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Juvenile nasopharyngeal angiofibroma (JNA) are locally growing highly vascular tumours treated primarily by surgical excision (open approach as wide as a mid facial degloving or endoscopic approach). All our patients underwent exclusive endoscopic tumour excision after a pre-operative embolisation. The tumours were completely resected with acceptable blood loss and no recurrences or residual masses were seen. Post-operative morbidity was minimal without external scar-marks. To conclude endoscopic excision is a very effective method to resect JNA even for extensive tumours.
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Endoscopic Approach to Fisch Stage II to III-b Juvenile
Nasopharyngeal Angiofibroma
Brajendra Baser Shenal Kothari Arvind Kinger
Received: 25 August 2010 / Accepted: 10 October 2010 / Published online: 13 January 2011
ÓAssociation of Otolaryngologists of India 2011
Abstract Juvenile nasopharyngeal angiofibroma (JNA)
are locally growing highly vascular tumours treated pri-
marily by surgical excision (open approach as wide as a
mid facial degloving or endoscopic approach). All our
patients underwent exclusive endoscopic tumour excision
after a pre-operative embolisation. The tumours were
completely resected with acceptable blood loss and no
recurrences or residual masses were seen. Post-operative
morbidity was minimal without external scar-marks. To
conclude endoscopic excision is a very effective method to
resect JNA even for extensive tumours.
Keywords Endoscopy Juvenile nasopharyngeal
angiofibroma Intracranial Extradural Antral window
Septal window
Juvenile nasopharyngeal angiofibroma (JNA) is a benign
vascular tumour forming about 0.05% of all head and neck
tumours [1]. Grossly, these are pale red to blue smooth
masses often lobulated, non-encapsulated, sessile or
pedunculated arising in pterygopalatine fossa. They grow
along the tissue planes following the path of least resis-
tance and this is of benefit in surgical clearance. Out of
various theories described for their pathogenesis androgen
dependence theory is most accepted.
The patient presents with recurrent epistaxis and nasal
blockage [2] with intranasal mass. Cheek swelling, visual
changes, hearing impairment and neurological deficits may
be present some times.
Various management options for control of JNA,
include radiotherapy, chemotherapy, hormonal therapy,
electrocoagulation and surgery. Surgery remains the
mainstay of treatment [2]. Surgical approaches range from
extensive mid facial degloving to minimally invasive
transnasal endoscopic excision.
The knowledge of wide maxillary antrostomies, anterior
ethmoidectomies, middle turbinate removal, maxillecto-
mies, and accessibility to pterygomaxillary fissure is a pre-
Although open approaches give the benefit of wider
exposure high morbidity, more hospitalisation, more
bleeding, facial disfigurement, sometimes delayed bone
growth in children, is a cause of concern. All these draw-
backs are preventable by endoscopic resection without
compromising the tumour excision. Pre-operative emboli-
sations help in blocking the feeding vessel (internal max-
illary artery) and thus decrease tumour vascularity. The
sinoscope gives better illumination and a panoramic view
and without disturbing the functional anatomy of the
sinuses. A residual mass may be left behind in extensive
tumours but this is rare.
Management of these patients is essentially based on a
thorough clinical and radiological study. The radiograph of
the paranasal sinuses and nasopharynx reveal presence of a
nasopharyngeal mass, anterior bowing of the posterior wall
of maxillary antrum (pathognomonic) and nasal septal
displacement. CT-MRI with contrast gives a better vision
of the extent of the tumour and a good delineation of the
tumour margins and a r e therefore more informative and
diagnostic tools. Angiography and embolisation pre-oper-
atively help to assess tumour vascularity and reduce it
B. Baser S. Kothari (&)A. Kinger
SAIMS Medical College, Indore-Ujjain State Highway,
Bhanwarsala, Sanwer, Indore, India
Indian J Otolaryngol Head Neck Surg
(January–March 2011) 63(1):1–4; DOI 10.1007/s12070-010-0061-1
Recurrences and relapses can be avoided by proper
evaluation, staging and good surgical plan. The recurrence
is common when tumours reach skull base [3], roof of
infratemporal fossa, cavernous sinus or body of sphenoid.
Fortunately these tumour remnants either regress or remain
stable [4,5]. If clinically or radiologically the tumour is
stable a close surveillance is all that is required.
Materials and Methods
Between Jan 2007 and Mar 2010, 12 patients with JNA
ranging from Stage II to Stage III-B (Fisch classification), all
young males in the age group of 10–17 years, were diag-
nosed and operated by a transnasal endoscopic excision with
pre-operative embolisation. Post-operative CT scan and
endoscopy did not reveal any residual disease or recurrences.
Surgical Technique
After adequate decongestion, tumour exposure was the first
requirement and following steps were adopted, the lower
part of middle turbinate amputated, creation of septal
window, removal of uncinate process, the maxillary ostia
widening, and removal of the medial wall of maxillary
sinus. Smaller tumours could be accessed with this expo-
sure. To create a septal window the posterior part of the
bony septum was removed. In this way a two surgeon-two
nostril approach was adopted and a wider working space
created. For larger tumours further exposure was achieved
by removing medial and posterior maxillary walls as per
the case. When the maxillary artery was encountered it was
coagulated. The tumour was mobilised from the most lat-
eral part of the pterygopalatine fossa. Then the sphenoid
extension was mobilised and displaced inferiorly. The
plane of dissection was further followed into the naso-
pharyngeal region and the tumour delivered orally. During
the entire operation bone removal was facilitated by use of
Kerrison’s punches and a microdebrider with a sharp burr.
In Case no. 5 the entire medial wall was removed along
with the posterior wall far laterally to get access to the
infratemporal fossa. The tumour in this case was reaching
up to the cavernous sinus intracranially but was safely
extradural which could be accessed and removed by trac-
tion and blunt dissection under endoscopic vision reaching
up to lateral aspect of the sphenoid.
For case no. 12 the posterior wall removal was through
transantral window and it was possible to access the most
lateral extension in the infratemporal fossa. The endoscope
was introduced through the maxillary sinus and the tumour
dealt through the nasal cavity.
Anterior nasal packing was done for haemostasis which
was removed the second post-op day and discharged
between the third and fifth post-operative day. First follow-
up was after 2 weeks and then every month for 3 months.
Overall, the length of follow-up was between 6 and
26 months.
There were no recurrences. Two patients developed
mucocele which were endoscopically excised.
All patients were discharged within a period of 2–5 days
post-operatively as against 10–15 days in an open
The tumours ranged from stage II to III-B as per Fisch
classification (Table 1).
Pre-operative embolisation (Figs. 1,2,3) was done in all
patients. This helped to minimize the intraoperative blood
loss. Only two patients needed one unit of blood, one
patient needed two units of blood and rest did well without
blood transfusion.
There were no recurrences or complication.
A young male presenting with complaints of epistaxis,
nasal obstruction and a nasopharyngeal mass is almost
diagnostic of JNA. The presence of anterior bowing of the
posterior wall of the maxillary sinus on imaging (Holman-
Miller sign) is a known pathognomonic finding [6].
These tumours grow slowly and do not erode sur-
rounding structures. All our patients had a history of nasal
obstruction for last 2–4 years and none had symptoms of
surrounding structures involvement. Intracranial extension
is very rare as in one of our cases (stage III-B) is rare which
was also excised by an exclusive endoscopic approach and
tumour delivered orally. Almost all, (if not all) JNAs with
intracranial extension remain extradural and extra cavern-
ous and this property allows for a safer dissection.
Endoscopic removal of JNA has been limited up to II-A
stage as per literature [7]. In an article by Jorrisen et al. [8]
endoscopic treatment for more than II-A stage has been
done. Carrau et al. [9] considered that the sphenoid
involvement can be treated with endoscopy alone.
Endoscopic resection in management of angiofibromas
is now a established approach. Our experience also sub-
stantiates that JFA can be safely and effectively excised by
endoscopic approach, with negligible morbidity. Several
studies which favour this approach as it is true with our
series also.
2 Indian J Otolaryngol Head Neck Surg (January–March 2011) 63(1):1–4
For tumours reaching infratemporal fossa an endonasal
approach assisted by transantral window as was done for
case no. 4 helps to achieve a wider exposure and improves
visualisation as wide angle endoscopes give a panoramic
view. Case no. 5 had an intracranial extradural extension
and this was completely removed under endoscopic guid-
ance by removing the medial maxillary sinus wall and a
part of medial pterygoid plate. In our study also we could
access the intracranial extension endonasally and there was
no recurrence. Onerci et al. recommended endoscopic
resection for lesions with minimal extension into the cra-
nium [10].
Pre-operative embolisation was instrumental for good
haemostasis. All patients in this study were embolised
24–36 h pre-operatively. There are studies in which
authors have reported less bleeding with hypotensive
anaesthesia alone without pre-operative embolisation.
Haemostasis was further achieved with harmonic and lig-
asure cautery.
Table 1 Details of observations made for endoscopically excised extensive angiofibromas
S No. Stage Nose & Npx S S PPF ITF Retro pter ext Intra Cr. Extra dural Pre-op embo Av. Bld loss (ml)
1II???-- --?300
2 III-a ????? ?-?1200
3II???-? --?400
4 III-a ????- --?300
5 III-b ????? ?-?700
6 III-a ????- --?500
7II???-- --?350
8II???-- --?400
9II???-- --?550
10 II ???-- --?1200
11 II ???-- --?500
12 III-A ????? ?-?900
Npx Nasopharynx, SS Sphenoid Sinus, PPF Pterygopalatine Fossa, ITF Infratemporal Fossa, Retro pter ext Retro pterygoid extension, Intr/Cr
Intracranial Extension, Extr/dur Extradural, Preop/embo Pre-operative embolisation, Av. Bld loss Average blood loss
Fig. 1 MRI showing enhancing mass (angiofibroma) in the sphenoid
extending intracranially (extradural) into right cavernous sinus of case
no. 5
Fig. 2 Case-12 exposure of most lateral Part of tumour in infratem-
poral fossa
Indian J Otolaryngol Head Neck Surg (January–March 2011) 63(1):1–4 3
Recurrence or any other complication was not seen in
any of the patients. Extensive tumours were also excised
endonasally without any external incision irrespective of
stage. Recurrence however if seen, as these masses are
inactive, is followed by a close surveillance alone and
considered for revision surgery only when they become
1. Wormald PJ, Van Hasselt A (2003) Endoscopic removal of
juvenile angiofibroma. Otolaryngol Head Neck Surg
2. Brentani MM, Butugan O (2003) Endoscopic laser assisted
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yngol Head Neck Surg 129:454–459
3. Bothwell MR, Piccirillo JF, Lusk RB, Ridenour BD (2002)
Longterm follow-up of facial growth after FESSO to laryngology.
Head Neck surg 126:628–634
4. Herman P, Lot G, Chapot R, Salvan D, Tran Ba, Hey P (1999)
Longterm follow-up of juvenile nasopharyngeal angiofibroma
analysis of recurrences. Laryngoscope 109:140–147
5. Jacobson M, Petruson B, Ruth M (1989) Involution of residual
juvenile nasopharyngeal angiofibroma with intracranial exten-
sion, a case report with C T assessment. Arch Otolaryngol Head
Neck Surg 115:238–239
6. Cummings CW (ed) (1998) Otolaryngology-head and neck sur-
gery, vol 2, 3rd edn. Mosby, St. Louis, p 1514
7. Radwoski D, McGill T, Heady GB et al (1996) Angiofibroma
changes in staging and treatment. Arch Otolaryngol Head Neck
Surg 122:122–129
8. Jorrisen M, Eloy P, Bachert C, Daele J (2000) Endoscopics in us
surgery for juvenile Nasopharyngeal angiofibroma. Acta Otolar-
yngol 54:201–219
9. Carrau RL, Synderman CH, Kassam AB, Jungreis CA (2001)
Endoscopic and endoscopic-assisted surgery for juvenile naso-
pharyngeal angiofibroma. Laryngoscope 111:483–487
10. Onerci TM, Yucel OT, Ogretmenoglu O (2003) Endoscopic
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J Pediatr Otorhinolaryngol 67:1219–1225
Fig. 3 One year post-operative endoscopic picture showing optic
chiasma in case no. 5
4 Indian J Otolaryngol Head Neck Surg (January–March 2011) 63(1):1–4
... JNA is a formidable, locally aggressive, benign tumor of nasopharynx that spreads submucosally. It occurs almost exclusively in adolescent males and forms 0.05% of all head and neck neoplasms [1,2]. This decade has witnessed a new armamentarium of diagnostic techniques that have revolutionized the management of JNA. ...
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Imaging plays an important role in the diagnosis, staging and prognosis of JNA. Certain radiological changes as seen on CECT were observed to be consistent in our case series. This study analysed preoperative and postoperative CECT of large series of JNA patients to evaluate the sites and pattern of spread of tumor. We evaluated the clinical significance of pterygoid wedge in preoperative and postoperative imaging and thus elucidating two new radiological signs. Retrospective analysis of the pre operative and post operative imaging data of 242 patients with JNA. The findings in the scan were clinically correlated with the endoscopic intraoperative findings. Preoperative evaluation of the pterygoid wedge revealed widening on the involved side in 99.1% of our cases which is 1.8 times greater compared to the uninvolved side. The possibility of residual/recurrent tumor was found to be significantly higher in those where the pterygoid wedge was not removed by drilling (p < 0.001) Drilling of the pterygoid wedge intra operatively, reduced the rate of residual/recurrence from 31.9 to 3.07%. Widening of the pterygoid wedge seen in the preoperative CECT, referred as RAM HARAN sign occurs in JNA. It has a significant diagnostic value as a radiological sign in JNA. Drilling of the pterygoid wedge intraoperatively reduces the rate of recurrence of JNA. Appearance of the two pterygoid plates on postoperative CECT, as two parallel lines, referred as Chopstick sign, has a remarkable prognostic value as a radiological sign in JNA.
Background: Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). Methods: Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. Results: The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. Conclusion: A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
Objective We compare the open and transnasal approaches for the excision of juvenile nasopharyngeal angiofibromas regarding the rate of morbidity, and residual tumor and its symptomatic recurrence over time. In addition, we present volumetric measurements of juvenile nasopharyngeal angiofibromas over time. Methods All surgically treated patients of our institution were reviewed back to 1969 for type of surgery, residual tumor by magnetic resonance imaging (MRI)-based volumetry, recurrence, and morbidity. We performed a prospective clinical and radiological follow-up on reachable patients. Results In total, 40 patients were retrievable from our records. We were able to follow up on 13 patients after a mean of 15.7 years since surgery (range: 1–47 years). Patients operated by the open approach had a higher rate of postoperative complications and thus a higher morbidity than endoscopic patients (4/4 vs 3/9; p = 0.007), although tumor sizes were equal among groups (p = 0.12). Persisting tumor was noted in 3/4 and 4/9 (p = 0.56) patients, respectively. The corresponding mean volumes of residual tumors were 16.2 ± 14.4 cm3 and 10.8 ± 6.6 cm3 (p = 0.27). No progression could be noted in endoscopically treated patients (p = 0.24, mean time between scans 2 years). Conclusions Our analysis shows that the endoscopic approach results in less morbidity. The open approach does not guarantee freedom from persisting tumor tissue. Age seems to be a most important risk factor for the conversion of an asymptomatic persistence into a symptomatic recurrence.
Juvenile angiofibroma is a rare, highly vascular, histologically benign but locally invasive tumour, affecting predominantly male adolescents. To describe our experience in diagnosis of angiofibroma and treatment by combined endoscopic and transpalatal route. We analysed a case series of 50 patients of nasopharyngeal angiofibroma in Fisch stages I and II who presented at our institute during a period of four years 2011–2014, their clinical presentation, their treatment by combined transpalatal and endoscopic approach, intraoperative and post operative course, complications and tumour recurrence. Patients were aged 8–26 years. All patients were treated surgically by combined approach endoscopic and transpalatal. The mean operation time was 90 min, and the mean bleeding volume was 300 ml. Only 8 % patients came with recurrence and only 10 % came with palatal perforation (fistula formation). With gratifying results we advocate this novel technique for the treatment of early to intermediate JNA.
Objective To systematically review the exclusive endoscopic treatment of juvenile nasopharyngeal angiofibroma in the literature to define the clinical features in terms of staging and the treatment outcomes in terms of bleeding, recurrence, residual tumor, and complications.Data SourcesOnline databases, including PubMed and EMBASE, were used. Reference sections of identified studies were examined for additional articles.Review Methods The literature was searched by 2 reviewers with the following inclusion criteria: English or French language and exclusive endoscopic treatment of juvenile nasopharyngeal angiofibroma. We were only able to perform a meta-analysis on the categorical outcomes using DerSimonian and Laird random effects models.ResultsNinety-two studies were included with a majority of retrospective studies (54/92; 58.6%). No randomized controlled trials were found. A total of 821 patients were identified. The Radowski classification was the most commonly used (29/92; 31.15%). The mean operative blood loss was 564.21 mL (minimum, 20 mL; maximum, 1482 mL). It was 414.6 mL (minimum, 20 mL; maximum, 1000 mL) and 774.2 mL (minimum, 228 mL; maximum, 1482 mL), respectively, in the group with and without embolization. No conclusion could be made because it was not stratified by tumor stage and because of the absence of randomized controlled trials. The random effect estimate of recurrence was 10% (95% confidence interval [CI], 8.3-11.7). It was 9.3% (95% CI, 7.2-11.5) for complications and 7.7% (95% CI, 5.4-10.1) for residual tumor.Conclusion The endoscopic treatment is an evolving modality. It is considered today the treatment of choice. A new classification system based on the endoscopic approach should be proposed in future studies.
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We sought to determine whether functional endoscopic sinus (FES) surgery performed in children with chronic rhinosinusitis alters facial growth. This was a retrospective age-matched cohort outcome study performed at a tertiary care hospital. Sixty-seven children participated. There were 46 boys and 21 girls, and the mean age was 3.1 years at presentation and 13.2 years at follow-up. There were 46 children who underwent FES surgery and 21 children who did not undergo FES surgery. Quantitative anthropomorphic analysis was performed using 12 standard facial measurements. A facial plastic expert performed qualitative facial analysis. Both quantitative and qualitative analyses showed no statistical significance in facial growth between children who underwent FES surgery and those who did not undergo FES surgery. In this study, there was no evidence that FES surgery affected facial growth. These results will aid physicians when discussing with parents the risks of FES surgery.
OBJECTIVE We sought to determine whether functional endoscopic sinus (FES) surgery performed in children with chronic rhinosinusitis alters facial growth. STUDY DESIGN AND SETTING This was a retrospective age-matched cohort outcome study performed at a tertiary care hospital. RESULTS Sixty-seven children participated. There were 46 boys and 21 girls, and the mean age was 3.1 years at presentation and 13.2 years at follow-up. There were 46 children who underwent FES surgery and 21 children who did not undergo FES surgery. Quantitative anthropomorphic analysis was performed using 12 standard facial measurements. A facial plastic expert performed qualitative facial analysis. Both quantitative and qualitative analyses showed no statistical significance in facial growth between children who underwent FES surgery and those who did not undergo FES surgery. CONCLUSIONS In this study, there was no evidence that FES surgery affected facial growth. SIGNIFICANCE These results will aid physicians when discussing with parents the risks of FES surgery.
Objectives/hypothesis: The mainstay treatment for juvenile angiofibromas is surgery. Endoscopic techniques have been applied to the resection of juvenile angiofibromas. The aim of the study is to establish the efficacy of endoscopic and endoscopic-assisted techniques for the removal of juvenile angiofibromas. Study design: Retrospective review. Methods: Retrospective review was made of all patients with juvenile angiofibromas who were treated with endoscopic and endoscopic-assisted surgery from January 1994 to July 1999. Results: Fifteen tumors in 13 patients were removed using endoscopic or endoscopic-assisted surgeries. In 11 patients, endoscopic surgery or endoscopic-assisted surgery (or both) was successful and the patients remained without evidence of disease at a median follow-up of 34 months. In two patients tumor persisted, which was detected during routine follow-up less than 6 months after the initial surgery. These tumors were managed with a second endoscopic or endoscopic-assisted surgery, and patients remained without evidence of disease. We encountered one postoperative complication, a progressive optic neuropathy that was successfully managed with endoscopic decompression. Conclusions: Endoscopic and endoscopic-assisted surgery is a feasible alternative or adjunct to traditional techniques.
Just as the operating microscope revolutionized ear surgery in the 1950s, the fiberoptic telescope is causing many otolaryngologists to change the way they think about paranasal sinus disease and the manner in which they will perform surgery in the 1990s. Endoscopic sinus surgery (ESS), which utilizes the fiberoptic telescope, is relatively new in the United States, and data about long-term follow-up of ESS cases are just beginning to appear in the literature. In a series of 100 consecutive cases, all with 2 years of follow-up, Rice1 noted that 7% needed revision surgery, and in each such case the problem was a narrowed middle meatus. Of the 93 cases that required a single procedure, 83% of the patients became completely asymptomatic, and 10% reported only occasional sinusitis. Although the majority of ESS is performed on adults, Gross et al2 reported their experience with 54 children diagnosed with recurrent or
• In September 1979 the patient, a man born in 1964, noticed pain and swelling of the right cheek in combination with periods of epistaxis. A computed tomographic scan revealed a tumor extending from the middle of the right nasal cavity into the right maxillary antrum and up toward the orbital floor with destruction of the medial and lateral walls of the antrum and continuing into the sphenoid sinus on the right side and dorsal to the pterygoid process up under the base of the skull. Angiography showed arterial supply mainly from the right external carotid artery, but also from the right internal carotid artery and the left external carotid artery. The process was diagnosed as a juvenile nasopharyngeal angiofibroma. In spite of two attempts at resection of the tumor and arterial embolization, the tumor progressed intracranially. Further operative attempts were decided against, and the patient was followed with repeated computed tomographic scans. The tumor eventually became involuted; eight years after the initial diagnosis, there was no evidence of computed tomographic scans of intracranial growth of the tumor. (Arch Otolaryngol Head Neck Surg 1989;115:238-239)
The apparent tendency of juvenile nasopharyngeal angiofibroma to involute with age has been known for many years but firm evidence of this has been lacking. This case report uses computerized tomography to provide the first documented evidence of this involution.
To identify specific preoperative tumor characteristics and potential surgical decisions that ultimately place a patient at a greater risk for tumor recurrence. The clinical presentation, management, and prognosis of 23 consecutive cases of juvenile nasopharyngeal angiofibroma were reviewed retrospectively from January 1, 1977, to June 30, 1993. A minimum follow-up of 12 months was necessary for study inclusion. A single, tertiary care pediatric facility. All available preoperative imaging studies were reevaluated to ensure consistency in reporting. Preoperative computed tomography was performed in 21 patients, but only 18 scans were available for review. Preoperative angiography with embolization was performed in 21 of 23 patients. Surgical excision was the primary mode of treatment in 22 of 23 patients, and complete surgical excision was possible in 21 of 23 patients. The rate of recurrence was examined with respect to time of presentations, initial tumor stage, intraoperative blood loss, and surgical approach. When compared with patients without a recurrent tumor, there was no difference in age at presentation, primary symptom, or duration of symptoms before diagnosis. Preoperative tumor stage was found to be the primary factor affecting tumor recurrence. A recurrence rate of 21.7% (five of 23 patients) was identified after an average 6-year follow-up. A trend toward use of the midfacial degloving approach for surgical exposure was identified and was not associated with an increased risk of recurrence. All patients were ultimately cured of their tumor without the need for open craniotomy despite a 32% incidence of stage IIIA and IIIB tumors. No deaths were reported during the study. Juvenile nasopharyngeal angiofibromas are benign tumors occurring almost exclusively in adolescent males. Recent advances in radiographic imaging techniques allow for more accurate preoperative staging, especially in regard to skull base involvement. Recognition of the extent of the tumor before surgical extirpation reduces the risk of recurrence.
Juvenile nasopharyngeal angiofibroma often recurs if the tumor is large. This report is a long-term follow-up of these cases. It establishes the prognostic values of tumor extensions, analyzes the anatomic factors involved in recurrences, describes the spontaneous evolution of remnants based on a radiographic follow-up, and evaluates the pertinence of complex combined surgical approaches for invasive tumors and the value of complementary endoscopy. Retrospective review of 44 cases treated between 1985 and 1996. Statistical analysis of the correlation between recurrence and tumor extension as evaluated by systematic analysis of 18 putative tumor extensions on preoperative computed tomography scans. Invasion of the skull base affected two-thirds of the patients, and the rate of recurrence was 27.5%. Extensions to the infratemporal fossa, sphenoid sinus, base of pterygoids and clivus, the cavernous sinus (medial), foramen lacerum, and anterior fossa were correlated with more frequent recurrence. Long-term radiographic follow-up revealed putative residual disease in nine asymptomatic patients: these remnants gradually involuted. The data in the current study emphasize the prognostic value of skull base invasion and the difficulty of complete resection of extended lesions. Tumor remnants detected in symptom-free patients should be kept under surveillance by repeated computed tomography scan, since involution may occur. Recurrent symptoms may be treated by radiotherapy (30 Gy) rather than by extended combined procedures. Endoscopic surgery should be combined with surgery for better control of skull base extensions.
Juvenile nasopharyngeal angiofibroma is a rare tumour of the head and neck with very specific characteristics: adolescent males, choana-nasopharynx, pterygomaxillary fossa widening, specific and intense vascularisation. Staging is very important in the decision of the surgical approach. Endoscopic management of juvenile nasopharyngeal angiofibroma is technically possible after preoperative embolisation. Up to now 13 angiofibroma have been treated using the endonasal endoscopic sinus surgery approach in Belgium (Leuven 8; Mont-Godinne 2; Ghent 1; Liege 1; Woluwe 1). In smaller tumors endoscopic resection has been successful in four cases without any recurrence. Five larger tumors, extending in the pterygomaxillary fossa, were also successfully resected. Extension into the infratemporal fossa or the cavernous sinus can be endoscopically removed, but recurrences may occur as they do after classical, external approaches. In conclusion, the endoscopic approach is an acceptable alternative in small to middle sized juvenile nasopharyngeal angiofibroma.