How should I excise sinonasal tumours, open or endoscopic? En bloc or piecemeal?
Reviewed by Gentle Wong

Sinonasal tumours often present late because initial symptoms mimic benign disease. They tend to produce more unilateral nasal symptoms, and patients with advance disease often describe paraesthesia and other cranial neuropathies. They only account for approximately 3% of upper aerodigestive malignancies. Squamous cell carcinoma (SCC) is the commonest, followed by adenoid cystic carcinoma, and adenocarcinoma. Mucosal melanoma, olfactory neuroblastoma, and sinonasal undifferentiated carcinoma are all rare. Surgery for sinonasal malignancies has traditionally been via open techniques. However, there is an increasing paradigm shift in endoscopic resections utilising the principles of tumour disassembly and negative margins. Proponents argue that transoral laser surgery and Mohs micrographic surgery, which are similar examples of effective piecemeal resection, yield good results so why not sinonasal piecemeal resection? Opponents speculate that oncological integrity would be compromised by piecemeal resections, but this has now been disputed with evidence demonstrating patients who undergo piecemeal open resections have same outcomes as those with en bloc resections. The endoscopic technique is also more likely to produce lower morbidity, such as cosmesis, speech and swallowing. Hospital stay is also likely to be shorter. Endoscopic technique shows much promise, but there are occasions where this is contra-indicated. Open approaches are still better when there is orbital disease, or skin or palate involvement, or where disease is lateral or superior to carotid / optic nerve. Therefore, surgeons must be prepared to switch to the appropriate procedures if negative margins cannot be obtained endoscopically. 

Surgical techniques for sinonasal malignancies.
Farag A, Rosen M, Evans J.
NEUROSURGERY CLINICS OF NORTH AMERICA
2015;26(3):403-12.