Craniofacial resection for malignant nasal and paranasal sinus tumors assisted with the endoscope

Surgical Management of Sinonasal Cancers: A Comprehensive Review

Surgery plays an important role in the treatment of sinonasal cancer. Many surgical approaches have been described, including open, endoscopic, or combined approaches. The choice is based on several criteria: general criteria related to the oncological results and morbidity of each technique, specific criteria related to the tumor (tumor extensions, tumor pathology), the patient, or the surgeon himself. The aims of this review are (i) to provide a complete overview of the surgical techniques available for the management of sinonasal malignant tumors, with a special focus on recent developments in the field of transnasal endoscopic surgery; (ii) to summarize the criteria that lead to the choice of one technique over another. In particular, the oncological outcomes, the morbidity of the different techniques, and the specificities of each histologic subtype will be discussed based on a comprehensive literature review.

Locally advanced maxillary sinus carcinoma controlled by para-latero-nasal approach

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Treatment of maxillary sinus carcinoma depends on its local and regional extension. It consists on a complete surgical excision followed most often by radiation therapy.

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Surgical excision corresponds to a partial, total, or extended maxillectomy, with resection of the neighboring anatomical structures affected by the tumor. This tumor resection must respect three precise rules: The most complete possible excision of the tumor, adequate excision margins in order to avoid possible recurrence, while combining the most possible aesthetic result.

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External approach is a therapeutic alternative when tumor extension does not allow satisfactory endoscopic resection.

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Regardless of the surgical approach, maxillary sinus carcinoma has an overall survival rate of 63% at 12 months, 20% at 24 months and 9% at 5 years.

Sino-nasal cancers are a rare pathology, with an incidence of 0.2–0.8% of all cancers, and less than 5% of ENT cancers. The site that is most often affected is the maxillary sinus in 35% of cases, followed by ethmoid sinus (30%) and of the nasal cavity in (16%). Several histological variants are described, but squamous cell carcinoma remains the most frequent in the maxillary sinus. Its diagnosis is often late making local control very difficult. Multimodal treatment allows an improvement in the survival rate compared to single treatment.

Due to the progress of endoscopic surgery, external surgery is neglected. With this work we want to highlight the value to the external approach, especially in advanced cases.

A combination of modified transnasal endoscopic maxillectomy via transnasal prelacrimal recess approach with or without radiotherapy for selected sinonasal malignancies

An external approach for resection of sinonasal tumors is associated with increased morbidity. Therefore, we employed a modified transnasal endoscopic maxillectomy combined with pre and/or postoperative radiotherapy for early stage maxillary carcinomas. It aims to evaluate our early experience with endoscopic resection of selected malignant sinonasal tumors. The medical and radiology records of patients who underwent endonasal endoscopic resection of malignant sinonasal tumors between 2008 and 2012 were retrospectively reviewed. Ten cases of selected malignant tumor were performed to resect by modified transnasal endoscopic maxillectomy. All the patients were without evidence of disease at a mean follow-up of 26.8 months. No major complications were recorded. The mean hospitalization stay was 6.6 days. In very carefully selected cases of malignant tumors, modified transnasal endoscopic maxillectomy is acceptable. The postoperative complication rate is low, cosmetic outcome is excellent and patients do not require a long hospitalization.

Celebrating the golden anniversary of anterior skull base surgery: reflections on the past 50 years and its historical evolution

With its inception nearly half a century ago through the pioneering work of Dandy, McLean, and Smith, anterior skull base (ASB) surgery is a relatively young discipline. It became a distinct entity in 1963 when Ketcham popularized the combined transcranial transfacial approach for en bloc resection of tumors of the paranasal sinuses extending into the anterior cranial fossa. However, because these procedures resulted in major morbidities and mortalities, alternative modes of treatment were sought. Since the 1970s, the introduction and promotion of the surgical endoscope by Messerklinger, Stammberger, and Kennedy, commenced the era of endoscopic sinus surgery. Thaler and colleagues described the utility of the endoscope for ASB surgery at the turn of the century. This allowed direct visualization and safer, more accurate removal of tumors. In 2001, Casiano reported the first purely endoscopic endonasal ASB resection, a novel technique that has been adopted by major skull base centers. The success of ASB surgery can be attributed to both the development of the skull base team as well as improvements in surgical techniques, instrumentation, and visualization technology. In this article, we review the historical evolution of ASB surgery as we approach the 50th anniversary since its recognition as a distinct entity.

[Craniofacial resection for tumors of paranasal sinuses involving the anterior skull base]

INTRODUCTION

Craniofacial resection is a treatment of choice for paranasal malignant and benign tumors invading the skull base.

THE AIM OF THE STUDY

In this article the authors present the experience in craniofacial resection for malignant tumors invading the anterior skull base.

MATERIALS AND METHODS

The material consisted of four patients operated in the Department of Otolaryngology and Laryngology Oncology CM UMK between 2007 and 2010. The patients were treated for malignant neoplasms of the paranasal sinuses with anterior skull base involvement. THe age range of the group were between 60 and 75 years. Of these patients three were females and one male.

RESULTS

We performed a lateral rhinotomy for laryngological acces for the tumor. The neurosurgeon performed anterior skull base osteotomy at and appropriate site above. The patients recovered uneventfully. The follow up period ranged between 13 and 42 months. The overall 3-year survival for all patients in our series was 66,6%.

CONCLUSIONS

Combined craniofacial resection of tumors of the anterior skull base is an effective approach for the management of these pathologies. This type of approach in elderly patients over 70 years old could be associated with increased mortality and complications leading to poorer outcome.

Endoscopic resection and topical 5-Fluorouracil as an alternative treatment to craniofacial resection for the management of primary intestinal-type sinonasal adenocarcinoma

Introduction. Intestinal-type adenocarcinoma of the sinonasal tract is very rare and is responsible for less than 4% of tumours of the sinuses. Craniofacial resection has been the mainstay of treatment for many years; however, techniques for endoscopic resection are constantly being developed. Discussion. The use of transnasal endoscopic resection (TER) and topical chemotherapy applications as an alternative to cranio-facial resection (CFR) is discussed. TER offers advantages over CFR in terms of fewer intra-operative complications and an improved cosmetic outcome. Survival and metastatic rates are similar between both procedures. Patients with locally invasive tumours are better managed with CFR. Topical applications of 5-Fluorouracil has been shown to be effective in increasing survival in patients with sino-nasal malignancy. Conclusion. Trans-nasal endoscopic resection and topical 5-Fluorouracil could potentially offer an acceptable alternative treatment to the standard of cranio-facial resection. This should be investigated in trials with a longer followup period than this paper in order to directly compare the two treatment modalities.

Endoscopic endonasal surgery in the management of selected malignant naso-ethmoidal tumors

OBJECTIVE

The objective of this study was to report the cases of three patients with sinonasal malignant tumors who underwent en bloc tumor resection using endoscopic endonasal approaches, and to discuss the advantages and limitations of endoscopic endonasal tumor resection.

METHODS

Three patients with malignant naso-ethmoidal tumors underwent en bloc resection with endoscopic endonasal approach.

RESULTS

In very carefully selected cases of naso-ethmoidal malignant tumors that were preoperatively evaluated on endoscopic findings and magnetic resonance imaging to be limited to within the nasal cavity and/or ethmoid sinus and to have some safe margins between the tumor and skull base and/or lamina papyracea, tumors were resected en bloc using endoscopic endonasal approaches. A case of cerebrospinal fluid leakage was safely managed with the endoscopic approach.

CONCLUSIONS

In selected T1-T2 naso-ethmoidal malignant tumors with some safe margins, endoscopic endonasal surgery may offer a satisfactory alternative to external procedures.

Nasal downward swing approach coupled with the facial dismasking flap

OBJECTIVE

For the purpose of an en bloc resection with sufficient margins, a wide surgical field is necessary. We have reported on the application of a facial dismasking flap for removals of craniofacial lesions in order to provide a better surgical field with less morbidity. In this paper, we are introducing a new method, which is called the "nasal downward swing approach".

METHODS

This approach is a modification of the facial dismaking flap, which elevates the nasal bone along with the facial skin.

RESULTS

This approach offers an extremely wide surgical field on the facial front, especially the nasal cavity, while keeping scarring or facial paresis down to a bare minimum.

CONCLUSION

This approach helps to preserve the entire shape of the nasal bone in particular, therefore, a good surgical option for pediatric patients.