Endoscopic Approach to Sinonasal Malignancies Stirs Debate

With tissue flap repair, the risk of CSF leaks during endoscopic surgery is now comparable to traditional techniques, noted Dr. Snyderman. In a consecutive series of 150 patients undergoing endoscopic skull base surgery with septal mucosal flap reconstruction, the incidence of a postoperative CSF leak was 4%, he said, citing unpublished data.

One important element to preventing CSF leaks during minimally invasive resection is separating the intracranial and sinonasal components with multilayered skull base reconstruction, said Dr. Batra.

Pedicled nasoseptal flap based on the posterior septal artery has been described (Hadad G et al. Laryngoscope 2006;116: 1882-6) as an alternative to the traditional multilayered reconstruction, noted Dr. Batra.

In research of Dr. Batra’s that has not yet been published, he and his colleagues observed a CSF leak rate of 6.5% with the multilayered approach in patients with anterior skull base tumors. These two persistent leaks resolved with lumbar drainage without need for additional surgery.

The decision of lumbar drain placement for CSF leak management is done on a case-by-case basis, explained Dr. Batra. In his series of patients, only 25% required lumbar drains, helping the remaining 75% avoid drains and their associated morbidity.

In addition to CSF leaks, the risks of endoscopy are similar to those of open surgery and include bleeding and damage to vision or the brain, said Dr. Osguthorpe, but such risks tend to diminish with endoscopic approaches to early-stage lesions, as fewer soft tissues are disrupted with the approach.

Spilling tumor cells that could potentially implant in sinonasal tissue is a theoretical concern of endoscopic procedures that remove malignancies a little at a time, noted Dr. Snyderman.

However, most tumors hang down into the nasal cavity, so physicians are rarely at risk of violating healthy tissue when they remove the malignancy, he said.

In more than 10 years of performing endoscopic resections of sinonasal malignancies, Dr. Snyderman hasn’t seen any cancer implants attributable to endoscopic techniques.

Necessary Expertise

To avoid associated risks, minimally invasive endoscopic resection of sinonasal malignancies needs to be performed by physicians with endoscopy training as well as a background in head and neck surgery, noted Dr. Snyderman. They need to be able to get all the cancer out and not rely on other therapies such as radiation to mop up afterward, he said.

Endoscopic surgeons performing resection of sinonasal tumors require formal training in head and neck oncology and supporting disciplines, said Dr. Kraus. Working with a neurosurgeon who is experienced with an endoscope is also beneficial, he added.