1

Introduction

Juvenile nasopharyngeal angiofibroma (JNA) is a histologically benign tumor or tumor-like lesion that has local invasions. It is a vascularized lesion without any capsule. Juvenile nasopharyngeal angiofibroma is almost always seen in males, and its peak age is around the adolescence age groups. Although this tumor is the most common benign neoplasm of the nasopharynx, some existing reports indicate the presence of angiofibroma in nasal septum, middle turbinate, hard palate, and alveolar ridge . It is responsible for less than 0.05 percent of all head and neck tumors . The tumor usually originates from the superior border of the sphenopalatine foramen, which is formed by the junction of the trifurcation of palatine bone, horizontal wing of vomer, and the roof of pterygoid plates . The origin of the tumor is of the greatest importance because it elucidates its pattern of distribution. In addition, it affects the surgical approach by which it will be managed. Initially, the tumor grows in the submucosal plane of the nasopharyngeal roof, reaching the septum and posterior aspect of nasal space, creating a mass that may cause nasal airway obstruction. As the tumor grows, the anterior face of sphenoid sinus is affected and becomes invaded by the tumor. Angiofibroma may laterally extend to the pterygomaxillary fissure and cause bowing of the posterior wall of the maxillary sinus. Further, it may involve the infratemporal fossa and middle cranial fossa. The simultaneous involvement of bilateral sphenopalatine foramen by JNA is also reported . The diagnosis of JNA is essentially based on clinical and radiologic examination . During initial evaluation, computed tomography (CT) scan with and without contrast reliably assesses tumor extensions. Magnetic resonance imaging studies, however, may be more accurate than CT in assessing the intracranial extensions. The preoperative angiography is also helpful for the evaluation of feeding vessels and also allows embolization of these vessels. Although radiotherapy, hormone therapy, cryotherapy, electrocoagulation have all been recommended in the literature, surgery remains the treatment of choice for JNA . The conventional surgical approaches including transpalatal, lateral rhinotomy, midfacial degloving, transmandibular, transhyoid, with or without extensions such as the upper lip split or concomitant craniotomy and infratemporal fossa approaches, have been examined. The management of nasopharyngeal angiofibroma has always been regarded as a formidable challenge to endoscopic surgeons as well as head and neck surgeons . Kamel et al , in 1996, described transnasal endoscopic approach for the limited angiofibroma lesions. In that study, the eligible tumors for endoscopic surgery were limited to tumors of nasopharynx, nasal cavity, ethmoid, and sphenoid sinuses. Based upon the recent findings reported in the literature, not only is endonasal surgery combined with a preoperative embolization of the arterial supply suggested for small- and middle-size JNAs, but it is also used for large tumors extending to the pterygopalatine fossa and medial aspect of the infratemporal fossa. Note that minimal intracranial extension is not an absolute contraindication . The endoscopic resection provides several advantages over more traditional surgical techniques, which include the avoidance of facial incisions and plating of the maxilla and the minimization of bone removal. These maneuvers may result in facial growth asymmetry when performed on adolescents. The endoscopes permit a multiangle and magnified view of the tumor and surrounding structures . The purposes of this study are to report the efficacy of the endoscopic approach for JNA at all stages of Radkowski’s classification (see Table 1 ) and to compare the related intra- and postoperative complications with findings from similar studies and other approaches in the literatures. This study is a retrospective report of 47 cases of JNA that were treated with nasal endoscopic surgery for a given period, as discussed in the following sections.

2

Materials and methods

Between August 1998 and May 2005, 47 patients with JNA who had undergone exclusive endoscopic surgery or endoscopic-assisted surgery at the Tertiary Department of Otolaryngology, Head and Neck Surgery of Amiralam hospital were studied.

At first, patients with JNA in various stages were selected; however, once a patient with a significant bleeding in stage IIIB was encountered, similar patients with advanced intracranial involvement were referred for radiotherapy.

Neurosurgeons were always present when patients of stage IIIA or IIIB tumors were being operated on.

All patients who underwent JNA endoscopic surgery were evaluated endoscopically in 2 weeks after surgery, then monthly, for the first 6 months, and annually afterward. An annual CT scan evaluation had begun since the third month postoperation. The mean follow-up period for each patient was about 2.5 years, and all subjects were examined with both endoscopic techniques and CT scan, as noted earlier. If an unusual situation was encountered during endoscopy while these patients were observed for recurrence, the findings were confirmed with a contrast-enhanced CT-scan imaging. The diagnosis of JNA was based on the clinical manifestations and the data obtained from CT scan imaging ( Fig. 1 ), and sometimes with or without magnetic resonance imaging.

(A) Preoperative contrast-enhanced coronal paranasal sinus CT scan of the patient with stage IIIB JNA. (B) Computed tomography scan was taken about 2 years post endoscopic operation of the same patient.

Among 47 patients who were included in our study, 31 (66%) cases were primarily treated (see Table 2 ), but the remaining 16 (34%) cases were treated secondarily in our center (see Table 3 ), which were previously operated on, using conventional or endoscopic methods.

Table 3

Patients who were secondarily treated with endoscopic surgery

Patient	Age	Symptoms and signs	Tumor location	Tumor stage ⁎	Cranial nerve injury	Hospitalization days	Follow-up (mo)	Embolization	Intraoperative bleeding (mL)	Transfused blood (U)	Tumor recurrence
1	37	NO + E + P + VL	Right	IIIB	–	8	14	–	8500	32	–
2	15	NO	Left	IB	–	3	74	–	300	–	–
3	17	NO + T	Right	IIIA	–	2	26	–	2500	8	+
4	14	NO	Left	IIC	–	5	18	–	2500	8	–
5	22	Ch.S + E	Left	IIB	–	3	57	–	1500	4	–
6	19	NO	Left	IIB	–	4	17	–	1250	3	–
7	15	NO + E	Left	IIC	–	5	31	–	1000	2	–
8	7	NO + E	Right	IIC	–	5	32	–	1000	2	–
9	15	Ch.S + E	Left	IIC	–	3	20	–	1050	2	–
10	15	NO	Right	IIC	–	4	28	–	1250	3	–
11	23	E	Right	IA	–	1	20	–	300	–	–
12	14	NO + E	Right	IA	–	2	49	–	1250	3	–
13	18	NO	Left	IIC	–	2	53	–	2000	6	–
14	14	NO + Ch.S + E	Left	IIC	–	4	8	–	300	–	+
15	12	Ch.S + E	Left	IIC	–	3	44	–	1500	4	–
16	19	NO	Right	IIC	–	1	13	–	1000	2	+

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Benefit from bimodal hearing in a group of prelingually deafened adult cochlear implant users
2. Epistaxis due to Wegener’s granulomatosis in a pediatric patient
3. Recurrent contralateral abducens nerve palsy in acute unilateral sphenoiditis
4. Radiologic appearance of chronic parapharyngeal Teflon granuloma

Stay updated, free articles. Join our Telegram channel

Join