27 Endoscopic Treatment of Juvenile Angiofibroma: Surgical Technique

Ahmad Safadi, Alberto Schreiber, Dan M. Fliss, Piero Nicolai


Endoscopic approach for the resection of juvenile angiofibroma (JA) has become the mainstay of treatment of this lesion, and more advanced lesions are being managed by a pure endoscopic approach. In this chapter, we present the endoscopic endonasal approach for JA in a step by step manner.

27 Endoscopic Treatment of Juvenile Angiofibroma: Surgical Technique

27.1 Introduction

JA is a rare vascular lesion of the nasopharynx and nasal cavity. It affects young male adolescents mainly between 9 and 19 years old. 1 JA is a highly vascular tumor composed of a proliferating and irregular vascular component within a fibrous stroma. JA originates from the upper portion of the sphenopalatine foramen where the sphenoid process of the palatine bone meets the sphenoid bone and vomer (▶ Fig. 27.1).

Fig. 27.1 Intraoperative endoscopic view of the right nasal fossa showing the junction between the sphenoid process of palatine bone (indicated by the suction tip) and anterior wall of sphenoid sinus. Asterisk indicates the sphenopalatine foramen.

Although benign, JA has a local invasive and destructive behavior, and has the tendency to spread not only through minor resistance areas, but also through fissures and sutures and even by direct invasion of cancellous bone.

JA follows a characteristic pattern of spread, which distinguishes it from other vascular lesions of the pediatric skull base. From its origin in the sphenopalatine foramen, JA spreads to the nasal cavity and nasopharynx in a submucosal and subperiosteal plane. Laterally it usually spreads anterior to the pterygoid plates and involves the pterygopalatine fossa (PPF) in more than 70% of cases. 2 Filling the PPF, the lesion anteriorly displaces the posterior maxillary wall, and in extreme cases the maxillary sinus is obliterated. Posteriorly, the tumor remodels and erode the pterygoid plates and may reach the pterygoid fossa. Laterally, the tumor spreads through the pterygomaxillary fissure to the infratemporal fossa (ITF). Superiorly JA spreads through the inferior orbital fissure (IOF) to involve the orbit and through the superior orbital fissure (SOF) and foramen rotundum it reaches the cavernous sinus. The sphenoid sinus can be involved by a submucosal spread of the tumor from the nasopharynx as well as through erosion and expansion of the vidian canal. A posterolateral route of extension is less common, and consists of tumor spread from the nasopharynx to the pharyngeal recess, and laterally to the pterygoid fossa posterior to the medial pterygoid plate or through erosion of the medial pterygoid plate. From the pterygoid fossa JA may progress to the parapharyngeal space laterally, while superior extension will involve the foramen lacerum and carotid canal. Bony involvement by JA can have one of three patterns: erosion, remodeling, and direct cancellous bone invasion. JA spreads through fissures and foramens by means of expansion, thinning, and remodeling of the involved bones, and has a tendency to erode and involve cancellous bone, most typical in the clivus and pterygoid base. Large tumors with extensive infratemporal spread may also destruct the greater sphenoid wing. Intracranial extension occurs in 10% to 20% of cases, while intradural extension is very rare 3 (Box 27.1).

Box 27.1 Juvenile angiofibroma pattern of spread

  • JA originate from the sphenopalatine foramen

  • In more the 70% involve the PPF

  • Vidian canal and cancellous bone invasion are typical findings

  • 10–20% IC extension, extradurally

Surgical treatment of JA is challenging due to the young age of the patients, the complexity of skull base anatomy, and the rich vascularity of the lesion. Many external approaches have been used for surgical excision of JA, including transpalatal, Le Fort I osteotomies, lateral rhinotomy, midfacial degloving, facial translocation, anterior craniofacial and lateral infratemporal/subtemporal approaches. Each approach has its own advantage over the other according to tumor extent. Midfacial degloving has been widely adopted due to avoidance of facial scars. However, external approaches usually involve extensive osteotomies which are associated with increased blood loss, and may interfere with the normal facial growth of the adolescent patient. Since Kamel 4 first introduced the endoscopic endonasal approach for resection of JA, this approach gained increasing popularity and was recently adopted in large centers for advanced tumors. 5 11 The endoscopic approach has many advantages over external transfacial approaches, which include the avoidance of facial incisions, osteotomies, and bone plating, which do not expose young patients to the risk of craniofacial alterations. In addition, the magnified field of view and angled view “behind the corner” may be associated with more complete inspection of the resection cavity and shorter hospitalization time. In this chapter, we present the endoscopic endonasal approach for JA in a step by step manner.

27.2 Diagnosis and Preoperative Management

JA is often suspected when a young male boy presents with nasal obstruction and epistaxis. Nasal endoscopy commonly shows a hypervascularized lobulated mass with a smooth surface typically bulging behind the tail of the middle turbinate, obstructing the choana or completely filling the nasal fossa (▶ Fig. 27.2).

Fig. 27.2 Juvenile angiofibroma filling the left nasal cavity, pushing the middle turbinate (yellow star) laterally.

Diagnosis is made by the typical clinical and imaging findings, while tissue biopsy is unnecessary and may lead to brisk hemorrhage. At imaging, JA appears as a highly vascularized and expansile lesion centered on the PPF in both contrast-enhanced computerized tomography (CT) and gadolinium-enhanced magnetic resonance imaging (MRI). CT and MRI are complementary in the diagnosis of JA, as CT emphasizes skull base bony involvement while MRI is superior in the demonstration of intracranial, orbital, and cavernous sinus invasion. On both T1- and T2-weighted, unenhanced MRI, the lesion shows flow-void spotty signals, due to enlarged blood vessels. The typical pattern of spread of JA and the typical bony changes associated with this lesion as well as its rich vascularity distinguish this lesion from other lesions that may involve the skull base, and obviate the risk of tissue sampling (▶ Fig. 27.3).

Fig. 27.3 Juvenile angiofibroma in a 15-year-old male. (a) Contrast-enhanced CT, coronal plane, showing involvement of the pterygopalatine and infratemporal fossae with remodeling of the IOF, and destruction of the pterygoid plates. (b) Gad-enhanced T1-weighted MRI, coronal plane, showing extensive infratemporal fossa involvement; notice the hour-glass appearance of tumor due to extension through the pterygomaxillary fissure. (c) T2-weighted axial MRI showing involvement of the greater wing of sphenoid bone; the tumor juxtaposes the clival internal carotid artery. Notice the dark spots presenting signal voids. (d) Gad-enhanced T1-weighted MRI, coronal plane, showing intracranial extradural involvement.

Staging is most commonly according to Andrews 12 or Radkowski’s 13 staging systems. Recently, Snyderman et al 15 proposed the UPMC staging system, emphasizing the role of residual tumor vascularization by the ICA following embolization and the route of intracranial extension (medial or lateral to ICA and cavernous sinus) as the most important factors for determining the feasibility of endoscopic resection and the risk of residual or recurrent tumor. ▶ Table 27.1 shows the staging systems most commonly highlighted in the literature.

Table 27.1 Staging systems most commonly adopted in the literature

Andrews et al 12


Limited to the nasopharynx and nasal cavity. Bone destruction negligible or limited to the sphenopalatine foramen


Invading the pterygopalatine fossa or the maxillary, ethmoid, or sphenoid sinus with bone destruction


  • Invading the infratemporal fossa or orbital region without intracranial involvement

  • Invading the infratemporal fossa or orbit with intracranial extradural (parasellar) involvement


  • Intracranial intradural without infiltration of the cavernous sinus, pituitary fossa, or optic chiasm

  • Intracranial intradural with infiltration of the cavernous sinus, pituitary fossa, or optic chiasm

Radkowski et al 13


  • Limited to posterior nares and/or nasopharyngeal vault

  • Involving the posterior nares and/or nasopharyngeal vault with involvement of at least one paranasal sinus


  • Minimal lateral extension into the pterygopalatine fossa

  • Full occupation of pterygopalatine fossa with or without superior erosion orbital bones

  • Extension into the infratemporal fossa or extension posterior to the pterygoid plates


  • Erosion of skull base (middle cranial fossa/base of pterygoids)—minimal intracranial extension

  • Extensive intracranial extension with or without extension into the cavernous sinus

Snyderman et al 15


No significant extension beyond the site of origin and remaining medial to the midpoint of the pterygopalatinefossa


Extension to the paranasal sinuses and lateral to the midpoint of the pterygopalatinefossa


Locally advanced with skull base erosion or extension to additional extracranial spaces, including orbit and infratemporal fossa, no residual vascularity following embolization


Skull base erosion, orbit, infratemporal fossa Residual vascularity


Intracranial extension, residual vascularity

M: Medial extension

L: Lateral extension

Preoperative embolization is usually considered for all cases of JA except for very small lesions. Embolization is done through a transarterial approach (TAE). This technique uses small particle material (PVA—polyvinyl alcohol, microspheres, …) that is introduced by a superselective catheterization of the feeding vessels. In advanced JA lesions, a blood supply from the ICA branches should be sought, as embolization in these feeders is discouraged, as it may result in neurologic complications due to particle dislodgement to the central nervous system. Embolization should be done close to the scheduled operation, usually within 24 to 72 hours before the surgery, as collateral blood supply may develop and reduce the efficacy of embolization (Box 27.2).

Box 27.2 Preoperative embolization

  • Transarterial embolization should be done 24–72 hours before surgical intervention

  • Embolization is discouraged in cases with significant ICA blood supply

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Feb 8, 2021 | Posted by in HEAD AND NECK SURGERY | Comments Off on 27 Endoscopic Treatment of Juvenile Angiofibroma: Surgical Technique
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