Advanced Sinonasal Malignant Tumors Treated by Endoscopy-Assisted Approaches

Background: Endoscopic surgery has played an important role in the treatment of selected sinonasal malignant tumors, including exclusively endoscopic resections. Another use of the endoscopic technique is the endoscopy-assisted approach, when a classical external approach is overlapped with endoscopic surgery, which is used as a tool to assist the removal of the lesion, especially with deep surgical margins.

Objectives: The aim of this study was to describe how the endoscopy-assisted approaches can be useful in the treatment of advanced sinonasal malignant tumors.

Patients and Methods: From June 2005 to July 2014, 22 patients with sinonasal malignant tumors were treated with classical external approaches and with endoscopy-assisted approaches at a single institution. All these surgeries were performed in patients with local advanced tumors.

Results: A total of 22 patients underwent external approaches, with Weber-Ferguson performed in 15 patients, midfacial degloving in 2 patients, transpalatal approach in 2, infratemporal fossa approach type C in 2 and, Caldwell-Luc in 1 patient. In all patients, an endoscopy-assisted approach was also used. Histopathology types were squamous cell carcinoma in 11 patients, adenoid cystic carcinoma in 8 cases, 1 melanoma, 1 sarcoma, and 1 ex pleomorphic adenoma carcinoma. The use of endoscopy-assisted approach allowed a more extensive surgery in 13 patients. Of these, negative microscopic margins were achieved in 9 of 13 cases. The surgeries were extended to sphenoid sinus, posterior ethmoid, infratemporal fossa, frontal sinus, anterior base of the skull, inferior orbital fissure, and V2 or vidian nerves. In nine patients, the type or extension of surgery was changed because of findings of the endoscopy-assisted approach. In four of these nine patients, the tumor was completely resected combined endoscopic approach with a less complex surgery, avoiding surgeries with higher morbidity. In two patients, an unscheduled craniotomy was necessary and in two other patients, a planned craniotomy was not performed. One patient had an advanced nonresectable tumor.

Discussion: Currently, there is no consensus of the validity of endoscopic approaches in the treatment of sinus cancer diseases. However, it is clear that endoscopic surgery can improve the resection margins of the deep sinus cavity. Surgeries for tumors that reach the ethmoid roof, sphenoid sinus, or that are beyond the posterior maxillary wall have clear benefits with these combined approaches. In our study, the endoscopic phase was able to improve the size of the surgery in 13 cases. In addition, the final margins were free as a direct result of this technique in seven cases. In nine cases, the endoscopic phase changed the initial planned surgery, resulting in a smaller or more ample approach. The endoscopic surgeries combined with classical open approaches were crucial in modifying the standard approaches, demonstrating the value of this technique in advanced sinonasal malignant tumors, especially in cases where doubts exist about the need for a craniotomy surgical phase.

Conclusion: Endoscopy-assisted approach is a good complementary technique for the surgical treatment of advanced malignant sinonasal tumors. It may improve the extension of resection with negative margins easily reached, and additionally, the surgical plan can be changed because of intraoperative findings.