Exclusively endoscopic removal of juvenile nasopharyngeal angiofibroma: trends and limits

OBJECTIVE: To determine the feasible conditions for exclusive endoscopic resection of juvenile nasopharyngeal angiofibroma. DESIGN: Retrospective study of 20 patients, with a mean follow-up of 22 months. SETTING: Six academic referral hospitals. INTERVENTIONS: All patients had a preoperative computed tomographic or magnetic resonance imaging scan and at least 1 follow-up computed tomographic and/or magnetic resonance imaging scan 6 or 12 months after surgery. Exclusive endoscopic removal was performed using conventional functional endoscopic sinus surgery instrumentation after preoperative embolization. RESULTS: Using Radkowski staging, 4, 7, and 9 patients had stage I, II and IIIA tumors, respectively. Seven patients were operated on for a recurrence after open surgery. Extension toward the sphenoid sinus, pterygomaxillary fossa, or infratemporal fossa could be removed. There was no attempt at endoscopic removal of deep skull base or temporal fossa invasion. The mean surgery duration was 135 minutes; mean dimensions of the tumor were 4.5 x 4 x 3 cm; and mean blood loss was 350 mL (median, 300 mL). No recurrences occurred in this series; there were small asymptomatic remnants in 2 cases. CONCLUSIONS: An exclusively endoscopic management of juvenile nasopharyngeal angiofibroma appears to be effective for small to medium tumors. It should be considered as a first-choice option for these cases (in view of the minimal bleeding, shorter duration, and efficacy).     

Surgical treatment of juvenile nasopharyngeal angiofibroma

Twenty-five cases of juvenile nasopharyngeal angiofibroma are reviewed. Surgical removal via a transpalatal approach accompanied by a gingivobuccal incision and exploration of the pterygomaxillary space to remove lateral extension is advocated. This procedure is almost uniformly successful in eradicating tumors without intracranial extension. Pre-operative estrogen therapy and temporary ligation of the ipsilateral carotid artery in selected cases appears to decrease blood loss at surgery. Pre-operative angiography delineates the nasopharyngeal mass, shows any pterygomaxillary space extension, and demonstrates any middle cranial fossa extension. A fairly accurate estimate of the percentages of vascular contribution is also obtained, allowing the surgeon to plan possible vascular control by ligation. Intracranial fossa extension generally greatly increases the operative blood loss and risk, because of probable subtotal resection but is not an absolute contraindication to surgery.     

The infratemporal fossa approach for nasopharyngeal tumors

The technique and results of the infratemporal fossa surgical removal of carcinomas and juvenile angiofibromas of the nasopharynx are presented. Effective palliative removal of T4 and radical removal of T1 and T2 nasopharyngeal carcinomas was achieved. A classification of juvenile nasopharyngeal angiofibroma is presented. The infratemporal fossa approach allows radical removal of type III tumors and subtotal removal of type IV tumors. If residual tumor has to be left back in the cavernous sinus, irradiation is used to stop further growth of the tumor. If radiotherapy fails the neurosurgical removal of the intracranial portion of the tumor is indicated.     

Recent advances in the treatment of juvenile angiofibroma

PURPOSE OF REVIEW: Juvenile nasopharyngeal angiofibroma is a rare vascular tumor almost exclusive to the nasopharynx of adolescent males. Traditionally, juvenile nasopharyngeal angiofibroma has been treated surgically using open surgical approaches and has been associated with frustratingly high recurrence rates. This article reviews recent contributions to the study and treatment of this disease. In particular, advances in minimally invasive endoscopic resection of juvenile nasopharyngeal angiofibroma are evaluated. RECENT FINDINGS: The growth patterns of juvenile nasopharyngeal angiofibroma are evaluated. Young age does not appear to correlate with more aggressive disease. The major recent advance in the treatment of juvenile nasopharyngeal angiofibroma has been the application of endoscopic endonasal surgery to the treatment of select tumors. This article reviews the indications and inclusion criteria recently put forth to help select patients for this minimally invasive approach. In properly selected patients with Radkowski stage I and II lesions, recurrence rates range between 0 and 7%. Advanced lesions continue, in most cases, to require open approaches, some of which are also presented. SUMMARY: With proper patient selection, endoscopic resection of juvenile nasopharyngeal angiofibroma is feasible and may be preferable to traditional open approaches. Results suggest that after endonasal resection, disease recurrence is low. Most larger lesions, especially those with intracranial spread, continue to require open approaches for complete resection.     

Endoscopic management of benign tumors extending into the infratemporal fossa: a two-surgeon transnasal approach

OBJECTIVES/HYPOTHESIS: Preliminary results of the endoscopic two-surgeon technique for the management of benign infratemporal fossa tumors are presented. METHODS: Four patients with juvenile nasopharyngeal angiofibroma, a patient with an inverting papilloma, and a patient with a maxillary nerve schwannoma were reviewed. The average age was 22.7 years; the male-to-female ratio was 5:1. The endoscopic anatomy and surgical technique are presented. RESULTS: The two-surgeon technique allowed complete resection of all six tumors extending into the infratemporal fossa. There has been no recurrence of tumor within the infratemporal fossa, after a mean follow-up of 31.3 months (SD = 11.2 mo). CONCLUSION: The two-surgeon transnasal technique allows benign infratemporal fossa tumors to be resected endoscopically.     

Three-dimensional conformal radiotherapy for treatment of extensive juvenile angiofibroma: report on two cases

These case reports describe the application of three-dimensional conformal radiotherapy for the treatment of extensive juvenile angiofibroma. The affected areas included the pterygomaxillary fossa, infratemporal fossa, orbit, middle cranial fossa and maxillary sinus. Three-dimensional conformal radiotherapy was used to deliver the tumor dose of 3800-4140 cGy. The radiation dose to the surrounding normal structures including the optic nerve, optic chiasm, spinal cord, parotid and brain was limited. The tumor showed an excellent clinical and radiological response in both patients. There was no appreciable late toxicity. In conclusion, three-dimensional conformal radiotherapy provides several advantages over conventional radiotherapy in the treatment of extensive juvenile angiofibroma.     

鼻内镜下治疗蝶窦非垂体源性病变53例

目的:探讨蝶窦非垂体源性病变的诊断及鼻内镜治疗方法。方法:53例蝶窦非垂体源性病变患者均经CT扫描发现蝶鞍区病变并提示了病变范围。8例局限性病变者经蝶窦前壁自然口入路完成手术,2例鼻咽纤维瘤侵犯蝶窦者经鼻中隔中线入路,其余经上鼻道或蝶筛入路暴露病变。结果:53例蝶窦非垂体源性病变中,蝶窦囊肿及脓囊肿23例、蝶窦真菌感染8例、蝶窦出血性息肉2例、垂体瘤切除术后蝶窦炎性肉芽肿1例、蝶窦乳头状瘤5例、蝶窦脑脊液鼻漏1例、蝶窦骨化纤维瘤2例、鼻咽血管纤维瘤侵犯蝶窦2例、筛蝶窦脑膜瘤1例均行鼻内镜下蝶窦开放切除病变或修补脑膜,术后症状明显改善;蝶窦内血肿并颈内动脉假性动脉瘤3例仅作鼻内镜检查,经DSA证实并行血管内介入栓塞治疗后治愈;蝶窦恶性肿瘤3例,经蝶筛入路切除蝶窦内大部分肿瘤后辅以放化疗;鼻咽癌侵犯蝶窦2例病理检查证实后行放化疗。结论:蝶窦鞍区病变以头痛、眼部症状为常见症状,CT、MRI及DSA检查对蝶窦病变的及早发现和诊断起着重要作用,鼻内镜下处理蝶窦病变径路多样,选择适当径路可达到直接、安全、微创等目的。     

Diagnosis, staging, and treatment of juvenile nasopharyngeal angiofibroma (JNA)

Nineteen patients with juvenile nasopharyngeal angiofibroma (JNA) were surgically treated with different techniques from January 1968 through December 1985. Two patients had undergone a previous operation at another hospital; all patients were males (mean age 15.4), and the most common symptom was nasal obstruction (84.2%). Lateral extension into the pterygomaxillary fossa occurred in 14 patients (73.6%), and 2 also had intracranial invasion (10.5%). In five cases, the tumor's cytosol was analyzed for hormonal receptors. Negative values for estrogen and progesterone receptors were obtained, although the content of dehydrotestosterone receptors was highly positive. These results tend to support the hypothesis of JNA's androgen-dependence. The authors emphasize the need of a preoperative staging classification based on clinicoradiological data in selecting the most adequate surgical approach. Tumors with lateral extension into the pterygomaxillary fossa can be easily removed through a midface degloving; large involvement of the infratemporal fossa requires, also, a transzygomatic dissection. In JNAs with intracranial extension a combined intracranial-extracranial approach is advisable.     

不同临床时期鼻咽血管纤维瘤的手术方式选择

目的探讨如何选择恰当的手术方式切除不同临床时期的鼻咽血管纤维瘤。方法2003年6月—2006年7月中南大学湘雅医院耳鼻咽喉科手术治疗的22例鼻咽血管纤维瘤，患者均为男性，年龄9～30岁，中位年龄16岁。按鼻咽血管纤维瘤Fiseh分期，6例临床Ⅰ期患者采取单纯经鼻内镜下肿瘤切除；6例临床Ⅱ期和2例临床Ⅲ期患者采取内镜下经中鼻道上颌窦后壁入路切除肿瘤；3例临床Ⅲ期和2例临床Ⅳ期患者采取内镜下经中鼻道一下鼻道扩大上颌窦后壁入路切除肿瘤；1例Ⅳ期患者采取显微镜下经耳前颞下窝入路联合内镜下经中鼻道．下鼻道扩大上颌窦后壁入路切除肿瘤；2例Ⅳ期患者采取鼻外上颌骨入路切除肿瘤。结果21例患者肿瘤全切，1例肿瘤次全切除，术后9个月再次经鼻内镜手术全切肿瘤残灶。无手术并发症，术后随访9个月至3年无复发病例。结论以鼻咽血管纤维瘤的临床分期为基础，分别以肿瘤是否占据整个鼻腔、是否达颞下窝外侧区及是否侵入颅内为依据，选择恰当的手术方式，对减少手术损伤，提高手术疗效具有重要意义。     

Surgical management of nasopharyngeal angiofibroma involving the cavernous sinus

Involvement of the cavernous sinus by juvenile nasopharyngeal angiofibroma represents a therapeutic challenge. We present our experience over the past 5 years with the surgical management of six cases of juvenile nasopharyngeal angiofibroma involving this site. Three of six patients had involvement of the medial aspect of the cavernous sinus and tumor was removed using a midline extracranial approach. Of three remaining patients, two had invasion of the medial and inferior margin of the cavernous sinus and one represented a recurrent lesion. The tumor in these three cases was resected using a combined frontotemporal and lateral infratemporal fossa approach. An extracranial recurrence occurred in one patient, and the remaining five patients have had no evidence of recurrent disease 12 to 71 months following surgery. Morbidity has been limited to trismus, facial hypesthesia, and serous otitis media.     

Endoscopic resection of nasopharyngeal angiofibromas by combined transnasal and transoral routes

PURPOSE: To determine the role of endoscopic surgery in decreasing intraoperative bleeding, morbidity, and hospitalization period of juvenile nasopharyngeal angiofibroma resection and to describe combined endoscopic transnasal and transoral approaches. PATIENTS AND METHODS: Twelve cases of juvenile nasopharyngeal angiofibroma diagnosed by endoscopic examination, computed tomography, and angiography were selected for endoscopic resection. Tumor staging ranged from stage I(A) to II(B). Ten patients underwent preoperative selective arterial embolization, and in 1 case selective arterial ligation was used. In general, the tumors were approached endoscopically through nasal and oral cavities with 0 degrees and 30 degrees 4-mm telescopes without any incision and no packing at their termination. RESULTS: The patients were followed by endoscopy and computed tomography. There was a dramatic decrease in intraoperative bleeding and postoperative morbidity. No early postoperative complications were seen. Two recurrences were observed in 12 patients up to a mean follow-up of 15 months. CONCLUSIONS: Minimal bleeding, decreased morbidity, and shorter hospitalization period were the main reasons that prompted us to use endoscopic technique for the removal of juvenile nasopharyngeal angiofibroma. Adding transoral endoscopic approach to the transnasal endoscopic approach provides 2-sided exposure and appreciate access to angiofibroma.     

Endoscopic sinus surgery for benign and malignant nasal and sinus neoplasm

PURPOSE OF REVIEW: Endoscopic sinus surgery has become widely accepted as the standard of treatment for chronic inflammatory diseases of the paranasal sinuses unresponsive to medical treatment. With increased skill with endoscopic surgical technique, advanced technologies such as intraoperative imaging systems, and a better understanding of the complex anatomy of the paranasal sinuses and surrounding vital structures, many otolaryngologists have increasingly applied their expertise in endoscopic sinus surgery to the resection of nasal and sinus neoplasms. The following represents a review of the recent literature on the latest trends regarding endoscopic resection of nasal and paranasal sinus neoplasms. RECENT FINDINGS: There has been an increasing popularity in the removal of nasal and paranasal sinus neoplasms through an endoscopic approach. In the recent literature, emphasis has been on the endoscopic surgery of benign tumors, especially inverted papilloma and nasopharyngeal angiofibroma. Other benign neoplasms have also been reported, but only in small case reports. There have been a few recent reports supporting endoscopic removal of malignant neoplasms as well. However, the follow-up is too short and study groups too small to make definitive conclusions. SUMMARY: In the hand of experienced and skilled surgeons, complete endoscopic removal is attainable in most cases. Especially for the more common benign neoplasms, such as inverted papilloma and early stage angiofibroma. En bloc resection is not necessary to achieve oncologic cure. However, several factors have to be considered before selection of this surgical approach. Large tumor size, intracranial or orbital extension, and extensive frontal or infratemporal fossa involvement are relative, but not absolute limitations.     

Endoscopic and KTP laser-assisted surgery for juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a highly vascular tumor arising from the area around the sphenopalatine foramen. Various radical and extended radical surgeries have been advocated to surgically excise both extranasopharyngeal and nasopharyngeal juvenile angiofibromas. However angiofibromas involving the nasopharynx, nose, and sphenoid with minimal lateral extension via the sphenopalatine foramen can also be adequately managed endoscopically either alone or with 1 of the traditional approaches. Nine cases of juvenile nasopharyngeal angiofibroma were successfully managed between January, 1999, and March, 2001, by preoperative selective embolization of the internal maxillary artery with or without external carotid artery clamping, followed by endoscopic excision. Two of the 9 cases underwent KTP/532 laser-assisted endoscopic excision, whereas the transpalatal approach was used along with the endoscope in another 2 cases. The patients remained free of disease after a median follow-up period of 17 months. We report our preliminary experience in endoscopic and KTP laser-assisted excision of juvenile nasopharyngeal angiofibroma.     

Endoscopic vs. open surgery for treating large, locally advanced juvenile angiofibromas: a comparison of local control and morbidity outcomes

Juvenile nasopharyngeal angiofibroma is a combined vascular and fibrous neoplasm that most commonly affects prepubertal and adolescent boys. These tumors have traditionally been managed with open surgery, but interest in endoscopic resection-particularly for small tumors-has increased in recent years. To the best of our knowledge, no comparative study of open and endoscopic approaches for treating large, locally advanced tumors has been previously published in the literature. We conducted a retrospective study of 42 males, aged 6 to 21 years (mean: 13 ± 2.1), who had been treated for histologically proven and locally advanced juvenile nasopharyngeal angiofibroma with either open surgery (n = 29) or endoscopic excision (n = 13). Our two primary outcomes measures were local control and surgical morbidity. We found that the endoscopic approach was as good as or better than open approaches for patients with large tumors.     

Surgical policy in patients with basally advanced form of juvenile nasopharyngeal angiofibroma

The authors has modified surgical policy in a basicranially extending form of juvenile nasopharyngeal angiofibroma (JNA) which is classified into tumors of stage I, II and III. Basally advanced tumors were diagnosed in 28 of 40 JNA patients: basicranially extended tumor (n=12, 30%), stage I tumor invading nasopharynx, nasal cavity, sphenoid sinus (n=4, 14.3%), stage II tumor invading nasopharynx, nasal cavity, sphenoid sinus, pterygopalatine fossa, ethmoid sinuses (n=9, 32.1%), stage III tumor invading nasopharynx, nasal cavity, sphenoid sinus, pterygopalatine fossa, ethmoid sinuses, infratemporal fossa, orbit, maxillary sinus and parapharyngeal space (n=15, 53.6%). Differential surgical treatment according to Owens (stage I tumors), Denker (stage II tumors), Moure (stage III tumors) provides radical removal of the tumor in the majority of the patients (87.7%) and therefore is an effective therapy of surgical treatment of the above patients.     

Endoscopic management of sphenoid sinus cerebrospinal fluid leaks

OBJECTIVES: Cerebrospinal fluid (CSF) leaks that originate within the sphenoid sinus pose a unique surgical challenge due to difficulties with access and visualization The objective of this report is to illustrate concepts for the successful management of sphenoid sinus CSF leaks. METHODS: Retrospective data analysis was performed on 9 patients who presented to a tertiary care medical center for endoscopic repair of a sphenoid sinus CSF leak from January 2002 to January 2006. RESULTS: The patient cohort included 7 women and 2 men with a mean age of 51.7 years. In 5 cases the CSF leak was caused by a previous neurosurgical procedure; the other 4 cases were idiopathic. An endoscopic pterygomaxillary fossa approach was required in 4 cases. A layered reconstruction of the sphenoid sinus wall with collagen allografts (cadaveric acellular dermal allograft, 8 patients; bovine collagen membrane, 1 patient) and mucosa under endoscopic visualization with intraoperative surgical navigation was performed in all cases. The reconstruction was buttressed with autologous bone in 2 cases and with cartilage in 2 cases. Fibrin sealant was used in 7 cases. Two patients developed transient diabetes insipidus after the repair. Two patients developed a recurrent CSF leak necessitating revision repair 2 and 15 months, respectively, after the initial repair procedure. The average hospital stay was 6.5 days. The mean length of follow-up was 21.1 months. CONCLUSIONS: This series demonstrates that minimally invasive endoscopic repair of sphenoid sinus CSF leaks may be accomplished with an acceptable rate of morbidity and excellent outcomes. Extended endoscopic approaches, including the pterygomaxillary fossa approach, may be useful in selected instances.     

Huge nasopharyngeal angiofibroma with intracranial extension: change in the dura mater and choice of surgical management

We aimed to review (1) the imaging changes in the dura mater in cases of huge, lobulated juvenile nasopharyngeal angiofibroma, and (2) the choice of surgical management. Imaging from four cases of juvenile nasopharyngeal angiofibroma showed extrapharyngeal extension of the tumour. The sphenoid sinus, sella turcica and clivus were extensively eroded, and the tumour had spread deep into the cranial fossa. In three cases, intracranial exploration was performed to treat the intracranial tumour lobule. Subsequently, the tumours were removed using extracranial approaches. No perforation of the dura mater was found in these three cases, although the dura mater in the superior orbital fissure was congested, haemorrhagic and solid. Pre-operative imaging for two cases (i.e. the first operation for one and the second operation for the other) revealed no dura mater perforation. A transantral approach via a midfacial degloving incision was used to remove these tumours completely. We conclude that change in the dura mater is a crucial indication for the choice of management. If the dura mater is intact, a transantral approach via a midfacial degloving incision may remove the tumour successfully.     

Juvenile nasopharyngeal angiofibroma. A report of eighteen cases

Juvenile nasopharyngeal angiofibroma is a disease afflicting mainly adolescent males. The lesion is benign but characterized by local aggressive growth. In advanced cases the tumour may extend intracranially. In this study 18 cases of juvenile nasopharyngeal angiofibroma were investigated. Tumour extension was assessed with the use of angiograms and CT and the individual cases staged in four different categories on the basis of tumour extension. Two cases were staged as I (tumour confined to the nasopharynx), 7 cases as II (tumour extending into nasal cavity and/or sphenoid sinus), 8 as III (tumour extending into one or more of the following: antrum, ethmoid sinus, pterygomaxillary and infratemporal fossae, orbit and/or cheek) and one as IV (tumour extending into the cranial cavity). Preoperative arterial embolization was performed in 8 cases. All patients underwent surgery; none received irradiation. The follow-up period was 6 yrs 4 mo (6 months-17 years). In one case of intracranial extension, tumour recurrence occurred. It is concluded that with the aid of CT and arteriograms to evaluate the extension of the tumour and preoperative embolization, this lesion can be cured in the vast majority of cases, with surgery as the method of choice.     

Endoscopic surgery for juvenile angiofibroma: when and how

OBJECTIVES/HYPOTHESIS: In recent years, the indications for endoscopic surgery of the sinonasal tract, originally introduced for the treatment of inflammatory diseases, have been expanded to include selected cases of benign and malignant neoplastic lesions. The aim of the present study was to establish the efficacy of endoscopic surgery in the management of small and intermediate-sized juvenile angiofibromas.STUDY DESIGN: Retrospective study. METHODS: We reviewed the clinical records and the preoperative and postoperative imaging studies of 15 patients with juvenile angiofibroma who were treated with an endoscopic approach after embolization in the period from January 1994 to April 2000. All patients were prospectively followed by endoscopic and magnetic resonance imaging evaluations performed at regular intervals (every 4 months during the first year and, subsequently, every 6 months). RESULTS: According to a staging system reported in 1989, there were two patients with a type I, nine with a type II, three with a type IIIA, and one with a type IIIB juvenile angiofibroma. Angiography demonstrated that the vascular supply was strictly unilateral in 11 patients and bilateral in 4. Intraoperative blood loss ranged from 80 to 600 mL (mean blood loss, 372 mL). During follow-up (range, 24-93 mo; mean follow-up, 50 mo [SD +/- 19.9 mo]), only one patient presented a residual lesion on magnetic resonance imaging, which was 16 mm in diameter and was detected 24 months after surgery. CONCLUSIONS: The endoscopic approach is a safe and effective technique that allows removal of small and intermediate-sized juvenile angiofibromas (without extensive involvement of the infratemporal fossa and cavernous sinus) with a low morbidity. Advanced lesions are more appropriately treated by external approaches.     

Juvenile nasopharyngeal angiofibroma with intracranial extension: Analysis of 23 Egyptian patients

The purpose of this study was to present our experience with definitive surgical management of patients with Juvenile nasopharyngeal angiofibroma with intracranial extension. The study included 23 male adolescents with histologically proven juvenile nasopharyngeal angiofibroma. The mean age was 14.7 years (12-20 years). CT, MRI ± angiographies were for taken for the patients. Preoperative embolization was done with gel foam before the operation. Two surgical procedures were used; anterior subcranial transfacial transmaxillary approach (21 patients), while craniofacial resection was used in two patients. Middle cranial fossa was affected in 22 patients while anterior cranial fossa was affected in only one patient. Complete resection of the tumor was achieved in 19 patients with residual or recurrence in four patients. Complications of the surgical approaches were reported in 14 patients. The subcranial transfacial transmaxillary approach avoids the complications of craniotomy and provides adequate access for excision of Juvenile nasopharyngeal angiofibroma with intracranial extradural extension.