Wound and Radiation Complications in Craniofacial Resection of Sinonasal Tumors

Introduction: Sinonasal tumors can require extensive craniofacial resection (CFR) and radiation. We review our institutional experience to characterize wound and radiation complications.

Methods: Our electronic surgical records were searched for patients from 1995–2015 for patients that had CFR for sinonasal tumors. One hundred and sixty patients were found and 126(79%) had adequate electronic records. Collected data included patient characteristics, surgical approach, pathology, neo-adjuvant and adjuvant therapies, radiation and wound complications, and follow-up. Wound complications were characterized as immediate or delayed and major or minor. Immediate complications occurred postoperatively or within 30 days of discharge. Minor wound complications required a simple surgical or major if they required significant operative intervention. Radiation complications were minor if temporary or asymptomatic and major if requiring significant operative intervention or permanent neurologic deficit. Alopecia, minor mucositis, skin changes, and weight-loss without loss of ability to eat were excluded as radiation complications.

Results: Mean patient age was 52.8 ± 14.7(12–82) years and 77(61%) were male with a median follow-up of 42(4–233) months. Surgical approaches included bifrontal craniotomy(n = 6), bifrontal craniotomy and endoscopic endonasal(n = 21), bifrontal craniotomy with lateral rhinotomy (n = 82), and bifrontal craniotomy with lateral rhinotomy and orbital exoneration(n = 17). Reconstruction included non-vascularized graft(n = 11), non-vascularized graft with vascularized pericranial flap (n = 87), and vascularized rotational or free-flap (n = 28). Eleven (9%) patients had an immediate postoperative complication. Six were minor (CSF leak treated with lumbar drain or EVD) and 5 were major [CSF leak requiring operative repair (n = 2), infection requiring wash-out (n = 1), postoperative free-flap hematoma (n = 1), and wound dehiscence requiring reconstructive free-flap (n = 1). There were 20 delayed minor complications with a median onset of 22 (4–177) months including chronic sinusitis requiring multiple endoscopic washouts (n = 1), nasolacrimal duct obstructions (7=1), exposed bone graft and hardware (n = 2), flap overgrowth obstructing vision (n = 1), nasocutaneous fistulas (n = 2), mucoceles (n = 2), meningocele (n = 1), nasal outflow obstruction (n = 1), superficial infections treated with oral antibiotics (n = 1), and chronic sinusitis requiring multiple endoscopic wash-outs (n = 1). There were 12 major delayed wound complications with a median onset of 24 (8–105) months including wound breakdowns (n = 3), wound infection (n = 3) large nasocutaneous fistula requiring prosthesis (n = 1), and delayed CSF leaks (n = 6).

One-hundred-one patients(81%) had neo-adjuvant(n = 5) or adjuvant radiation(n = 96) with a median follow-up of 41(4–233) months. Five(5%) patients had minor radiation complications including mucositis leading to PEG placement (n = 4) and temporal lobe radiation necrosis(n = 1). Eleven(11%) developed a major radiation complication; eight were managed with surgery including radiation necrosis and infection(n = 3), radiation necrosis alone(n = 4), and radiation-associated squamous cell carcinoma(n = 1). Three were managed without surgery: radiation necrosis leading to functional decline(n = 2) and unilateral optic neuritis and blindness(n = 1).

Conclusions: Overall we had minor and major immediate wound, delayed wound, and radiation complication rates 5% and 4%, 16% and 10%, and 5% and 11% respectively