Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4434_Библиотеки_им_академика_М_И_Перельмана.pdf
14 Head andNeck Surgical Access intheManagement ofHead andNeck Malignancy
365
14.9 Impacts onTreatment
Outcomes
Surgical access plays an important role in ensuring a complete resection of head and neck tumour.
Limited view of surgical bed and inadequate
space for dissection will make the surgery more
difcult. In addition, many cold instruments like
endoscopes, retractors, artery forceps, and ultrasonic cutter are used during surgery, which occupies more space.
Limited space will also limit the assistant’s
view for a better retraction. All of these factors
lead to inefcient surgery with longer operation
time. The surgery-related morbidities may also
increase. Critically, the risk of leaving behind
malignant cells is high if tumour clearance is not
complete due to inadequate access and inefcient
surgeon’s performance.
14.10 Complications andPrognosis
ofHead andNeck
Malignancy
Surgical treatment of head and neck malignancy
is crucial as it is the main modality of treatment.
Thus, surgery needs to be performed comprehensively so as to remove all the macroscopic and
microscopic tumour margin. The involved margin carries higher chance of tumour recurrence
and metastatic spread.
Importantly, a good surgical bed exposure and
access will assist in a complete tumour removal.
The bleeding can be controlled more efciently,
and the risk of injury to adjacent structures can be
avoided. Complications of surgery in the head
and neck regions are monumental. Multiple neural and vascular structures are at risk, which can
lead to signicant functional impairment. This in
turn will impair the patient’s quality of life.
Managing recurrent tumour is highly challenging. The majority of cases already reach the
maximum dose of radiation or chemotherapy
cycles. The head and neck region also becomes
brotic and poses surgical difculty. The dissection is difcult as tissues become thickened and
hard. The anatomical landmarks and structures
change and derange due to this brosis.
Subsequently, the risk of bleeding, neural injury,
and other related complications is high.
14.11 Conclusion
Adequate surgical access is a prerequisite in head
and neck cancer surgery. This allows a negative
resection margin, which is one of the determinants of patient prognosis. The risk of recurrence,
occult metastases, and distant systemic spread is
lessened, with the attained better oncologic resection of primary tumour. The soft tissue approach
and bony approach are equally important in providing a wider adequate access for a surgery.
Sternotomy, mandibulotomy, mandibulectomy,
and clavicle osteotomy need to be considered in
selected cases of head and neck malignancy in
order to achieve a better tumour resection. The
advent of minimally invasive surgery with the
availability of multi-angle endoscopes and robotic
systems has escalated the surgical approach of
head and neck malignancy. The functionality is
retained, and the morbidity is less.
References
1. Goh HK, Ng YH, Teo DT. Minimally invasive surgery for head and neck cancer. Lancet
Oncol. 2010;11(3):281–6. https://doi.org/10.1016/
S1470- 2045(09)70379- 1.
2. Golusiński W, Pieńkowski P, Majchrzak E. Robotic
surgery (da Vinci Xi system) in head and neck cancer—own experience. Otolaryngol Pol. 2019;74(1):1–
5. https://doi.org/10.5604/01.3001.0013.5262.
3. Luu K, Pakdel A, Wang E, Prisman E.In house virtual
surgery and 3D complex head and neck reconstruction. J Otolaryngol Head Neck Surg. 2018;47(1):75.
Published 2018 Dec 12. https://doi.org/10.1186/
s40463- 018- 0320- 9.
4. Tateya I, Shiotani A, Satou Y, et al. Transoral surgery for laryngo-pharyngeal cancer—the paradigm
shift of the head and cancer treatment. Auris Nasus
Larynx. 2016;43(1):21–32. https://doi.org/10.1016/j.
anl.2015.06.013.
5. Yee S. Transoral robotic surgery. AORN J.
2017;105(1):73–84. https://doi.org/10.1016/j.
aorn.2016.11.011.
6. Fu Y, Wu M, Fu J, etal. Transoral endoscopic thyroidectomy via submental and vestibular approach:
366
N. Mat Lazim et al.
a preliminary report. Front Surg. 2020;7:591522.
Published 2020 Nov 23. https://doi.org/10.3389/
fsurg.2020.591522.
7. Jongekkasit I, Jitpratoom P, Sasanakietkul T,
Anuwong A. Transoral endoscopic thyroidectomy
for thyroid cancer. Endocrinol Metab Clin N Am.
2019;48(1):165–80. https://doi.org/10.1016/j.
ecl.2018.11.009.
8. Zorron R, Bures C, Brandl A, etal. Tipps und technische Aspekte zur Durchführung der transoralen
endoskopischen Thyreoidektomie mit vestibulärem
Zugang (TOETVA): eine neue narbenlose Technik
für die Halschirurgie [Tips and technical issues for
performing transoral endoscopic thyroidectomy with
vestibular approach (TOETVA): a novel scarless technique for neck surgery]. Chirurg. 2018;89(7):529–36.
https://doi.org/10.1007/s00104- 018- 0658- 6.
9. Hamilton D, Paleri V. Role of transoral robotic surgery in current head & neck practice. Surgeon.
2017;15(3):147–54. https://doi.org/10.1016/j.
surge.2016.09.004.
10. Finegersh A, Holsinger FC, Gross ND, Orosco
RK.Robotic head and neck surgery. Surg Oncol Clin
N Am. 2019;28(1):115–28. https://doi.org/10.1016/j.
soc.2018.07.008.
11. Gun R, Ozer E. Surgical anatomy of oropharynx
and supraglottic larynx for transoral robotic surgery. J Surg Oncol. 2015;112(7):690–6. https://doi.
org/10.1002/jso.24020.
12. Durmus K, Gokozan HN, Ozer E.Transoral robotic
supraglottic laryngectomy: surgical considerations. Head Neck. 2015;37(1):125–6. https://doi.
org/10.1002/hed.23645.
13. Gorphe P. A contemporary review of evidence
for transoral robotic surgery in laryngeal cancer.
Front Oncol. 2018;8:121. https://doi.org/10.3389/
fonc.2018.00121.
14. Hans S, Chekkoury-Idrissi Y, Circiu MP, Distinguin
L, Crevier-Buchman L, Lechien JR.Surgical, oncological, and functional outcomes of transoral robotic
supraglottic laryngectomy. Laryngoscope. 2020 [published online ahead of print, 2020 Jul 23]. https://doi.
org/10.1002/lary.28926.
15. Simon C, Holsinger FC, Rheinwald M, Kemper J,
Lambercy K. A new endoscopic surgical approach
to the larynx, hypopharynx, and neck lymphatics:
the robotic-assisted extended “Sistrunk” approach
(RESA). Head Neck. 2020;42(9):2750–6. https://doi.
org/10.1002/hed.26273.
16. Sharma A, Albergotti WG, Duvvuri U.Applications
of evolving robotic technology for head and neck surgery. Ann Otol Rhinol Laryngol. 2016;125(3):207–
12. https://doi.org/10.1177/0003489415606448.
17. Byeon HK, Holsinger FC, Kim DH, etal. Feasibility
of robot-assisted neck dissection followed by transoral robotic surgery. Br J Oral Maxillofac Surg.
2015;53(1):68–73. https://doi.org/10.1016/j.
bjoms.2014.09.024.
18. Sormaz İC, Uymaz DS, İşcan AY, et al. The value
of preoperative volumetric analysis by computerised tomography of retrosternal goiter to predict
the need for an extra-cervical approach. Balkan
Med J. 2018;35(1):36–42. https://doi.org/10.4274/
balkanmedj.2017.0161.
19. Casella C, Molno S, Cappelli C, Salvoldi F,
Benvenuti MR, Portolani N. Thyroiditis process
as a predictive factor of sternotomy in the treatment of cervico- mediastinal goiter. BMC Surg.
2019;18(Suppl 1):20. Published 2019 Apr 24. https://
doi.org/10.1186/s12893- 019- 0474- z.
20. Sari S, Erbil Y, Ersöz F, et al. Predictive value of
thyroid tissue density in determining the patients
on whom sternotomy should be performed. J Surg
Res. 2012;174(2):312–8. https://doi.org/10.1016/j.
jss.2011.01.019.
21. McKenzie GA, Rook W. Is it possible to predict
the need for sternotomy in patients undergoing thyroidectomy with retrosternal extension? Interact
Cardiovasc Thorac Surg. 2014;19(1):139–43. https://
doi.org/10.1093/icvts/ivu094.
22. Riffat F, Del Pero MM, Fish B, Jani P.Radiologically
predicting when a sternotomy may be required in
the management of retrosternal goiters. Ann Otol
Rhinol Laryngol. 2013;122(1):15–9. https://doi.
org/10.1177/000348941312200104.
23. Mat Lazim N, Abdullah B, Wan Ismail WFN.Approach
for recurrent thyroid carcinoma with a clavicle osteotomy. Medeniyet Med J. 2018;22(4):336–41.
Orbital Exenteration inHead
andNeck Malignancy
NorhazaMat Lazim , GiacomoSpinato,
RomanCarlosZamora, andPaoloBoscoloRizzo
15
15.1 Introduction
Orbital exenteration is a delicate surgical procedure. It entails the removal of the entire orbital
contents with a subperiosteal dissection. This
includes the removal of all eye socket contents
including the muscles, lacrimal gland system,
optic nerve, as well as varying parts of the bone
of the orbit. Orbital exenteration has long been
considered the treatment of choice for managing
periocular tumours invading the orbit or primary
orbital malignancies. Importantly, this surgery
causes signicant aesthetic embarrassment especially in young patient category.
Orbital exenteration is indicated for tumours
originating in the eyelids, the eye, the orbit, or
the paranasal sinuses. Orbital exenteration is a
physically debilitating procedure that may be
indicated in the management of orbital malignancy. It requires a committed multidisciplinary
N. Mat Lazim (*)
Department of Otorhinolaryngology-Head and Neck
Surgery, School of Medical Sciences, Universiti Sains
Malaysia, Health Campus, Kubang Kerian,
Kelantan, Malaysia
e-mail: norhaza@usm.my
G. Spinato · P. B. Rizzo
Department of Neurosciences, Section of
Otolaryngology and Regional Centre for Head and
Neck Cancer, University of Padova, Treviso, Italy
R. C. Zamora
ENT Department, Head and Neck Oncology Group,
Hospital Universitario Reina Soa, Cordoba, Spain
approach, both preoperatively and post-operatively. The multidisciplinary team management
is crucial, especially the rehabilitation team, that
plays signicant roles not only preoperatively,
but also post-operatively. Additionally, strong
and persistent family and adequate psychosocial
support ensure the best treatment outcomes for
this subset of patients. The preoperative and
post- operative counselling should be made by a
multidisciplinary team consisting of an ocularist,
orbital surgeon, specialist wound care nurse, and
a clinical psychologist.
Preoperative counselling with an ocularist is
pivotal in deciding on the timing of surgery and
the best surgical approach possible for the patient.
For example, whether osseointegration is
required at the time of exenteration and before
radiotherapy will save the patient later need for
hyperbaric oxygen [1]. Orbital invasion is frequently observed in tumours involving the maxillary, ethmoid, and frontal sinuses given the
proximity of the orbit to the sinonasal tract and
ventral skull base. For an extensive maxillary
sinus carcinoma, the superior extension with the
evidence of periorbital fat invasion is a clear indication for orbital exenteration together with total
maxillectomy as a standard treatment approach.
Orbital exenteration is a severely disguring
procedure that is indicated in primary orbital and
adnexal malignancies that cannot be controlled
by simple excision or radiotherapy. It is also
occasionally indicated for non-malignant pro-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
N. Mat Lazim et al. (eds.), Head and Neck Surgery : Surgical Landmark and Dissection Guide,
https://doi.org/10.1007/978-981-19-3854-2_15
367
368
orbital exenteration with skull base defect
penetrating orbitomaxillary defect
with loss of a several orbital walls/rims
N. Mat Lazim et al.
Type I
Orbital exenteration
Type III
Pterional craniotomy extended
Fig. 15.1 Types of orbital exenteration which is commonly practised
Extended orbital exenteration
with loss of a single orbital wall/rim
gressive disease with intractable pain or orbital
fungal infections, but the majority of cases are
orbital malignancies [2]. Total exenteration
involves the removal of the entire orbital content,
including the eyelids. Extended orbital exenteration involves the removal of the entire orbital
content together with the paranasal sinus and/or
bony orbit (Fig.15.1). Orbital exenteration with
eyelid sparing is to remove the entire orbital content without the eyelids and is therefore best
Type IIa
Extended orbital exenteration with
tion, however, should take precedence over
cosmetic concerns. Often, removal of part of the
bony orbit is necessary adding to the postoperative facial rehabilitation management plan.
Histology-specic induction chemotherapy can
be used for high-grade sinonasal cancers in order
to downstage the tumour and increase the possibility of orbital preservation. In the future, the
development of tailored medicines and immunotherapies may alter our therapeutic decisions.
suited for posterior orbital tumours.
Surgical resection with negative margins rep-
resents the cornerstone of management for
15.2 Orbital Exenteration
benign and low-grade malignant tumours.
Histology-specic induction chemotherapy can
be used for high-grade sinonasal cancers in order
to downstage the tumour and increase the possibility of orbital preservation [3]. Tumour eradica-
The most common indication for orbital exenteration is orbital invasion by periocular cutaneous
malignant tumours, of which 90% are basal cell
carcinoma. Other tumours that can present with
Type IIb
Extended orbital exenteration
Type IV
15 Orbital Exenteration inHead andNeck Malignancy
369
orbital invasion include inverted papillomas,
bro-osseous lesions, juvenile angiobromas,
low-grade malignancies, and high-grade cancers
[4]. Orbital invasion can present with mass effect
such as globe displacement or ptosis, or signs of
tissue inltration including restricted ocular
motility, immobile eyelids, or xation of the
tumour to bone. When these signs are present,
orbital exenteration is deemed necessary, be it for
curative or palliative intent.
The decision about orbital exenteration in
cases of sinonasal malignancies is facilitated if
the patient already has clear clinical signs of intraconal invasion such as visual loss, restriction of
ocular mobility, or inltration of the eye globe [4].
However, in borderline situations, conrmation
of orbital involvement should be performed intraoperatively. In selected cases with minimal orbital
invasion without functional compromise, orbitsparing surgery can be done with acceptable oncological outcomes [4]. Appropriate reconstruction
of any surgical defects is essential in order to minimize complications and optimize functional and
aesthetic outcomes. Orbital apex invasion represents a negative prognostic factor [3]. Orbital
reconstruction depends on the surgeon’s speciality: healing by secondary intention and split-thickness skin grafts are mostly performed by
oculoplastic surgeons, whereas regional or free
aps are mostly performed by ENT surgeons [5].
Exenteration can be classied as total, subtotal,
or extended; subtotal exenteration spares either or
both the eyelids and the conjunctiva, and the
extended type removes also the diseased bone or
soft tissue. Although subtotal exenteration offers a
better cosmetic outcome, faster healing, and less
chance of sino-orbital stula formation, it should
not be chosen at the expense of a complete surgical
cure. Typically, the detailed types of orbital exenteration include lid- and conjunctiva- sparing anterior exenteration, lid- sparing anterior exenteration,
anterior exenteration, lid- and conjunctiva-sparing
total exenteration, lid-sparing total exenteration,
total exenteration, lid- and conjunctiva-sparing
extended exenteration, lid-sparing extended exenteration, and extended exenteration [6].
The surgical specimen should be sent for
checking of margin involvement, although a clear
margin does not necessarily indicate a complete
cure. Orbital exenteration allows surgical resection of R0 tumours in 42.5–97% of cases. Overall
survival following orbital exenteration is 83%
and 65% at 1 and 5years, respectively [5].
15.2.1 Surgical Steps
15.2.1.1 Lid-Sparing Exenteration
1. The patient lies supine under GA.
2. A 4-0 black silk suture is threaded through
the skin, orbicularis muscle, and supercial
tarsus of the upper and lower lids and tied
together. This allows traction during the
procedure.
3. A skin incision is made 2.0 mm above the
upper eyelash and 2.0mm below the lower
eyelash, inferior to both medial and lateral
canthi. Only the skin and orbicularis oculi
muscle are cut through. This is undermined
superiorly and inferiorly until the periosteum
outside the orbital rim is exposed (Fig.15.2).
4. A monopolar cautery is used to make incision through the periosteum, 2.0mm outside
of the orbital rim, to expose the underlying
bone.
5. A periosteal elevator is used to free the periosteum around the bony orbital margin and
into the orbital cavity. The supraorbital nerve
should be identied and preserved in order to
preserve sensation to the forehead (Fig.15.2).
6. Meticulous dissection should be practised
when the periosteal elevator is used nasally
to prevent fracturing the ethmoid bone lamina papyracea, which is extremely thin.
When the periosteum is freed posteriorly, the
enucleation scissors are inserted between the
periosteum and bone on the inferonasal side
and gently advanced to the orbital apex.
7. The tissues are then cut as near to the orbital
apex as possible, and the orbital contents are
removed by continued traction on the silk
sutures in the eyelids while cutting the residual adhesions in the posterior orbit.
8. The socket is immediately packed with moist
gauze, which is left in place for 5–10 min.
The gauze is then removed, and the orbital
370
N. Mat Lazim et al.
a
d
Fig. 15.2 Surgical steps during lid sparing exenteration:
(a) lids are tie together; (b) incision is made above the
lower lid; (c) skin ap raised till periosteum of orbital rim
is exposed; (d) incision through periosteum via a monop-
b
e
apex is inspected. Residual soft tissue at the
orbital apex is removed piecemeal, and bipolar cautery and repeat packing are used until
there is no further bleeding.
9. Some surgeons prefer to clamp the tissues at
the orbital apex before excising the specimen. Caution should be used with Bovie
cautery within the orbit to minimize the risk
of CSF leak or damage to periorbital tissues.
10. A rubber drain is placed in the socket after
complete haemostasis, and the skin of the
upper and lower eyelids is sutured together
with interrupted 5-0 silk sutures. This leaves
the residual orbital cavity lled with air.
11. The drain suture is removed in 12–24h postsurgery, and the drain is removed in 24–48h
depending on the drainage volume.
15.2.1.2 Total Exenteration
1. Two 4-0 silk tarsorrhaphy sutures are placed,
which act as traction sutures during the
procedure.
2. A monopolar cautery is then used to make an
incision through the skin and orbicularis
muscle around the orbital rim.
3. Dissection is carried out to the orbital rim
laterally and inferiorly. The superior orbital
c
f
olar; (e) the orbital content is removed with a traction
suture; (f) the lids are sutured after removal of orbital content and small drain is secured
rim is identied, and the periosteum is
elevated.
4. The lateral orbital rim is incised along the
periosteum. Superiorly, the periosteum is
elevated from the orbital rim.
5. Laterally, the periosteum is elevated from
the lateral orbital rim and lateral wall. In this
area, the zygomatico-facial and zygomaticomaxillary neurovascular bundles should be
identied.
6. This bundle should be transected with a
monopolar cautery. Medially, the anterior
ethmoidal neurovascular bundle is identied and cauterized. It is important not to
compromise the thin bone of the medial
orbital wall to prevent sino-orbital stula
formation.
7. Posteriorly, the posterior ethmoidal neurovascular bundle is identied and cauterized.
After transection of the infraorbital ssure as
well as the nasolacrimal duct, the curved scissors are used to transect the posterior obit.
8. In doing this, the ophthalmic artery is transected and there is signicant bleeding. One
can apply a ligaclip prior to transection. The
periosteum is largely intact other than the
posterior orbit.
15 Orbital Exenteration inHead andNeck Malignancy
9. Haemostasis is secured with bipolar cautery.
The area is then packed for haemostasis prior
to harvesting of the split-thickness skin graft.
10. Other options for covering the defect or
reconstruction include granulation, use of
local aps such as a cheek lift and median
forehead ap, and use of a free ap.
15.2.2 Case Illustrations
371
This is a case of advanced left maxillary sinus
carcinoma with orbital involvement (Fig. 15.3).
CT scan showed extensive maxillary tumoural
mass, which invaded the orbital cavity and multiple small lymph nodes ipsilaterally. Patient was
planned for left total maxillectomy, segmental
mandibulectomy with left total orbital exenteration and left anterolateral neck dissection, and
tracheostomy. The reconstruction of the defect
was performed by plastic reconstructive team.
Intraoperatively, a modied Weber-Ferguson
skin incision is used with lid incision for orbital
exenteration and transcervical inferior limb extension for ipsilateral neck dissection (Figs.15.4 and
15.5). Total maxillectomy was performed rst.
Subsequently, superior maxillectomy bony cut
was incorporated with inferior orbital bony cut
(Fig.15.6). The periosteum was elevated from the
orbital rim. Before cutting on the orbital tissues
and its content, the neurovascular bundle needs to
be identied (Fig.15.7) and clipped. This avoids
unnecessary bleeding. Once the orbital tissue is
Fig. 15.4 A skin incision has been marked for left total
maxillectomy, left orbital exenteration, and left anterolateral neck dissection
Fig. 15.5 A modied Weber-Ferguson skin incision for
maxillectomy
Fig. 15.3 A patient with advanced left maxillary sinus
carcinoma with left orbital involvement
Fig. 15.6 An inferior cut of the orbital wall incorporating
with maxillectomy osteotomy
372
N. Mat Lazim et al.
removed, the residual tissue at the orbital apex can
be removed by piecemeal technique (Fig.15.8).
The bleeding can be controlled with bipolar diathermy and a suction (Fig.15.9). The total maxillectomy, segmental mandibulectomy, and total
orbital exenteration were completed (Fig.15.10).
The left orbital tissue specimen (Figs.15.10 and
15.11) is sent to pathology for detailed histology
examination and determination of surgical margin
involvement (Fig.15.12).
15.2.3 Complications
There are multiple complications that can arise
from the orbital exenteration. These complications can severely affect the patient’s quality of
Fig. 15.7 Bipolar is used to cauterize the vascular bundle
that may cause uncontrolled bleeding during dissection
life. Signicant numbers of patients may develop
sino-orbital stulas from perforated sinuses
occurring intraoperatively. The thin ethmoid
bones can be fractured during the surgery, leading to an opening or stula between the orbit and
the nasal cavity. This can be very challenging to
manage especially if the patients have comorbidities like diabetes mellitus, which impairs healing
post-operatively.
The most common post-operative complications are ethmoid stula and infection of the
operative site, encountered in 0–50% and
0–43% of cases, respectively. Martel et al.
reported that an ethmoidal stula was the most
common post- operative complication identied
in their study [7].
Intracranial infection is another potential
complication of orbital exenteration. This can be
eliminated by obliterating the cavity in its entirety
with soft-tissue free aps. This allows a safer and
more therapeutic management of the socket leading to improved post-operative management and
cosmetic outcome. Other disadvantages of secondary healing of an exenterated orbit include
delayed healing, prolonged post-operative socket
care, and delayed facial rehabilitation.
Another critical complication is a recurrent
tumour. A high rate of recurrence is reported to
occur in medial canthal tumours. This is especially true for a high-grade tumour, and in most
of the cases it requires adjuvant radiation
post-operatively.
Fig. 15.8 Tissue at the orbital apex is removed by piecemeal technique
Fig. 15.9 Tissue at the orbital apex is cauterized with
bipolar and suction
15 Orbital Exenteration inHead andNeck Malignancy
373
Cerebrospinal uid leakage is the most common intraoperative complication. This can be
repaired intraoperatively using an overlay fascia
or fat graft. Post-operatively, the patient can be
covered with intravenous antibiotic that crosses
the blood-brain barrier such as the thirdgeneration cephalosporin.
15.2.4 Reconstruction Option
Following Orbital
Exenteration
Fig. 15.10 Total maxillectomy is complete, left orbital is
exenterated, and segmental mandibulectomy is
performed
Fig. 15.11 The exenterated left orbit
Fig. 15.12 The left orbit specimen
Goals of reconstruction include separating the
sino-orbital cavities and creating a safe, stable
wound that can withstand adjuvant radiation.
Adjuvant radiation is indicated in the majority of
patients who underwent orbital exenteration, as
most of the tumours are T3 and T4 tumours. The
reconstruction also allows improvement of cosmesis outcomes post-operatively. Additionally,
the reconstructed ap will provide a good cutaneous coverage, ensure rapid healing, and allow
closure of orbital nasal and sinus communications, or of orbital and cranial communications.
This is imperative to enhance post-operative
treatment outcomes.
When planning for orbital rehabilitation, it is
important to create a concave cavity that can
accommodate a prosthesis. This is primarily
achieved through secondary granulation or splitthickness skin grafts [8]. The prosthesis application needs to be handled by a team of expertise,
and patients need to be fully counselled regarding
the necessary steps involved and the expected
outcomes. As the eyes are the most important
components of the face regarding aesthetics, the
rehabilitation of patients undergoing exenteration
is of importance. Patient condence, self-esteem,
and their return to normal social life are possible
with the use of orbital prostheses. Most of the
patients were consulted for rehabilitation, following near-complete epithelialization of the exposed
area [9, 10]. Recently, the use of dermal allografts
374
N. Mat Lazim et al.
has been investigated and has shown good success with epithelialization of the orbital cavity.
For complex orbitomaxillectomy defects, musculocutaneous free tissue aps remain the mainstay
for reconstruction [8].
The majority of treated patients required a free
ap reconstruction, especially when an extended
exenteration defect or adjuvant treatment was
anticipated. The anterolateral thigh ap was the
most commonly used donor site [10]. Other
choices of ap include latissimus dorsi and levator scapula aps. Before reconstruction, the surgical specimen should be conrmed to have
negative surgical margins. This reduces the risk
of early recurrence, as early recurrence will certainly hamper the effort of ap reconstruction.
15.3 Impact ofOrbital
Exenteration
Over the past decades, attention has been directed
toward reducing the perioperative morbidity by
developing new surgical devices and new strategies and promoting cosmetic rehabilitation by
providing adequate facial prostheses, following
an orbital exenteration. Despite these advances,
several studies have questioned the role of orbital
exenteration in improving the overall survival
[11]. This is in view of the fact that the majority
of patients who underwent orbital exenteration
had stage IV disease. The prognosis for stage IV
disease is mostly poor.
In contrast, other proponents for orbital exenteration reported that although orbital exenteration has failed to demonstrate any overall survival
benet, it allows satisfactory local control of the
disease with an increasingly less invasive procedure. The local control of the disease can be further improved with the addition of radiation.
Some of the identied risk factors for poor
overall survival include age, tumour histology
(worse prognosis with choroidal melanoma, better prognosis with basal cell carcinoma), non-R0
surgical resection, locally advanced tumours
(size >2.0 cm), and presence of metastases at
diagnosis. Recent studies have demonstrated
favourable outcomes when managing locally
advanced basal cell carcinoma, lacrimal gland
cancer, and conjunctival melanoma with targeted
therapies or immunotherapies without performing orbital exenteration [7]. These immunotargeted therapies, however, are costly and only
available at a well-developed head and neck
oncology centre globally. Importantly, not all
patients will be suitable for targeted therapy.
Only selected patients who met certain criteria
like positive EGFR will have a better treatment
response.
15.4 Conclusion
Orbital exenteration is a delicate procedure with
multiple complications that can impair the
patient’s quality of life post-operatively. A meticulous consideration is necessary in deciding
which patients are indicated for orbital exenteration and which groups of patients do not need
orbital exenteration, as the majority of patients
have stage III or stage IV disease. This allows an
optimal treatment outcome for these subset of
patients.
References
1. Rahman I, Cook AE, Leatherbarrow B. Orbital
exenteration: a 13-year Manchester experience. Br
J Ophthalmol. 2005;89(10):1335–40. https://doi.
org/10.1136/bjo.2004.062471.
2. Kasaee A, Eshraghi B, Nekoozadeh S, Ameli K,
Sadeghi M, Jamshidian-Tehrani M. Orbital exenteration: a 23-year report. Korean J Ophthalmol.
2019;33(4):366–70. https://doi.org/10.3341/
kjo.2018.0052.
3. Castelnuovo P, Lambertoni A, Sileo G, et al.
Critical review of multidisciplinary approaches
for managing sinonasal tumors with orbital
involvement. Acta Otorhinolaryngol Ital.
2021;41(Suppl. 1):S76–89. https://doi.
org/10.14639/0392- 100X- suppl.1- 41- 2021- 08.
4. Vartanian JG, Toledo RN, Bueno T, Kowalski
LP. Orbital exenteration for sinonasal malignancies: indications, rehabilitation and oncologic
outcomes. Curr Opin Otolaryngol Head Neck
Surg. 2018;26(2):122–6. https://doi.org/10.1097/
MOO.0000000000000441.
5. Martel A, Baillif S, Nahon-Esteve S, et al. Orbital
exenteration: an updated review with perspectives.