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

20

KUANetal.

Benign orbital lesions and neoplasms This section covers updated evidence surrounding endo scopic management of benign intraconal tumors since ICSB2019. 5 Since then, the Orbital Resection By Intranasal Technique (ORBIT) classification was developed to classify surgical complexity of intraconal orbital lesions. Inflam matory conditions of the orbit, such as IgG4-related ophthalmic disease (formerly orbital pseudotumor) and Tolosa–Hunt syndrome (THS), are also part of the differen tial diagnosis of oculo-orbital symptoms and are discussed in this section as well. Endoscopic resection of intraconal orbital lesions

Value

Endoscopic intervention requires familiarity with endoscopic surgery and endoscopic equipment including tools for hemostasis.

judgments

Policy level Recommendation. Intervention In experienced institutions, endoscopic and

combined approaches are the preferred surgical approaches for management of JNA.

Techniques for hemostasis in JNA

Aggregate grade of evidence

C (Level 4: eight studies)

Benefit

Preoperative embolization reduces intraoperative bleeding and may reduce LOS, surgical duration, and need for perioperative blood transfusion. Risk of inadvertent embolization of ICA-supplied structures via internal–external anastomosis, puncture site hematoma, contrast exposure. Possible additional cost of ∼ $36,500 and need for prehospitalization for procedural planning. The procedural risks of embolization are significantly less than the perioperative benefit of reduced bleeding and improved visualization; the procedural cost may be offset by reduced LOS and need for blood products. Choices for or against specific embolic agents or instruments for intraoperative hemostasis should be guided by surgeon/interventionalist experience and preference.

Aggregate grade of evidence

C (Level 2: two studies; Level 4: nine studies)

Benefit

Higher rates of GTR with reduced local morbidity relative to open approaches among patients with lesions medial to optic nerve and/or inferior to POR. Risk of diplopia related to necessity for translaminar approach.

Harm

Harm

Cost

Cost

Associated costs with surgery and preoperative evaluations. Balance of benefits and harms.

Benefit–harm assessment

Benefits–harm assessment

Value

No study to date has compared endoscopic and open approaches directly. However, in appropriately selected patients (e.g., tumor medial to the optic nerve and/or inferior to POR), endoscopic orbital surgery was preferred to traditional open approaches with reduced external morbidity. Not all patients are candidates for an endoscopic orbital approach, with tumors lateral and superior to POR and/or concern for invasion of local structures.

judgments

Value

judgments

Policy level Recommendation. Intervention For advanced tumors, and possibly for locally

limited tumors, preoperative embolization of ECA feeder vessels reduces perioperative bleeding, may reduce LOS and need for transfusion, and should be considered.

Policy level Option. Intervention Endoscopic orbital surgery approach may be

offered in lieu of open surgery by trained multidisciplinary orbital teams following appropriate workup and candidacy determination.

Congenital midline nasal masses Congenital midline nasal masses (CMNMs) are relatively rare (estimated to occur in between 1:20,000 and 1:40,000 births). They are composed of dermoid and epidermoid cysts, glial heterotopia, and meningoencephaloceles. Early treatment is indicated for aesthetic concerns and to prevent infection and intracranial complications. Many lesions may be approached endoscopically, including those that extend intracranially, though some lesions extend through the skin and may benefit from a combined approach.

Section 3: Malignant neoplasms Table I.1 provides a summary of the LOE surrounding histopathology-based management of SNM. Sinonasal squamous cell carcinoma De novo sinonasal SCC is the most common SNM, accounting for 40%–50% of cases. This section includes