-case basis. It is highly surgeon dependent to accurately assess the sites of involvement or attachment. If negative margins are unable to be achieved, an open or combined approach may be necessary, especially in cases of malignant or aggressive pathologies. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms.

judgments

Policy level Recommendation. Intervention Endoscopic attachment-oriented surgery

should be considered to minimize morbidity when feasible and when

negative margins can likely be achieved. In cases of locally advanced disease, an open or combined approach may be necessary for disease clearance.

Policy level Option. Intervention Use of en bloc versus piecemeal resection is

Risk of tumor seeding

Aggregate grade of evidence

C (Level 2: one study; Level 3: two studies; Level 5: one study) Careful dissection technique and close inspection can minimize risk of tumor seeding. Spread of tumor via seeding presents a significant challenge in management often requiring aggressive surgery and/or adjuvant treatment of a separate site. Cost comparison analyses have not been undertaken. Since reports are limited to case series, there is no evidence to suggest that tumor seeding is impacted by surgical approach. Piecemeal resection could theoretically have a higher risk of tumor seeding due to tumor capsule violation, while open surgery may expose uninvolved soft tissues to tumor. based on tumor seeding is an option. There is no evidence that an open or endoscopic approach to sinonasal tumors carries a higher risk of tumor seeding. Given the lack of case reports, either approach appears to have a low risk of tumor seeding. Upfront recognition and prevention are key to minimize this risk. Balance of benefits and harms.

Benefit

Treatment of sites of attachment

Harm

Aggregate grade of evidence

Benefit

Cost

Benefits–harm assessment

Value

judgments

Harm

Policy level Option. Intervention Consideration of approach and technique

Cost

Benefits–harm assessment

(Continued)