The Endoscopic Endonasal Approach for Intracranial Juvenile Nasopharyngeal Angiofibromas

Objective: Juvenile nasopharyngeal angiofibromas (JNAs) are vascular non-encapsulated tumors that arise in adolescent males and may erode the skull base to extend intracranially. Endoscopic approaches have been successfully applied to the treatment of many intranasal and intracranial pathologies. A logical extension of this approach is for intracranial extension of JNAs.

Methods: Between January 2008 and June 2015, 34 patients underwent endoscopic endonasal combined with Caldwell-Luc approach for JNAs employing transnasal and transmaxillary corridors. Twelve of these patients were found on preoperative imaging to have intracranial extension. These 12 cases underwent retrospective review.

Results: The average age was 13 years (range 7–16 years). Six patients (50%) had prior surgical treatment, none had prior radiation treatment. Six of the 12 cases underwent staged surgery and a total of 20 surgeries were performed. All patients underwent preoperative embolization of the external carotid artery contribution. All patients had persistent blood supply to the tumor from cavernous and petrous internal carotid artery feeders. Radiographic gross total resections were seen in 7 patients (58%). In the remaining patients, there was a greater than 90% resection of the tumor and the residual that was left was located in either the cavernous sinus, around the internal carotid artery, in meckel’s cave, or in the middle fossa. The average length of stay in the hospital was 6.8 days (range 1–22 days). Postoperative complications were seen in 6 patients, the most common being transient cranial nerve VI palsy in 4 patients with complete resolution. One patient suffered unilateral blindness secondary to central retinal artery occlusion 2 days after surgery. Another patient suffered a carotid injury requiring carotid sacrifice without postoperative neurological sequela. There were no postoperative cerebrospinal fluid leaks, meningitis, infections, or mortalities. With an average follow-up of 29 months, 2 patients had growth of their residual tumor (17%) and required further endoscopic endonasal treatment. No patient required radiation.

Conclusions: JNAs with intracranial extension are challenging due to residual vascularity from the internal carotid artery. Despite their advanced stage, endoscopic skull base surgery is effective for the treatment of these tumors but there is an increased risk of residual cavernous sinus or intracranial disease. A minority of these patients will require additional surgery.