xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

Policy level

Recommendation for EEA for IP and other benign lesions. Option for EEA for malignant tumors based upon anatomical involvement and at the discretion and comfort of the surgeon. technique for the resection of most IP confined to the maxillary sinus to reduce morbidity and recovery times while achieving similar outcomes to open surgery. Endoscopic maxillary surgical approaches should be considered on a case-by-case basis for malignancies and other benign tumors in the maxillary according to the tumor location, surgeon experience, patient preference, and tumor grade, with consideration of the risk–benefit ratio of alternative treatment options.

With the advent of extended maxillary sinus approaches such as medial maxillectomy, modified Denker maxillec tomy, and the prelacrimal approach, tumors involving all walls of the maxillary sinus, including the anterior wall, may now be accessed via a minimally invasive approach with generally low morbidity. Such approaches have increasingly become the first-line choice for manag ing benign maxillary neoplasms (e.g., inverted papilloma [IP]), and may also have value for surgical treatment of malignancies. Extended endoscopic approaches to the maxillary sinus Aggregate grade of evidence C (Level 4: 12 studies) Benefit Compared to open maxillary surgical approaches, endoscopic maxillary surgical approaches generally yield improved

Intervention EEA should be the first-line surgical

Management of the orbit ∙ Various grading systems exist for staging orbital invasion by sinonasal tumors. ∙ Orbital resection, whether partial or complete (e.g., exenteration) or via endoscopic or open approaches, should be guided by oncologic principles. Limited peri orbital involvement by tumor may often be locally resected with favorable outcomes and functional preser vation, but involvement of the extraocular muscles, optic nerve, and intraconal space may be more effec tively treated with exenteration. Consideration should be given to orbital preservation whenever possible, but only if negative margins can be achieved. There is emerging evidence to suggest that orbital preservation may be possible with induction chemotherapy, though currently no upfront predictors of response are known. ∙ The nasolacrimal system may undergo stenosis or scar ring after surgical and/or radiation therapy. Posttreat ment epiphora, which is estimated to occur in up to 15% of cases, should be routinely assessed. Margin analysis Obtaining negative surgical margins remains the key goal of surgical resection for most SNM, and careful planning

morbidity and shorter recovery times with comparable or even improved outcomes based on the IP literature. Potential for failure to achieve GTR with negative margins in extensive or high-stage tumors, particularly those with bony maxillary wall and/or palatal invasion, which could result in tumor progression or surrounding structure invasion. Reduction in cost is possible with EEA related to reduced operative times, shorter hospital LOS, and reduced morbidity. Preponderance of benefits over harms. Current conclusions are primarily based on limited data focused on inverted papilloma (IP) resection. It is unclear how these data will translate to treatment of other primary maxillary neoplasms, including malignancies, especially those with bony invasion. Moreover, many studies have small sample sizes and cannot adjust for patient comorbidities, covariates, or tumor stage. Larger prospective cohort studies are needed to develop clear recommendations for maxillary surgical approach in malignancies. (Continued)

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Benefits–harm assessment

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judgments