xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

cameras and monitors becomes increasingly available in office settings, the ability to perform in-office sinonasal procedures has grown rapidly, including tumor biop sies. Strict adherence to operative biopsies is commonly regarded as unnecessary. In this section, the role of in office biopsies, indications, and technical considerations will be reviewed, as well as the order of sinonasal imaging and biopsy.

was consistent with in-office biopsies in 86.8% of cases, with three of the inconsistent cases being upgraded from benign inflammation to a benign or malignant lesion. No complications were reported. 155 Gomes et al. reviewed 150 patients who underwent punch biopsies of sinonasal lesions, reporting a high correlation with surgical pathol ogy (correlation coefficient 0.883, p < 0.001). 156 In contrast, Paz Silva et al. presented their 15-year experience with unilateral sinonasal disease ( n = 191), reporting that only two in-office biopsies were performed over this time period. The results of the biopsies did not change the clinical management in either case (IP and adenocarcinoma). They recommended against the use of in-office biopsies for unilateral sinonasal lesions, arguing that the biopsies do not change clinical management, must be confirmed by surgical biopsies, and incur additional unnecessary cost to the healthcare system. 157 In summary, in-office biopsies in patients with sinonasal lesions appear to be a safe alternative to operative biopsies in appropriately selected patients. There is a moderate risk of a false-negative diagnosis. One potential explanation for the false-negative results may relate to the tendency of sinonasal lesions to develop overlying polypoid edema, which may mask the underlying lesion. 155 A high degree of clinical suspicion may help clinicians identify cases of inaccurate diagnosis and prompt a surgical biopsy. Aggregate grade of evidence : C (Level 3: five studies; Level 4: one study) for diagnostic role of in-office biopsy and C (Level 3: three studies) for safety of in-office biopsy B Indications There are no studies specifically discussing the indications for in-office biopsy in sinonasal lesions. However, some cri teria can be summarized from the studies presented above. Lesions should be easily visualized with a nasal specu lum or endoscope within the nasal cavity, or accessible sinuses. 153,154 Lesions that are suspected to be vascular or in continuity with the intracranial space (i.e., encephalo celes) are considered to be contraindicated for in-office biopsies. 153,155 Unilateral vascular sinonasal lesions in ado lescent and young adult males should be treated with particular caution, given the specific risk of JNA, which would be contraindicated due to risk of severe hemor rhage. Deep-seated lesions within the sinonasal cavity (i.e., beyond the middle turbinate) and submucosal lesions may be more technically challenging, or pose an increased risk of bleeding and were not included in the studies presented. 152–155 Patient selection may be as important as the anatomical considerations. For example, patients on antiplatelet or anticoagulation therapy or those who are highly anxious or pain intolerant are not the ideal

A Role of in-office biopsies for sinonasal lesions

In-office biopsies provide opportunities to avoid the risks associated with general anesthesia, as well as the conve nience of performing a biopsy in the office with increased flexibility and accessibility versus the operating room. However, in-office biopsies may be limited by vascular ity and accessibility of the lesion, and the close proximity to nearby critical structures. Much of the available litera ture discussing the role of in-office biopsies for sinonasal lesions is based on expert opinion. There have been six ret rospective chart reviews on this topic. Five of these studies conclude in-office biopsies may be a useful alternative to surgical biopsies, with one study recommending against in-office biopsies (Table VII.1). Three studies commented on the safety of in-office biopsies, with no major compli cations reported. Lee reviewed 121 patients with unilateral sinus disease, including 35 patients with large polypoid or mass lesion who underwent in-office punch biopsy. The results of the in-office biopsies were congruent in 33 of 35 cases (94.3%). The two cases with inaccurate in-office biop sies were a lymphoma and an IP with malignant change. 152 Han et al. reviewed 521 patients who underwent in-office biopsies, which were then compared to surgical pathology reports. A total of 302 patients had nonneoplastic lesions, 159 had benign neoplastic lesions, and 60 had malignant sinonasal lesions. They did report 33 false negatives for malignancy, with the majority of the false negatives being reported as nonneoplastic lesions. In their review, they did not identify any complications (i.e., bleeding). 153 Tabaee et al. reviewed 61 patients, with a total of 69 in-office biopsies. They reported two patients had experienced mild, self-limited epistaxis postbiopsy and five patients (7%) had nondiagnostic biopsies. No major complications were seen. Twenty-five patients ultimately underwent surgery, and histopathologic agreement with in-office biopsy results was present in 82% of cases. Four of the incongruent cases involved biopsies that initially reported inflammatory change, but were upgraded to malignant or benign neoplasms following surgery. 154 Segal et al. reviewed 46 patients who underwent in-office biop sies for unilateral sinonasal lesions. Surgical pathology