xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

Surgical approach With growing utilization and experience, research, and advanced understanding of indications and limitations of the endoscopic approach, many tumors, both benign and malignant, may be oncologically treated via min imally invasive means. The open approach remains of critical importance for those tumors that may not be fully resectable via an endoscopic approach (e.g., involvement of skin and soft tissue, gross orbital invasion, bony facial skeleton). Regardless of the choice of open, endoscopic, or combined approaches, the principles, margin status, and overall extent of tumor resection should remain the same and should be selected based on patient factors and surgical team experience. In many cases, the endo scopic approach is associated with shorter recovery times and lower morbidity, with generally comparable oncologic outcomes. Open versus endoscopic approach for sinonasal tumors Aggregate grade of evidence C (Level 2: one study; Level 3: nine studies; Level 4: 45 studies) Benefit Compared to open surgical approaches, endoscopic surgical approaches generally

Benefits–harm assessment

A preponderance of benefit over harm exists for the use of endoscopic surgery approaches in low-stage tumors. For high-stage tumors, benefits of endoscopic surgical approaches when negative surgical margins can be achieved, including reduced morbidity and shorter recovery time, may outweigh potential harms depending on the comfort and experience of the surgical team. Current conclusions are primarily based on limited data. Many studies have small sample sizes and cannot adjust for tumor stage, patient comorbidities, covariates, or tumor type. The above recommendations are based on data quality, evaluation of surgical outcomes, outcomes grouped by tumor stage, and systematic reviews that demonstrate consistent findings across many studies. Most studies include a heterogenous grouping of SNM, preventing clear recommendations for approach by tumor type or tumor location. Larger prospective studies are needed to develop clear recommendations for surgical approach, particularly in late-stage tumors where data on endoscopic approach outcomes are lacking. endoscopic surgery should be considered the first-line surgical approach to reduce morbidity and recovery times while achieving similar oncologic outcomes to open surgery. In advanced-stage tumors (such as T3–4) endoscopic SNM surgery approaches should be considered on a case-by-case basis according to the tumor location, surgeon experience, patient preference, and tumor grade, with consideration of the risk–benefit ratio of alternative treatment options.

Value

judgments

yield reduced morbidity and shorter recovery times with similar oncologic outcomes in low-stage tumors (stage T1–2; Kadish A–B) and certain high-stage tumors (stage T3–4; Kadish C-D) Failure to achieve GTR with negative margins in extensive or high-stage tumors, which could lead to tumor progression or invasion of surrounding structures. Potential for higher risk of cerebrospinal fluid (CSF) leak. Reduction in cost is possible with EEA related to reduced operative times, shorter hospital length of stay (LOS), and reduced morbidity. (Continued)

Policy level Recommendation for EEA for low-stage tumors. Option for EEA for high-stage tumors. Intervention In most low-stage sinonasal tumors,

Harm

Cost