Endoscopic Approach to Sinonasal Malignancies Stirs Debate

Moreover, having pathologists on staff who understand the variety of sinonasal tumors so an exact diagnosis can be made is critical, said Dr. Batra. Endoscopy and CT scan of the sinuses are paramount to delineate the extent of the tumor. Many cases require an MRI because of its ability to delineate soft tissue involvement at the skull base and orbital interfaces, he said. PET scan allows for detection of regional and distant disease, he said.

Weighing the Options

Certainly, in some circumstances, an open operation will make more sense than endoscopy, said Dr. Snyderman, adding that specific areas of the head and neck are difficult to access endoscopically. Coming up the front of the skull is especially hard to visualize with an endoscope inserted through the nose, he said. Additionally, if a malignancy is big and growing into superficial tissues or is invading the eye, an open approach may be more practical, he said.

However, tumor size rarely makes a difference as to whether the surgeon needs to use an open or endoscopic approach, said Dr. Snyderman.

Tumor size is not a contraindication to an endoscopic approach, agreed Dr. Batra. Tumors can be bulky and still be removed via endoscopy, he said.

However, patients with extensive dural or brain involvement or involvement over the lateral orbit will likely require a bifrontal or subfrontal craniotomy to clear the superior margin, said Dr. Batra. Additionally, patients with involvement of the facial soft tissues, extensive lacrimal pathway infiltration, or anterior table of frontal sinus may be better served by the open approach, he said.

Not every tumor is best managed by an only an endoscopic or an open approach, said Dr. Batra. Surgeons may opt to combine the two techniques to remove tumors, he said. Some surgeons will also perform an open procedure then put the endoscope in to look at the results or to biopsy residual tissue, he added.

Additionally, to avoid facial incisions, surgeons may choose to use endoscopy to resect the intranasal portion of the tumor and perform a craniotomy if the cancer has spread to the intracranial region, noted Dr. Kraus.

Individualized Treatment the Bottom Line

Because all patients, surgeons, and tumors are different, treatment ultimately needs to be individualized, said Dr. Batra.

Dr. Batra and his colleagues present their cases of malignant sinonasal tumors to a tumor board consisting of endoscopic and traditional head and neck surgeons, radiation oncologists, and medical oncologists to best formulate a treatment plan.