Fully endoscopic resection of juvenile nasopharyngeal angiofibroma – Own experience and clinical outcomes

doi:10.1016/j.ijporl.2014.03.027

International Journal of Pediatric Otorhinolaryngology

Volume 78, Issue 7, July 2014, Pages 1015-1018

https://doi.org/10.1016/j.ijporl.2014.03.027 Get rights and content

Abstract

Objectives

The treatment of choice in juvenile nasopharyngeal angiofibroma (JNA) is surgery – nowadays endoscopic techniques. The aim of the study was to present the results of endoscopic treatment in patients diagnosed with juvenile angiofibroma.

Materials and methods

In this retrospective case series, 10 patients with a diagnosis of JNA treated at the Department of Otolaryngology of the Medical University in Poznań from 2006 to June 2013 were included. The age of patients were between 11 and 19 years old (14.6 on average). In 9 out of 10 patients the treatment was preceded by embolization. The surgery used the endoscopic approach through one nostril and the four-handed technique.

Results

Total resection was possible in all cases. Blood loss ranged from 100 to 250 ml. Post-operative hospitalization lasted from 3 to 5 days (3.3 days on average). Recurrence was reported in one patient. The observation lasted from six months to seven years (3.55 on average).

Conclusions

Endoscopic resection of juvenile angiofibroma is safe for the patient. Moreover, if the evaluation of the tumour size and staging is correct, the ability of total removal of the tumour is very high. It is also connected with small blood loss, short hospital stay and good cosmetic effects.

Introduction

Juvenile angiofibroma (JNA) is a benign tumour growing on the lateral wall of the nasopharynx around the sphenopalatine foramen. This well-vascularized tumour expands and destroys the surrounding structures. It can spread towards the paranasal sinuses, the pterygopalatine and infratemporal fossa, the orbital cavity, the skull base and the cavernous sinus, which poses a threat to the health and life of the patient [1]. The tumour is relatively rare and represents about 0.5% of all head and neck cancers [2], [3]. Surgical resection preceded by embolization of the vessels that supply blood to the tumour is the treatment of choice and usually includes the maxillary artery branches [4]. The treatment of these tumours has changed dramatically over the past 15 years. It has transformed from bloody surgical procedures, which were followed by numerous complications such as the presence of scars on the neck and face, facial deformities, a long period of healing and facial dysesthesia, into elegant endoscopic operations having little or minimal side effects. Also, hospitalization time has considerably reduced, which is important in the era of cost-effectiveness of treatment. The development of embolization methods [4] and endoscopic techniques [2], [3], [5], [6], [7], [8] had a significant impact on this evolution. Initially, only small tumours confined to the nasopharynx and paranasal sinuses regions were qualified for endoscopic operations, which gave good results [9], [10]. However, gradually the indications became more broad. Currently, endoscopic techniques are becoming the treatment of choice for all JNA without intracranial penetration [2], [7], [8]. The aim of the study was to present the results of endoscopic treatment in patients diagnosed with juvenile angiofibroma at the Department of Otolaryngology and Laryngological Oncology of the Medical University in Poznań.

Section snippets

Materials and methods

In Department of Otolaryngology and Laryngological Oncology in Poznan, Poland, 30 patients underwent surgery for JNA between 2000 and June 2013. The age ranged from 9 to 56 years with the mean age of 17.6. Patients were treated by open surgery (Denker's method), endoscopic assisted open approach and endoscopic approach only. The turning point was in June 2006, when endoscopy with navigation was introduced. The analysis included retrospective data from 10 patients undergoing endoscopic surgery

Surgical approach

The surgery used the approach through one or two nostrils and the four-handed technique. Endoscopic resection in IA and IB tumours involved the removal of the middle turbinated bone, front and back ethmoidectomy and wide meatal antrostomy, which revealed the posterior wall of the maxillary sinus. This allowed total resection of the tumour together with its attachment around the sphenopalatine foramen. In 5 out of 7 cases, the inferior turbinated bone was also resected in order to obtain the

Results

Total resection was possible in all cases. Blood loss ranged from 100 to 250 ml. No patient required blood transfusion in the perioperative period. Hospitalization after the surgery lasted from 3 to 5 days (3.3 days on average). Recurrence was observed in one patient (patient 8). This patient did not undergo embolization before the surgery. Diagnosis of juvenile angiofibroma was suspected intraoperatively. It was impossible to perform nasal endoscopy before the surgery due to the patient's lack

Discussion

Imaging techniques (CT, MRI) allow for precise determination of the juvenile angiofibroma spread. In addition, they were used to develop the appropriate classification depending on the tumour size. The extent of tumour spread beyond the nasopharynx is a common feature of all classifications. The classification introduced by D. Radkowski is commonly used today [11], though there are still several modifications relating to the progression of the tumour and the algorithm of surgical management [12]

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Endoscopic excision of juvenile nasopharyngeal angiofibroma: A case series
2017, Egyptian Journal of Ear, Nose, Throat and Allied Sciences
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These advantages have allowed tumours in various stages to be excised endoscopically, as seen in all six patients in this series. Tumours invading pteryopalatine fossa and infratemporal fossa, can be visualised and access after medial maxillectomy and removal of posterior wall of maxilla.10 A collaboration between ENT surgeons and neurosurgeons, tumours invading intracranially into cavernous sinus and orbital apex can be excised entirely via transnasal endoscopic route.
To present the outcome of excision of juvenile nasopharyngeal angiofibroma (JNA)-through endoscopic approach.
Retrospective case series review of six cases of JNA patients, encountered between 2013 and 2015. All patients underwent endoscopic excision, preceded by embolisation.
All patients were male, comprised of Chinese, Malay and Bidayuh ethnics, presenting with typical complaints of progressive unilateral nasal blockage, spontaneous painless epistaxis hyposmia and sleep disturbance. The patients' presentation comprised of all four stages based on Fisch classification, with one recurrence case. Maxillary artery was the main blood supply to the lesion. Surgical approach applied was endoscopic four-handed technique of excision. All patients were discharged well with no major complications, nor cases of recurrence.
Endoscopic approach is possible for varies stages of JNA. Preoperative angiographic embolisation has minimised the blood loss intraoperatively. The endoscopic method has reduced the post-operative morbidity.
Combined Endoscopic and Open Approaches in the Management of Sinonasal and Ventral Skull Base Malignancies
2017, Otolaryngologic Clinics of North America
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These limitations prompted the search for safer and improved methods for the surgical management of extensive paranasal sinus and anterior ventral skull base malignancies, which would improve the patient’s functionality and quality of life with satisfactory cosmetic results while preserving oncological principles. Advancing developments in endoscopic surgical technology, refinements in endoscopic techniques, and increased familiarity of the endoscopic endonasal anatomy have allowed the EEA to transcend its expected uses, where its applicability has expanded from its initial use for the treatment of inflammatory paranasal sinus disease to resection of benign sinonasal neoplasms,9,35,36 and ultimately to resection of malignant neoplasms, including those of the ventral skull base.21,37,38 In tumors with significant intracranial extension that is not amenable to a pure EEA, a combined transcranial/EEA (combined cranionasal approach) can be performed.8,10,12,37,39
Pediatric Vascular Tumors of the Head and Neck
2016, Oral and Maxillofacial Surgery Clinics of North America
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Surgical access is difficult and may explain the high recurrence rate (26%–46%) with local excision.57 Transfacial, intraoral (transpalatal, Le Fort I), and endonasal endoscopic techniques have all been described for the surgical removal of JNA.60 The technique is selected based on location and amount of tissue invasion.
Juvenile nasopharyngeal angiofibroma surgical treatment in paediatric patients
2019, Acta Otorrinolaringologica Espanola
El nasoangiofibroma juvenil es una neoplasia benigna sumamente vascularizada de tratamiento complejo, tanto en su preparación quirúrgica como en la cirugía a realizar, los riesgos y las recurrencias.
El objetivo es analizar el manejo y tratamiento quirúrgico para el nasoangiofibroma juvenil.
Se revisaron las historias clínicas e imágenes de los pacientes intervenidos por la especialidad de cirugía de cabeza, cuello y maxilofacial con resultado de proceso patológico compatible con nasoangiofibroma juvenil, en el periodo comprendido entre enero de 2008 a diciembre de 2016.
Se intervinieron 61 casos, todos ellos tratados con el mismo acceso quirúrgico por medio de una osteotomía Le Fort I. La totalidad de los pacientes fue de sexo masculino, con un promedio de edad de 13,3 años. Se utilizó la clasificación de Andrew-Fish para la estadificación de los casos, obteniendo los grados ii y i la mayor cantidad de casos.
El abordaje descrito provee un acceso quirúrgico extenso, el cual es adecuado para los diferentes estadios de la tumoración. Requiere de experiencia para poder llevar a cabo la resección de la tumoración con el menor sangrado posible.
The juvenile nasopharyngeal angiofibroma is a highly vascularised benign neoplasm of complex treatment in its surgical preparation, surgery to be performed, risks and recurrences.
The aim of the study was to analyze the management and surgical treatment for the pathology of juvenile nasoangiofibroma.
We reviewed the clinical histories and images of the patients who underwent surgery with a pathology result of juvenile nasoangiofibroma in the period from January 2008 to December 2016.
Sixty-one cases were treated; all of them treated using the same surgical access by means of a Le Fort I osteotomy. All of the patients were male, with an average age of 13.3 years. The Andrew-Fish classification was used for staging the cases, most were staged as grade II and I.
The described approach provided extensive surgical access, which was adequate for the different stages of the tumour. It requires experience to be able to resect the tumour with the least possible bleeding.
The risk factors for residual juvenile nasopharyngeal angiofibroma and the usual residual sites
2019, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Citation Excerpt :
Many surgical approaches have been used, such as the transpalatal, midfacial degloving, Le Fort I maxillotomy, transantral, lateral rhinotomy, and infratemporal approaches [6,7]. With minimum morbidity and better exposure, the endoscopic approach has become more widely utilized in the last two decades [8,9]. JNA is a benign tumor that does not metastasize, so recurrences are actually related to residual tumor growth.
Juvenile nasopharyngeal angiofibroma (JNA) is non-metastasizing but potentially locally destructive tumor of the nasopharynx. It can destroy the skull base and invade into the cerebrum. Surgical management is the primary standard but residual disease is always a risk factor. We aimed to determine the risk factors for residual disease and usual sites for these residual tumors.
The medical records of 131 patients (mean age 17.6 ± 6.8, range 9–71 years) with histologically proven JNA were retrospectively analyzed. The surgeries were all nasal endoscopic approaches, with or without assistant incision.
The prevalence of residual disease was 16.8%. Risk factors associated with JNA recurrence included tumor stage, intraoperative bleeding, and the year in which the operation was performed. The pterygoid canal, pterygoid process, and pterygopalatine foramen were the most frequent locations for residual tumor.
Surgical management should take particular care for the pterygoid canal, petrygoid process, and pterygopalatine foramen. Contrast-enhanced CT and MRI are effective tools to evaluate complete JNA excision in the first two days after primary surgery. Careful exploration of these areas may be the key to avoid residual JNA.
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2019, All around the Nose: Basic Science, Diseases and Surgical Management

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Fully endoscopic resection of juvenile nasopharyngeal angiofibroma – Own experience and clinical outcomes

Abstract

Objectives

Materials and methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Surgical approach

Results

Discussion

Otolaryngol. Pol.

Otolaryngol. Pol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Am. J. Otolaryngol.

Asian J. Surg.

Angiofibroma juvenile in the clinical material of Department of Otolaryngology in Poznan in the years 1977–2000

Otolaryngol. Pol.