Minimally invasive endoscopic resection for the treatment of sinonasal malignancy: the outcomes and risk factors for recurrence

Endoscopic Craniofacial Resection, an Emerging Epitome of Anterior Skull Base Tumor Resection

Anterior skull base (ASB) malignancies have conventionally been treated with craniofacial resection (CFR), yet this approach is associated with significant morbidity and mortality rates. Recent advancements in endoscopic surgical techniques offer a promising alternative. This study aims to evaluate the morbidity, mortality, recurrence, metastasis, and survival rates of open CFR versus endoscopic CFR for ASB malignancies. A retrospective analysis was conducted on 24 patients who underwent surgery for sinonasal malignancies between January 2017 and July 2023. Patient demographics, tumor characteristics, surgical details, complications, and outcomes were assessed. Surgical procedures included endoscopic resection or open CFR. Statistical analyses were performed using Fisher's exact test and Wilcoxon rank sum test. Survival was estimated using the Kaplan-Meier method. Among 24 patients, 18 underwent CFR, with 13 receiving endoscopic CFR and 5 undergoing open CFR. Male predominance (mean age 40.8 years) and squamous cell carcinoma were common. Endoscopic CFR showed favorable outcomes in terms of visualization, bleeding, surgery duration, complications, and cosmesis compared to open CFR. All endoscopic patients underwent piecemeal resection, with 12 achieving negative margins. Postoperative radiotherapy was administered to all patients. Mean survival time was similar between endoscopic (709±5.5 days) and open (707±7 days) groups, with no significant difference in recurrence rates. Endoscopic CFR emerges as a feasible alternative to open CFR for ASB malignancies, offering comparable outcomes with reduced morbidity. Advancements in endoscopic techniques demonstrate promising results, highlighting the potential of endoscopic surgery in this complex anatomical region. Further studies are warranted to validate these findings and establish endoscopic CFR as a standard approach for ASB malignancies.

Impact of Prolonged Operative Time on Complications Following Endoscopic Sinonasal Surgery

OBJECTIVE

To determine how prolonged operative time (POT) impacts 30-day outcomes in patients undergoing endoscopic sinonasal surgery (ESNS).

STUDY DESIGN

Retrospective study.

METHODS

Data from patients who underwent ESNS (nonsinus, sinus, and extended sinus) between 2005 to 2018 were collected from the American College of Surgeons National Surgical Quality Improvement database. Univariate and multivariate analyses were performed to evaluate the effect of POT on postoperative outcomes.

RESULTS

Among 1,994 ESNS cases, 495 nonsinus procedures, 1,191 sinus procedures, and 308 extended sinus procedures were identified. Median OT was 90 minutes (interquartile range [IQR], 51-165 minutes) for nonsinus procedures, 113 minutes (IQR, 66-189 minutes) for sinus procedures, and 187 minutes (IQR, 137-251 minutes) for extended sinus procedures. Other than older age (P = .008), POT was not significantly associated with baseline demographics and comorbidities for patients undergoing non-sinus procedures. Older age (P < .001), White and Black race (P < .001), ASA physical classifications III or IV (P < .001), and several preoperative comorbidities, including obesity (P = .045), and hypertension (P < .001) were associated with POT for sinus procedures. Older age (P = .030), male sex (P = .010), and lower body mass index (P = .004) were associated with POT for extended sinus procedures. After risk-adjustment, POT was independently associated with prolonged hospital stay (LOS) for all procedure categories, and associated with overall surgical complications and postoperative bleeding for sinus and extended sinus procedures specifically.

CONCLUSION

POT is independently associated with several adverse outcomes following ESNS, including prolonged LOS, overall surgical complications, and bleeding. Preoperative planning should include optimizing modifiable patient risk factors for POT and identifying surgeon-specific factors to enhance surgical efficiency.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:51-58, 2023.

Surgical Interventions for Advanced Parameningeal Rhabdomyosarcoma of Children and Adolescents

Owing to its rarity, rhabdomyosarcoma of the head and neck (HNRMS) has seldom been discussed in the literature. As most of the data is based only on the retrospective experiences of tertiary healthcare centers, there are difficulties in formulating a standard treatment protocol. Moreover, the disease is poorly understood at its pathological, genetic, and molecular levels. For instance, 20% of all histological assessment is inaccurate; even an experienced pathologist can confuse rhabdomyosarcoma (RMS) with neuroblastoma, Ewing’s sarcoma, and lymphoma. RMS can occur sporadically or in association with genetic syndromes associated with predisposition to other cancers such as Li-Fraumeni syndrome and neurofibromatosis type 1 (von Recklinghausen disease). Such associations have a potential role in future gene therapies but are yet to be fully confirmed. Currently, chemotherapies are ineffective in advanced or metastatic disease and there is lack of targeted chemotherapy or biological therapy against RMS. Also, reported uses of chemotherapy for RMS have not produced reasonable responses in all cases. Despite numerous molecular and biological studies during the past three decades, the chemotherapeutic regimen remains unchanged. This vincristine, actinomycin, cyclophosphamide (VAC) regime, described in Kilman, et al. (1973) and Koop, et al. (1963), has achieved limited success in controlling the progression of RMS. Thus, the pathogenesis of RMS remains poorly understood despite extensive modern trials and more than 30 years of studies exploring the chemotherapeutic options. This suggests a need to explore surgical options for managing the disease. Surgery is the single most critical therapy for pediatric HNRMS. However, very few studies have explored the surgical management of pediatric HNRMS and there is no standard surgical protocol. The aim of this review is to explore and address such issues in the hope of maximizing the number of options available for young patients with HNRMS.