Możliwości i ograniczenia techniki wewnątrznosowej operacji brodawczaka odwróconego nosa i zatok przynosowych – doświadczenia własne. Doniesienie wstępne

Abstract

The aim of this article is to present the technique of endonasal operation due to sinonasal inverted papilloma with it's limitations. Material consists of 21 patients operated with microscope and endoscopes. The tumor is resected in few pieces, but I try (especially in the beginning) to keep the resected tumor as much as possible in one part--which makes easier to assess the tumor borders. Mostly it is possible to leave at place the inferior turbinate and only the upper part of it must be resected with the tumor. Involvement of the frontal sinus is the contraindications for a purely endonasal approach, but this involvement must be assessed intraoperatively, due to preoperative CT scan limitations. Tumor involving the orbit is also contraindication to endonasal approach. Tumor is resected with anterior or total ethmoidectomy, because of coexistence of inflammations in sinuses. It is possible to resect tumor from all ethmoid cells and both sphenoid sinuses from endonasal approach. Mostly it is possible to resect tumor from maxillary sinus from endonasal approach. I leave a healthy mucosa of the maxillary sinus and resect only tumor and the margins. But in the case of prelacrimal recess involvement of the maxillary sinus or difficulty with removing tumor from the bottom of the sinus I open it through the Caldwell-Luck approach (2 cases). Postoperative cavity usually heals very well. In the presented material I didn't observed recurrence of the tumor and the patients are very well (17 patients: 1-4.5 years of observation, 4 patients: under 1 year of observation). Advantages of the endonasal method are: small bleeding, operation under magnification, good view around the corner in 70 degrees endoscope, leaving anterior bony wall of the maxillary sinus, leaving inferior turbinate and small post-op. disturbances, relatively small op. injury and quick healing, possibility of removing the tumor from the nose, ethmoidal and sphenoidal and maxillary sinuses (mostly), possibility to extend the operation with external approaches if needed. Disadvantages and limits of the method are: not possible to remove the tumor from frontal sinus, difficulty in removing the tumor from prelacrimal sac recess (sometimes combined approach needed).

Skull Base Inverted Papilloma: A Comprehensive Review

“…Massive skull base erosion, intradural or intraorbital extension, brain invasion, extensive involvement of the frontal [382] sinus or infratemporal fossa involvement [383], abundant scar tissue caused by previous surgery determined by preoperative CT or MRI, or the concomitant presence of squamous cell carcinoma were considered limitations for a purely endoscopic approach [92, 230, 359, 384, 385]. With more extensive tumors and lesions in difficult locations, better visualization can be obtained by a combined limited external and endoscopic endonasal approach or by radical external approaches.…”

“…This approach allows surgeons to see and access the tumor well without making incisions to the face or skull. EEA enables resection of benign and selected malignant sinonasal tumors and offers the benefits of no incisions to heal, no facial scars, no disfigurement to the patient, better functional and structural preservation of the sinonasal complex, minimal trauma to surrounding tissue, shorter recovery time, shorter hospitalization stay and lower costs, good success rates in preventing recurrence, excellent visualization, permiting removal of diseased mucosa while preserving vital anatomic structures, preserving the physiological properties of the mucosa while assuring proper ventilation of the nasal and sinus cavities [466], small bleeding, operation under magnification, good view around the corner in 70 degrees endoscope, leaving anterior bony wall of the maxillary sinus, leaving inferior turbinate and small postoperative disturbances, relatively small operative injury and quick healing, possibility of removing the tumor from the nose, ethmoidal and sphenoidal and maxillary sinuses (mostly), possibility to extend the operation with external approaches if needed, allowing for excellent postoperative surveillance, and better cosmetic outcomes than traditional open surgical approaches [348, 382, 428]. Endoscopic surgery proved to be successful even in large lesions affecting the posterior ethmoid, the sphenoid sinus, or the nasofrontal duct.…”

“…Performing an endoscopic surgery of tumor one has to be prepared to make an intraoperative conversion to open surgery [464]. Concerns with EES include obtaining clear margins given anatomic constraints, tumor seeding from piecemeal resection, inaccurate preoperative prediction related to variable sizes, and locations of the IP bases, particularly in the maxillary sinus and the frontal recess [363, 382, 403, 468]. Resection of the inferior turbinate to perform an endoscopic medial maxillectomy can cause atrophic rhinitis and shrinking of the maxillary sinus, resulting in difficulty following these patients for recurrence in the office; this can be avoided by inferior turbinate preservation [469, 470].…”