European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 405–411

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Review

Development of minimally invasive surgery for sinonasal malignancy

A. Moya-Plana a,∗ , D. Bresson b , S. Temam a , F. Kolb c , F. Janot a , P. Herman d
a
Département de cancérologie cervico-faciale, Institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France
b
Service de neurochirurgie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
c
Département de chirurgie plastique et reconstructrice, Institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France
d
Service de chirurgie ORL et cervico-faciale, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France

a r t i c l e i n f o a b s t r a c t

Keywords: Sinonasal malignancies are rare and histologically heterogeneous. Treatment is complicated by tumor
Sinonasal malignancy aggressiveness and location near critical anatomic structures (orbita, skull base, etc.). This low incidence
Transfacial approach and histologic diversity make prospective studies unfeasible, and thus therapeutic guidelines difficult
Endoscopic surgery
to establish. The gold standard for surgery is a transfacial approach, with craniofacial resection in case
Skull-base surgery
of skull-base involvement. However, these techniques are associated with non-negligible perioperative
morbidity. In the past two decades, endoscopic surgery has made major progress, extending its indica-
tions: initially developed for functional sinus surgery, it is now applied in benign skull-base pathologies
(CSF leakage, meningocele, etc.) and, more recently, in sinonasal malignancy. Literature analysis shows
a significant decrease in morbidity and improved quality of life associated with endoscopic endonasal
surgery, with oncologic safety and efficacy in well-selected cases, although dependent on operator expe-
rience. Additional studies with longer follow-up and comparison between histologic subtypes will be
needed.
© 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction the state of the art in endoscopic surgery, leading to oncologic

Sinonasal malignancy is rare, and shows wide heterogeneity on
histology [1,2]. Treatment is complicated by local aggressiveness
and proximity to critical neurovascular structures such as the orbita
and skull base [2]. The gold standard attitude is transfacial surgery
or, in case of skull-base extension, craniofacial resection combin-
ing subfrontal or transbasal craniotomy and a transfacial approach.
Endoscopic endonasal surgery has greatly progressed in the last 20
years, broadening its indications. It was first introduced as func-
tional endoscopic sinus surgery (FESS), and later developed for
benign skull-base pathologies such as cerebrospinal rhinorrhea and
meningocele. More recently, transnasal-transethmoid approaches
were developed, enabling an endoscopic approach to the ante-
rior level of the skull base, with transnasal craniotomy if needed
[2]. This technical progress, combined with improved understand-
ing of the natural history of sinonasal malignancy [3,4], has made
endoscopic endonasal surgery a genuine alternative to transfacial
approaches [3–11]. The present study first summarizes the clinico-
pathologic features of these tumors and the principles of treatment,
then describes the principles of transfacial surgical resection and
∗ Corresponding author. Tel.: +33 06 86 81 25 02.
E-mail address: antoinemoya@gmail.com (A. Moya-Plana).
application, indications for which are precisely defined.
2. Sinonasal malignancy: overview
Sinus and nasal cavity malignancy accounts for 3–5% of head and
neck cancer [1], with incidence of 5–10 per million per year [12–15].
Clinical sinonasal signs are often non-specific (nasal obstruction,
epistaxis, etc.), delaying diagnosis and treatment. Chronic uni-
lateral symptomatology is an alarm signal, especially in at-risk
occupations: occupational exposure is to be screened for system-
atically, whatever the histologic type and sinonasal location. Any
sinofacial cancer can be considered of occupational origin in case
of prolonged occupational exposure to tannins (wood, leather)
or nickel, according to the criteria of Tables 36, 37c and 47 of
the French occupational diseases listing [16]. Histologic identifica-
tion on well-conducted endoscopic biopsy is essential to diagnosis
and treatment, but should not involve ethmoidectomy with par-
tial tumor resection, which inevitably destroys important anatomic
landmarks.
Squamous cell carcinoma is the most frequent form of sinonasal
malignancy [2], especially in the maxillary sinus and nasal cavity.
It develops from respiratory mucosa subject to malpighian meta-
plasia. Inverted papilloma is the most frequent form of benign
sinonasal tumor, associated with squamous cell carcinoma in about

http://dx.doi.org/10.1016/j.anorl.2016.06.001
1879-7296/© 2016 Elsevier Masson SAS. All rights reserved.
406 A. Moya-Plana et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 405–411
10% of cases [2]. Mean age at onset is 60 years, with a male/female
sex-ratio of 2:1. The most frequent location is maxillary; lymph-
node involvement is found in 10–20% of cases. Overall 5-year
survival is 50–60%, taking all stages together [15].
Some 80% of sinonasal malignancies are of ethmoid origin.
Unlike in American series, intestinal adenocarcinoma is found in
80% of cases in Europe [1]. Most etiologies are occupational, involv-
ing prolonged wood-dust exposure (mean: 20–30 years, with a
minimum of 2 years) [17]. Other occupational factors have also
been reported, such as exposure to nickel, or chromium in the
leather industry. The strong male predominance is related to a male
predominance in these at-risk occupations. Mean age at diagnosis
is 60 years; symptom latency means that diagnosis is usually late,
with 65–80% of cases staged T3-4 [17,18]. Lymph-node involve-
ment is rare, as is remote metastasis. Overall survival is 64% at 5
years and 49% at 10 years [16].
Cystic adenoid carcinoma (CAC) is the third most frequent form.
The sex-ratio is 1, and mean age at onset ranges between 40 and 60
years [10]. It develops in accessory salivary glands of the face. The
most frequent location is maxillary. There is marked neurotropism,
with frequent perineural infiltration along V2 and V3. Lymph-node
involvement is rare [19]. Remote (pulmonary) metastasis is fre-
quent and often late [16]. Overall survival is 57% at 5 years and 33%
at 10 years [16].
Olfactory neuroblastoma is a rare neuroendocrine tumor devel-
oping in the olfactory epithelium; this location classically accounts
for the observed early invasion of the cribriform plate and anterior
level of the skull base, although forms not involving the cribri-
form plate exist [4]. Metastatic lymph-node involvement is found in
5–8% of patients at diagnosis and 20–25% of patients overall [19,20];
remote metastasis (lung and bone) is found in 10% of patients.
There are two main classifications: Kadish’s (clinical-radiological)
and Hyams’ (histological); recently, the Dulguerov classification
was reported to be of better prognostic value. Five-year survival
ranges between 37% and 85% [21]; recurrence-free survival is 77%
at 5 years and 53% at 10 years [21].
Mucosal melanoma accounts for 1% of melanomas and 3% of
sinonasal malignancies. It develops from melanocytes in the neu-
ral crests and disseminated in the sinonasal mucosa. There is male
Fig. 1. Diagnostic and therapeutic management of sinonasal malignancies according to the International and European Rhinology Societies’ guidelines [4].
predominance, and a mean age of 60 years at diagnosis. Classic
locations are: septum, turbinates (especially inferior) and maxil-
lary sinus. There is lymph-node invasion in 10–20% of cases, and
less than 5% remote metastasis at diagnosis [19]. Prognosis is poor:
5-year survival is less than 30%, with high risk of metastasis and
of locoregional recurrence [22,23]; median survival is 24 months
[23].
This diversity of histologic types and low incidence make
prospective studies unfeasible, and consensual guidelines difficult
to determine. A decision tree was drawn up by the International
and European Rhinology Societies in 2008 [2] (Fig. 1). Postopera-
tive radiation therapy is usually recommended [2,16]: preferably
intensity-modulated (IMRT), it provides benefit in local control and
5-year survival [2].
3. “Classic” surgical treatment of sinonasal malignancy
Transfacial approaches are the gold-standard surgical treat-
ment in sinonasal malignancy [24–26]. Various approaches have
been described for facial tumor. The paralateronasal approach
gives access to the ethmoid, while palpebral extension (Weber-
Ferguson) provides wide access to the whole mid-level of the face.
These are preferable to sublabial approaches (Caldwell-Luc, Rouge-
Denker, degloving), which entail less esthetic blemish but provide
less satisfactory operative site exposure, despite extensive release,
incompatible with oncologic requirements.
After performing a transfacial approach, two situations arise:
• the tumor involves the maxillary infrastructure, requiring maxil-
lectomy (usually in case of squamous cell carcinoma). Skull-base
involvement is rare in these cases, and classically contraindi-
cates craniofacial resection. When extension is restricted to the
infratemporal fossa, medial or paramedian mandibulotomy may
be associated: the hemimandible is luxated laterally to give
access to the parapharyngeal spaces and skull base, from the
pterygoid root medially to the floor of the medial cranial fossa
laterally. Free flap reconstruction now enables extensive facial
resection, with acceptable esthetic and functional results;
 A. Moya-Plana et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 405–411
• the tumor spares the maxillary infrastructure, as is classically the
case in tumor of ethmoid origin. Osteotomy, contoured according
to tumor location and extension, may give access to nasal cavity
or maxillary, ethmoidal or sphenoidal sinus lesions, then being
replaced and fixed at end of procedure; however, this entails
a non-negligible risk of radionecrosis in case of postoperative
radiation therapy. In this situation, tumor extension restricted
to the anterior skull base may be managed on a paralateronasal
transfacial approach, with oncologically satisfactory results [24].
Craniofacial resection is the classical approach for sinonasal
tumor extending to the anterior skull base; first described by
Dandy, it was promoted by Ketcham in 1963. It combines frontal
craniotomy and a transfacial approach; to avoid the latter when
there is no nasal bone or lacrimal pathway involvement, a sub-
frontal transcranial approach (Raveh’s approach) was developed:
osteotomy is naso-fronto-orbital, allowing direct access to the
ethmoid and anterior skull base, but less well-adapted for the
anteroinferior parts of the nasal cavity and maxillary sinus.
Skull-base defect reconstruction generally uses fascia lata or
an epicranial and/or pericranial flap. These procedures are per-
formed by a team comprising ENT and neuro-surgeon, and were
the gold standard of the 2000s.
However, this heavy and sometimes damaging surgery shows
a high rate of complications. In a multicenter cohort of 1193
patients, Ganli et al. reported a 36.3% rate of postoperative
complications (including 16.2% neurological, 4.8% general and
1.7% ophthalmological) and 5% perioperative mortality [25]. The
main neurological postoperative complications were cerebrospinal
rhinorrhea, pneumocephalus (sometimes compressive), infec-
tion (meningitis, abscess, empyema, etc.), hemorrhage (subdural
hematoma, intraparenchymal hemorrhage, etc.), frontal syndrome
and consciousness disorder, sometimes as severe as a coma. Oph-
thalmologically, optic pathway or oculomotor muscle lesions and
lacrimal pathway involvement (leading to chronic epiphora and
iterative dacryocystitis) were reported [25]. General complications
concern postoperative intensive care, prolonged hospital stay and
the patient’s comorbidities. There may also be late-onset com-
plications: following radiation therapy (which is more or less
systematic), necrosis in the naso-fronto-orbital osteotomy was
reported, with osteomyelitis of the frontal bone and skull base;
these complications may necessitate surgical removal of the flap
and reconstruction which is complex and may prove impossible
in a supra-infected post-radiation environment. There may also be
onset of nasofacial fistula (radiation-induced cutaneous necrosis
exposing the sinus cavities).
As well as elevated morbidity, craniofacial resection has cer-
tain technical limitations. En-bloc tumor resection is the oncologic
desideratum, but is often difficult to apply in skull-base surgery [2].
Despite the wide approach, en-bloc removal of the ethmoid (with
medial orbital wall, skull base and intranasal tumor extension)
is technically complex due to the deep and narrow surgical field
with non-extensible (bone) walls and proximity to critical struc-
tures: brain, optic nerve, brainstem, etc. The tumor is, in reality,
often fragmented. For these same reasons, a transfacial approach
does not usually allow precise intraoperative visualization of tumor
extension.
Finally, the high rate of postoperative complications greatly
increases mean hospital stay and delays initiation of radiation
therapy, which may even not be performed at all in case of
severe complications requiring several months’ hospitalization.
The skull-base bone defect is often large, delaying healing before
any radiation therapy can be applied to the skull-base plasty. Thus,
in view of early cerebral complications with onset after initiation
of radiation therapy at 6 weeks postoperatively, Lund et al. [26]
respected a mean 3-month interval before radiation therapy, to
407
allow adequate healing in the operative region. Delaying adjuvant
therapy may impair local control, however, and most teams rec-
ommend an interval of 6 weeks to 2 months.
4. Development of minimally invasive surgery
Indications for endoscopic endonasal surgery have greatly
progressed over the last 20 years, from a functional proce-
dure, to surgery for aggressive benign tumor (inverted papilloma,
nasopharyngeal fibroma) in the early 1990s, to skull-base surgery
(cerebrospinal rhinorrhea, meningocele, encephalocele, etc.), and
then malignancy surgery in the early 2000s. The first transnasal
craniotomies date back to 2005. Recent progress, in instrumen-
tation, imaging, video-cameras, navigation, anesthesia, etc., are
enabling ever more complex procedures, such as for parasellar
lesions in contact with the supraclinoid internal carotid artery
or cavernous sinus and even certain tumors of the craniocervical
junction (clivus chordoma, odontoid lesions, etc.) or of the sphe-
notemporal junction.
Management of sinonasal malignancy is multidisciplinary, and
technological progress has concerned several specialties. Sur-
gically, there has been particular progress in instrumentation,
notably with high-definition video cameras, powerful cold-light
sources (Xenon, then LED), long and angulated instruments,
microdebriders, and highly effective dedicated endoscopy motors.
Surgical technique has also progressed, with 3-hand (one-nostril
approach) or 4-hand endoscopic surgery (two-nostril after septal
resection), enabling 2-handed dissection of critical anatomic struc-
tures (skull base, meninx, brain, optic nerve, etc.) (Fig. 2).
Advances in imaging (CT and MRI) and the contribution of neu-
ronavigation (indispensable in case of prior surgery) have improved
pre- and intraoperative assessment of tumor extension and espe-
cially proximity to neurovascular structures (Fig. 3). Intraoperative
hemostasis has been optimized by innovative instrumentation
(bipolar coagulation, laser diode, intraoperative Doppler), new
hemostats (Surgicel® , Surgiflow® , Floseal® , etc.) and, especially,
progress in interventional neuroradiology (preoperative tumor
embolization, treatment of intraoperative vascular scars).
New endoscopic approaches have also been developed: trans-
maxillary approach, giving access to deep facial spaces, and anterior
level approaches, giving access to the entire anterior skull base
(Fig. 4). The latter enable resection of extension to the anterior skull
base, meninges, cerebral parenchyma, C1-C2 junction and poste-
rior fossa; they include a transnasal craniotomy step, and require
skull-base plasty at end of procedure [27].
Fig. 2. Four-hand surgery, enabling precise dissection of frontobasal dura mater.
408 A. Moya-Plana et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 405–411

Fig. 3. Left ethmoid olfactory neuroblastoma conserving orbita but involving cribriform plate and infiltrating the meninges. Cerebral parenchyma conserved.

Fig. 4. New endoscopic approaches to the face.

The application of endoscopic surgery in oncology was delayed
by the impossibility, usually, of achieving en-bloc tumor resection,
and was thus initially restricted to small (T1-T2) tumors. Results
from various pioneering teams in sinonasal and skull-base surgery
subsequently highlighted the fact that the key point is to remove
the whole tumor with safe margins, whether fragmented or not
[28–30].
Thus, for adenocarcinoma in patients in the wood industry, an
endoscopic resection technique has been codified, combining cen-
tripetal radical ethmoidectomy (or nasalization) and resection of
the olfactory cleft, which is the principal origin of these tumors [3].
An alternative approach was developed, also comprising cen-
tripetal tumor dissection with resection of the tumor implantation
base, whether mucosal, periosteal, osseous or meningeal [31].
This radical ethmoidectomy (endoscopic resection with transnasal
craniectomy: ERTC) comprises 6 steps:
• tumor debulking;
• nasal septum resection for a 4-hand approach;
• Draf III frontal sinusotomy and centripetal mucosal resection
with subperiosteal dissection;
 A. Moya-Plana et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 405–411
Fig. 5. Endoscopic view of skull base after complete tumor resection (resection of ethmoid bone, cribriform plate, crista galli, meninx and olfactory bulb).
Fig. 6. Principles of skull-base reconstruction by triple layer of fascia lata: intradural intracranial, extradural intracranial, extracranial. Photograph (left) showing positioning
of fascia lata; and (right) CT, sagittal slice, showing D1 postoperative aspect.
• resection of bone and/or cartilage in contact with tumor (skull
base, lamina papyracea, anterior side of the sphenoid);
• resection of dura mater, olfactory bulbs and periorbital region,
depending on tumor extension (Fig. 5);
• dura mater and skull-base plasty (Fig. 6).
These centripetal tumor dissection techniques enable precise
resection by “controlled fragmentation” under endoscopic and his-
tologic control. Iterative frozen section biopsy is performed in
macroscopically healthy tissue remote from the tumor through-
out the procedure to ensure exhaustive resection. This radical
ethmoidectomy with transnasal craniotomy, producing a transcrib-
riform approach, has thus become an alternative to craniofacial
resection, allowing strictly endoscopic resection of sinus tumors
with extension to the skull base, meninges or sometimes cerebral
parenchyma. It may be considered in tumors with strong potential
extension to the olfactory nerves (especially esthesioneuroblas-
tomas), and in case of large contact with or erosion of the skull
base or of limited meningeal invasion [31–35].
The advantages of an endoscopic approach are numerous. The
most obvious is the absence of postoperative scar or facial defor-
mity. Also, intraoperative visualization of anatomic structures
and tumor extension is improved. But its principal advantage
lies in significantly lower surgical morbidity, and consequently
shorter hospital stay and convalescence [36,37,32,38,39]. By avoid-
ing large-scale craniofacial dissection with osteotomy and cerebral
retraction, the overall complications rate is reduced to 9–11%
and perioperative mortality is virtually abolished [36,32], whereas
older craniofacial resection series showed a 36.3% complications
rate and almost 5% perioperative mortality [25]. The most frequent
complication is CSF leakage (3–4%). The complications rate is higher
in case of stage T4 tumor and of endoscopic craniectomy [38]. As
there is no osteotomy, post-radiation osteonecrosis, which is often
409
difficult to treat, is prevented. And finally, postoperative quality
of life has been shown to be better: several quality-of-life studies
based on the Anterior Skull Base QoL Questionnaire (general health
status, pain, independence, and taste, odor, esthetics, epiphora, rhi-
norrhea and vision) have been conducted, and showed significant
benefit with endoscopic surgery at 1 year postoperatively [36,38].
Minimally invasive surgery applies only to selected patients,
respecting contraindications (see Box 1) related to tumor exten-
sion: anterior facial skeletal involvement necessitates a transfacial
approach; massive orbital extension with muscular or eyeball
involvement requires exenteration; supra-orbital dural exten-
sion requires control by craniotomy; and maxillary infrastructure
involvement requires maxillectomy [2].
Box 1: Contraindications to exclusive endoscopic
approach in sinonasal malignancy [4].
Absolute contraindications:
• ocular extension;
• maxillary involvement other than sinonasal wall;
• cutaneous extension;
• anterior and/or lateral frontal sinus invasion;
• dural invasion with lateral extension beyond medial, orbital
wall;
• clear cerebral parenchyma invasion.
Relative contraindications:
• vascular invasion (internal carotid artery, cavernous sinus);
• optic chiasm involvement;
• posterior fossa involvement;
• tumoral extension under C2 plane.
410 A. Moya-Plana et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 405–411
5. Oncological results of endoscopic surgery
The assessment of the oncologic results of endoscopic endonasal
surgery is an essential step to validating applications in sinonasal
malignancy: a novel technique cannot be validated unless it is at
least equivalent to the gold standard technique – in the present
case, transfacial surgery. Prospective randomized studies in this
regard can hardly be set up, given the low incidence, wide his-
tologic heterogeneity and strong current trend in favor of the
endoscopic attitude in view of the highly favorable observed results
with respect to morbidity.
The unfeasibility of en-bloc resection initially appeared to be
a serious limitation of endoscopic oncologic surgery. However,
large tumors are generally fragmented, on whatever approach,
whether craniofacial or endoscopic [2]. It moreover would seem
that whether resection is en-bloc or piecemeal does not affect prog-
nosis as long as the margins are safe [28,29]. Positive margins, on
the other hand, constitute an independent risk factor for recurrence
and reduced survival [29,40]. The rate of positive margins in cra-
niofacial resection, taking all histologic types together, is reported
to be 15–17% [37,40]; rates for endoscopic surgery are comparable,
at 10–19% [37,32].
As stated above, sinonasal malignancy is a heterogeneous group,
with varying natural history and prognosis. The interpretation of
published results is therefore complicated by a large number of
series that are not comparable in terms of histology or manage-
ment. The present literature review therefore focused on results
according to histology, to minimize analytic bias.
Intestinal type adenocarcinoma (ITAC) of the ethmoid sinus is
the form of sinonasal malignancy for which cohorts and follow-
up are presently greatest. Oncologic results for transfacial surgery
were reported mainly in two retrospective series. Choussy et al.,
in a multicenter study of 418 patients undergoing surgery (with or
without postoperative radiation therapy), of whom 64.6% were T3-
T4, reported 64% overall 5-year survival [17]. De Gabory et al., in
a series of 95 patients (76% T3-T4) undergoing transfacial surgery
with postoperative radiation therapy, reported 77% overall 5-year
survival [18].
In endoscopic surgery, Vergez et al., in a multicenter retrospec-
tive study of 159 patients (49% T3-T4) at a mean 32.5 months’
follow-up, reported 62% overall 5-year survival and 74% specific
survival; postoperative radiation therapy was implemented in 130
cases [41]. Recently, Jorisen reported a single-center study of 123
patients (43.9% T3-T4) treated by endoscopic surgery followed by
radiation therapy; mean follow-up was 66 months; overall, specific
and recurrence-free survival were 68%, 82% and 62% respectively
at 5 years and 51%, 74% and 45% at 10 years [42]. Castelnuovo et al.
reported on 169 patients treated endoscopically, 58.6% of whom
received postoperative radiation therapy: median survival was 42.8
months, and 5-year overall and recurrence-free survival 68.9% and
63.6%, respectively [43]. The cohort included a large proportion of
advanced stages (50.9% T3-T4, with 25.4% T4b), with 103 ERTC pro-
cedures. The postoperative complications rate was high, with 6.5%
CSF leakage, but the rate of positive margins was very acceptable,
at 10.6%.
Few studies, however, have compared oncologic results
between these two techniques in ethmoid adenocarcinoma. An
American retrospective series of 66 patients, 26% operated on endo-
scopically and 74% transfacially, reported overall 5-year survival of
65.9%; the two groups, unfortunately, were not comparable but,
interestingly, for a given T stage overall survival was not affected
by the approach [44].
Grosjean et al. [39] reported the only single-center study to date
comparing two retrospective series of ITAC managed transfacially
(31 patients) and endoscopically (43 patients). Endoscopy enabled
management of older patients and more advanced stages (trend
for > T4b), with less perioperative morbidity (fewer complications,
shorter hospital stay). Three-year oncologic results, however, were
comparable between cohorts, with a trend toward better outcome
in endoscopic surgery (overall survival, 76.7% vs 61.3%; P = 0.547).
Analysis of the data thus suggests that the two techniques are
oncologically equivalent in selected cases of ethmoid adenocar-
cinoma. Preoperative assessment of tumor extension, histologic
type and comorbidities determines the approach and therapeutic
sequence: neoadjuvant chemotherapy, radiation therapy, etc.; the
less damaging approach should be chosen, so long as resection is
optimal.
A few similar studies have been conducted in olfactory neu-
roblastoma. One meta-analysis, totaling 390 patients undergoing
craniofacial resection, found 45% 5-year recurrence-free survival
[45]. Another, with 361 patients, compared endoscopic and cra-
niofacial resection and found better overall 10-year survival with
endoscopy [46], although with a major recruitment bias given
the predominance of advanced stages in the craniofacial group;
also, median follow-up was significantly shorter in the endoscopic
group, whereas olfactory neuroblastoma tends to show late recur-
rence.
Finally, in squamous cell carcinoma, the largest endoscopic
series to date [47] comprised 34 patients, with predominance of
T3-4 (85%). Five-year overall survival was 78% and recurrence-free
survival 62%. However, patient selection was strict and the sample
size small.
6. Conclusion
Analysis of the literature establishes the feasibility, low mor-
bidity and oncologic safety of endoscopic surgery for sinonasal
malignancy in rigorously selected patients. The significantly lower
postoperative morbidity allows earlier radiation therapy, which
may improve control. However, further studies with longer
follow-up (especially in slowly progressing pathologies such as
olfactory neuroblastoma) and histologic stratification are needed.
Management is multidisciplinary. The impact of neoadjuvant
chemotherapies, new radiation techniques (IMRT, proton therapy)
and innovative treatments (immunotherapy, targeted therapies)
remains to be determined.
Disclosure of interest
The authors declare that they have no competing interest.
References
[1] Thompson L. WHO 2005 World Health Organization classification of tumours:
pathology and genetics of head and neck tumours. Ear Nose Throat J
2006;85(2):74.
[2] Lund VJ, Stammberger H, Nicolai P, Castelnuovo P, Beal T, Beham A, et al.
European position paper on endoscopic management of tumours of the nose,
paranasal sinuses and skull base. Rhinol Suppl 2010;22:1–143.
[3] Jankowski 1 R, Georgel T, Vignaud JM, Hemmaoui B, Toussaint B, Graff P, et al.
Endoscopic surgery reveals that woodworkers’ adenocarcinomas originate in
the olfactory cleft. Rhinology 2007;45(4):308–14.
[4] Jankowski R, Russel A, Gallet P, Henrot P, Vignaud JM, Nguyen DT. Olfactory
neuroblastoma behavior inside and outside the olfactory cleft. Surg Radiol Anat
2015;37(5):507–15.
[5] Stammberger H, Anderhuber W, Walch C, Papaefthymiou G. Possibilities and
limitations of endoscopic management of nasal and paranasal sinus malignan-
cies. Acta Otorhinolaryngol Belg 1999;53:199–205.
[6] Goffart Y, Jorissen M, Daele J, Vander Poorten V, Born J, Deneufbourg JM, et al.
Minimally invasive endoscopic management of malignant sinonasal tumours.
Acta Otorhinolaryngol Belg 2000;54:221–32.
[7] Banhiran W, Casiano RR. Endoscopic sinus surgery for benign and malig-
nant nasal and sinus neoplasm. Curr Opin Otolaryngol Head Neck Surg
2005;13:50–4.
[8] Lund V, Howard DJ, Wei WI. Endoscopic resection of malignant tumours of the
nose and sinuses. Am J Rhinol 2007;21:89–94.
 A. Moya-Plana et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133 (2016) 405–411
[9] Carrau RL, Kassam AB, Snyderman CH, Duvvuri U, Mintz A, Gardner P. Endo-
scopic transnasal anterior skull base resection for the treatment of sinonasal
malignancies. Op Techn Otolaryngol 2006;17:102–10.
[10] Dave SP, Bared A, Casiano RR. Surgical outcomes and safety of transnasal
endoscopic resection for anterior skull tumours. Otolaryngol Head Neck Surg
2007;136:920–7.
[11] Jankowski R. Exérèse endoscopique de la cavité olfactive. Fr ORL
2007;93:341–6.
[12] Schwaab G, Julieron M, Janot F. Epidemiology of cancers of the nasal cavities
and paranasal sinuses. Neurochirurgie 1997;43(2):61–3.
[13] Youlden DR, Cramb SM, Peters S, et al. International comparisons of the
incidence and mortality of sinonasal cancer. Cancer Epidemiol 2013;37:
770–9.
[14] Kuijpens JH, Louwman MW, Peters R, Janssens GO, Burdorf AL, Coebergh
JW. Trends in sinonasal cancer in the Netherlands: more squamous cell can-
cer, less adenocarcinoma. A population-based study 1973–2009. Eur J Cancer
2012;48:2369–74.
[15] Turner JH, Reh DD. Incidence and survival in patients with sinonasal can-
cer: a historical analysis of population-based data. Head Neck 2012;34:
877–85.
[16] Référentiel REFCOR (Réseau d’expertise français sur les cancers ORL rares);
2009 [www.orlfrance.org/download.php?id=181].
[17] Choussy O, Ferron C, Védrine PO, Toussaint B, Liétin B, Marandas P, et al. Adeno-
carcinoma of ethmoid: a GETTEC retrospective multicenter study of 418 cases.
Laryngoscope 2008;118(3):437–43.
[18] De Gabory L, Maunoury A, Maurice-Tison S, Merza Abdulkhaleq H, Darrouzet
V, Bébéar JP, et al. Long-term single-center results of management of eth-
moid adenocarcinoma: 95 patients over 28 years. Ann Surg Oncol 2010;17(4):
1127–34.
[19] Simon C, Toussaint B, Coffinet L. Tumeurs malignes des cavités nasales et
paranasales. EMC Oto-rhino-laryngologie; 1997 [1-0. Article 20-405-A-10].
[20] Zanation AM, Ferlito A, Rinaldo A, Gore MR, Lund VJ, McKinney KA, et al. When,
how and why to treat the neck in patients with esthesioneuroblastoma: a
review. Eur Arch Otorhinolaryngol 2010;267(11):1667–71.
[21] Dulguerov P, Allal AS, Calcaterra TC. Esthesioneuroblastoma: a meta-analysis
and review. Lancet Oncol 2001;2(11):683–90.
[22] Wenig BM. Undifferentiated malignant neoplasms of the sinonasal tract. Arch
Pathol Lab Med 2009;133:699–712.
[23] Lund VJ, Chisholm EJ, Howard DJ, Wei WI. Sinonasal malignant melanoma: an
analysis of 115 cases assessing outcomes of surgery, postoperative radiothe-
rapy and endoscopic resection. Rhinology 2012;50(2):203–10.
[24] Jegoux 1 F, Ferron C, Malard O, Cariou G, Faure A, Beauvillain De Montreuil
C. Ethmoid adenocarcinoma: trans-facial approach for anterior skull base
resection. a series of 80 cases. Ann Otolaryngol Chir Cervicofac 2004;121(4):
213–21.
[25] Ganly 1 I, Patel SG, Singh B, Kraus DH, Bridger PG, Cantu G, et al. Complications
of craniofacial resection for malignant tumors of the skull base: report of an
International Collaborative Study. Head Neck 2005;27(6):445–51.
[26] Howard DJ, Lund VJ, Wei WI. Craniofacial resection for tumors of the
nasal cavity and paranasal sinuses: a 25-year experience. Head Neck
2006;28(10):867–73.
[27] Verillaud B, Bresson D, Sauvaget E, Mandonnet E, Georges B, Kania R, et al. Endo-
scopic endonasal skull base surgery. Eur Ann Otorhinolaryngol Head Neck Dis
2012;129(4):190–6, http://dx.doi.org/10.1016/j.anorl.2011.09.004 [Epub 2012
Feb 7].
[28] Snyderman CH, Carrau RL, Kassam AB, Zanation A, Prevedello D, Gardner P, et al.
Endoscopic skull base surgery: principles of endonasal oncological surgery. J
Surg Oncol 2008;97(8):658–64.
[29] Wellman BJ, Traynelis VC, McCulloch TM, Funk GF, Menezes AH, Hoffman HT.
Midline anterior craniofacial approach for malignancy: results of en bloc versus
piecemeal resections. Skull Base Surg 1999;9(1):41–6.
411
[30] Wood JW, Eloy JA, Vivero RJ, Sargi Z, Civantos FJ, Weed DT, et al. Efficacy of
transnasal endoscopic resection for malignant anterior skull-base tumors. Int
Forum Allergy Rhinol 2012;2(6):487–95.
[31] Nicolai P, Battaglia P, Bignami M, Bolzoni Villaret A, Delu G, Khrais T, et al.
Endoscopic surgery for malignant tumors of the sinonasal tract and adjacent
skull base: a 10-year experience. Am J Rhinol 2008;22:308–16.
[32] Nicolai P, Castelnuovo P, Bolzoni Villaret A. Endoscopic resection of sinonasal
malignancies. Curr Oncol Rep 2011;13:138–44.
[33] Nicolai P, Villaret AB, Bottazzoli M, Rossi E, Valsecchi MG. Ethmoid
adenocarcinoma–from craniofacial to endoscopic resections: a single-
institution experience over 25 years. Otolaryngol Head Neck Surg
2011;145(2):330–7.
[34] Carta F, Kania R, Sauvaget E, Bresson D, George B, Herman P. Endoscopy skull-
base resection for ethmoid adenocarcinoma and olfactory neuroblastoma.
Rhinology 2011;49(1):74–9.
[35] Antognoni P, Turri-Zanoni M, Gottardo S, Molteni M, Volpi L, Facco C, et al.
Endoscopic resection followed by adjuvant radiotherapy for sinonasal intesti-
nal type adenocarcinoma: retrospective analysis of 30 consecutive patients.
Head Neck 2015;37(5):677–84.
[36] Su SY, Kupferman ME, DeMonte F, Levine N, Raza S, Hanna EY. Endoscopic
resection of sinonasal cancers. Curr Oncol Rep 2014;16:369.
[37] Hanna E, DeMonte F, Ibrahim S, Roberts D, Levine N, Kupferman M. Endoscopic
resection of sinonasal cancers with and without craniotomy: oncologic results.
Arch Otolaryngol Head Neck Surg 2009;135:1219–24.
[38] Castelnuovo P, Lepera D, Turri-Zanoni M, Battaglia P, Bolzoni A, Bignami M,
et al. Quality of life following endoscopic endonasal resection of anterior skull
base cancers. J Neurosurg 2013;119:1401–9.
[39] Grosjean R, Gallet P, Baumann C, Jankowski R. Transfacial versus endo-
scopic approach in the treatment of woodworker’s nasal. Head Neck
2015;37(3):347–56.
[40] Patel SG, Singh B, Polluri A, Bridger PG, Cantu G, Cheesman AD, et al. Cra-
niofacial surgery for malignant skull base tumors: report of an international
collaborative study. Cancer 2003;98:1179–87.
[41] Vergez 1 S, du Mayne MD, Coste A, Gallet P, Jankowski R, Dufour X, et al. Multi-
center study to assess endoscopic resection of 159 sinonasal adenocarcinomas.
Ann Surg Oncol 2014;21(4):1384–90.
[42] Camp S, Van Gerven L, Vander Poorten V, Nuyts S, Hermans R, Hauben E, et al.
Long-term follow-up of 123 patients with adenocarcinoma of the sinonasal
tract treated with endoscopic resection and postoperative radiation therapy.
Head Neck 2014, http://dx.doi.org/10.1002/hed.23900 [Epub ahead of print].
[43] Nicolai P, Schreiber A, Bolzoni Villaret A, Lombardi D, Morassi L, Raffetti E,
et al. Intestinal type adenocarcinoma of the ethmoid: outcomes of a treatment
regimen based on endoscopic surgery with or without radiotherapy. Head Neck
2015, http://dx.doi.org/10.1002/hed.24144 [Epub ahead of print].
[44] Bhayani MK, Yilmaz TA, Sweeney A, Calzada G, Roberts DB, Levine NB, et al.
Sinonasal adenocarcinoma: a 16-year experience at a single institution. Head
Neck 2013;36(10):1490–6, http://dx.doi.org/10.1002/hed.23485 [Epub 2014
Jan 29].
[45] Ow TJ, Hanna EY, Roberts DB, Levine NB, El-Naggar AK, Rosenthal DI, et al.
Optimization of long-term outcomes for patients with esthesioneuroblastoma.
Head Neck 2014;36(4):524–30, http://dx.doi.org/10.1002/hed.23327 [Epub
2013 Jun 18].
[46] Devaiah AK, Andreoli MT. Treatment of esthesioneuroblastoma: a 16-
year meta-analysis of 361 patients. Laryngoscope 2009;119(7):1412–6,
http://dx.doi.org/10.1002/lary.20280.
[47] De Almeida JR, Su SY, Koutourousiou M, Vaz Guimaraes Filho F, Fernandez
Miranda JC, Wang EW, et al. Endonasal endoscopic surgery for squamous cell
carcinoma of the sinonasal cavities and skull base: oncologic outcomes based
on treatment strategy and tumor etiology. Head Neck 2015;37(8):1163–9,
http://dx.doi.org/10.1002/hed.23731 [Epub 2014 Jul 11].