Orbital preservation in surgical management of sinonasal malignancy

Objective: To determine the oncological and functional outcome when applying defined criteria for orbital preservation during surgical treatment of sinonasal malignancy encroaching on the orbital structures. Study Design: Retrospective consecutive review of patients in tertiary care center setting. Methods: Analysis of 66 patients undergoing surgical treatment for sinonasal malignancy encroaching on the orbit. Orbital preservation was performed in all patients with tumor extension up to and including resectable periorbital involvement. Minimum follow-up was 2 years. Detailed analysis of oncological and functional outcomes is included. Results: Of 66 tumors abutting or invading into the orbit, 54 were amenable for surgical treatment with orbital preservation and the remaining 12 underwent orbital exenteration. Histopathological findings were divided into five subgroups: squamous cell carcinoma, adenomatous carcinomas, sinonasal undifferentiated carcinoma, sarcoma, and other. Squamous cell carcinoma represented the largest subgroup (24 patients), and 5-year overall actuarial survival was not statistically different (P = 1.4; relative risk, 0.713) between patients treated with orbital preservation (53%) versus those undergoing exenteration (46%). Similarly, no difference in survival was found in the adenomatous carcinoma subgroup. Within the orbital preservation group as a whole, local recurrence occurred in 30% patients (16 of 54) compared with 33% patients (4 of 12) treated with orbital exenteration. Of note, eye-sparing surgery was associated with local recurrence at the original site of orbital involvement in only 7.8% of cases (4 of 54). Overall eye function was graded as functional without impairment in 54% of patients (29 of 54), functional with impairment in 37% (20 of 54), and nonfunctional in 9% (5 of 54). The most common abnormality was globe malposition (enophthalmos or hypophthalmos) that was seen in 34 patients (63%) and was associated with the lack of adequate rigid reconstruction of subtotal or total orbital floor or multisegment orbital defects. However, enophthalmos was asymptomatic in the majority of cases, and persistent diplopia occurred in only five patients (9%). Various ocular sequelae were present in 20 of the 49 patients (41%) with functional eyes. Radiation therapy increased the risk of ocular complications, in particular, optic atrophy, cataract formation, excessive dryness, and ectropion. Conclusions: Selective orbital preservation is oncologically safe and is a worthwhile undertaking in attempting to maintain a functionally useful eye with surgical management of sinonasal malignancy encroaching on the orbit. Consideration should be given to rigid orbital reconstruction in larger defects resulting from subtotal or total orbital floor resection or resections involving two or more orbital walls.