Endoscopic Approach to Sinonasal Malignancies Stirs Debate

During the recent Ogura lecture, Dr. Levine noted that 60 patients have now been treated, and that the 20-year disease specific survival is 81.2%.

In other recent research supporting the use of endoscopy, a 10-year retrospective analysis (Nicolai P et al. Am J Rhinol 2008; 22:308-16) evaluated 184 patients with nasoethmoidal malignancies possibly involving the adjacent skull base. Of these, 134 were treated with an exclusive endoscopic approach (EEA) and 50 were treated with a cranioendoscopic approach (CEA).

Researchers found that the five-year disease-specific survival was 91.4% for the EEA group and 58.8% for CEA patients, respectively, indicating that endoscopic surgery, when properly planned and in expert hands, may be a valid alternative to standard surgical approaches for the management of malignancies of the sinonasal tract.

Additionally, in a prospective cohort study (Lund V et al. Am J Rhinol 2007;21: 89-94), 49 patients underwent an endoscopic resection as an alternative to craniofacial resection for pathologies including adenocarcinoma, malignant melanomas, and olfactory neuroblastomas. Thirty-seven patients received radiotherapy and 14 received adjuvant chemotherapy.

The overall survival of patients was 88% at five years. Mean hospital stay was five days, with no significant postoperative complications. Thirty-six patients were alive and well at follow-up (a mean of 36 months), seven had residual disease, and six patients had died. Three patients were converted to craniofacial resection. Researchers concluded that endoscopic resection may provide an alternative to craniofacial resection in selected cases of sinonasal malignancy.

Benefits of Endoscopy

Despite the debate surrounding endoscopy and the lack of long-term research, most physicians can agree that the technology has a number of potential benefits.

An endoscopic approach results in less morbidity for the patient, less manipulation of the brain tissue, and faster and easier recovery compared with open surgery, said Dr. Snyderman.

Additionally, patients may have better cosmetic results because endoscopy avoids facial incisions, said Dr. Batra. However, even though endoscopic surgery can facilitate a quicker recovery and reduce complications, it shouldn’t be viewed as a panacea, he said.

The benefits of endoscopy, or any other approach, open surgical or otherwise, are irrelevant if the tumor isn’t fully controlled, cautioned Dr. Osguthorpe.

Risks of Endoscopy

One of the biggest challenges that exists with endoscopic resection is the ability to reconstruct the dura in patients undergoing resection intracranial extension, including involvement of the dura and the brain, said Dr. Kraus.