Juvenile Nasopharyngeal Angiofibroma: A Series of 96 Surgical Cases

Introduction  Juvenile nasopharyngeal angiofibroma (JNA) is a benign vascularized tumor that affects almost exclusively male adolescents. Surgery is the treatment of choice for JNA. Objectives  The present study is a 42-year retrospective review of a series of JNA cases treated surgically without previous embolization. Methods  The present is a retrospective, descriptive study based on medical records of 96 patients with JNA who underwent microscopic or endoscopic excision without previous embolization from 1978 to 2020 in a single institution. The patients were categorized according to the Andrews et al. stage, and data were collected on age, gender, tumor staging, surgical approach, affected side, and outcome. Results  All patients were male, with an average age of 17 years. The predominant tumor stage consisted of type II, with 52.1%. A total of 33.3% of the patients were submitted to the microscopic technique and 66.7%, to the endonasal technique. The rate of intraoperative blood transfusion was of 17.7%. Conclusion  The present study reinforces that resection of JNA in various stages is viable without previous artery embolization.

Integrated Molecular and Histological Insights for Targeted Therapies in Mesenchymal Sinonasal Tract Tumors

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of mesenchymal sinonasal tract tumors (STTs), a distinct subset of STTs. Despite their rarity, mesenchymal STTs represent a unique clinical challenge, characterized by their rarity, often slow progression, and frequently subtle or overlooked symptoms. The complex anatomy of the sinonasal area, which includes critical structures such as the orbit, brain, and cranial nerves, further complicates surgical treatment options. This underscores an urgent need for more advanced and specialized therapeutic approaches.

RECENT FINDINGS

Advancements in molecular diagnostics, particularly in next-generation sequencing, have significantly enhanced our understanding of STTs. Consequently, the World Health Organization has updated its tumor classification to better reflect the distinct histological and molecular profiles of these tumors, as well as to categorize mesenchymal STTs with greater accuracy. The growing understanding of the molecular characteristics of mesenchymal STTs opens new possibilities for targeted therapeutic interventions, marking a significant shift in treatment paradigms. This review article concentrates on mesenchymal STTs, specifically addressing sinonasal tract angiofibroma, sinonasal glomangiopericytoma, biphenotypic sinonasal sarcoma, and skull base chordoma. These entities are marked by unique histopathological and molecular features, which challenge conventional treatment approaches and simultaneously open avenues for novel targeted therapies. Our discussion is geared towards delineating the molecular underpinnings of mesenchymal STTs, with the objective of enhancing therapeutic strategies and addressing the existing shortcomings in the management of these intricate tumors.

Incidence of Neoplasm in Patients Referred for Epistaxis

Objectives: The primary objective was to identify the incidence of neoplastic disease in patients referred for epistaxis. Secondary objectives included identification of any mass lesion, and the need for further workup with imaging and/or biopsy as well as risk factors associated with identification of a mass lesion. Study Design: Retrospective cohort study. Methods: Medical records of adult patients who presented to Tufts Medical Center over an 11 year period (2010-2021) with a chief complaint of epistaxis were reviewed. The primary outcome was identification of a nasal or nasopharyngeal mass. Patient characteristics including age, sex, race, smoking status, anticoagulation, comorbidities (hypertension, allergic rhinitis, vasculitis), and treatment of epistaxis (used as surrogate for severity of epistaxis) were also examined. Results: A total of 1164 patients met inclusion and exclusion criteria. Thirty-six nasal masses were found among patients presenting with epistaxis (3.09%, P < .001), comprised primarily of benign etiology (2.66%) including nasal polyposis and thornwaldt cyst. Asian race correlated with finding of mass lesion (75%, P = .007). Five malignancies were found (0.43%) including nasopharyngeal carcinoma (2 patients), extranodal natural killer T-cell lymphoma (2 patients), and nasal adenocarcinoma (1 patient). Conclusions: Epistaxis is a common cause for referral to otolaryngology. Although the incidence of neoplasm in our patient population was low, nasal mass lesions warranting further workup were identified in 36 patients. Findings of neoplasm were more common in patients of Asian ethnicity, which may reflect the increased prevalence of nasopharyngeal carcinoma in this population. Otolaryngologic evaluation and nasal endoscopy should be considered in all cases of epistaxis.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

A Rare Association of Pituitary Macroadenoma With Nasopharyngeal Angiofibroma: A Case Report

Pituitary macroadenoma and angiofibroma are two distinct and diverse types of tumors that can develop in different anatomical locations and clinical characteristics and are not typically related to each other in terms of their hormonal or developmental aspects. This case describes an adult male with pituitary macroadenoma with nasal angiofibroma. A 35-year-old male was diagnosed with pituitary macroadenoma and incidentally found to have juvenile nasopharyngeal angiofibroma (NPA). The patient underwent a diagnostic workup, including imaging studies and hormonal assays, which confirmed the concomitant presence of both tumors. The patient underwent successful endoscopic surgical excision of the NPA and transnasal transsphenoidal endoscopic pituitary macroadenoma excision as a two-stage operation. The patient was followed up postoperatively and had no evidence of tumor recurrence or hormonal imbalances. The importance of complete and comprehensive diagnostic workup and multidisciplinary management in achieving successful and optimum treatment outcomes for coexisting NPA and pituitary macroadenoma in an adult patient is highlighted in the present report.

Preoperative Embolization Techniques in the Treatment of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review

OBJECTIVE

Preoperative embolization has proven beneficial in the surgical treatment of juvenile nasopharyngeal angiofibromas (JNA). However, the consensus for the best embolization practices remains unclear. This systematic review seeks to characterize the reporting of embolization protocols throughout the literature and to compare differences in surgical outcomes.

DATA SOURCES

PubMed, Embase, and Scopus.

REVIEW METHODS

Studies investigating embolization in the treatment of JNA from 2002 to 2021 were selected from defined inclusion criteria. All studies underwent a 2-stage blinded screening, extraction, and appraisal process. Embolization material, time to surgery, and embolization route were compared. Embolization complications, surgical complications, and rate of recurrence were pooled.

RESULTS

Of 854 studies, 14 retrospective studies with 415 patients met the criteria for inclusion. A total of 354 patients underwent preoperative embolization. A total of 330 patients (93.2%) underwent transarterial embolization (TAE) and 24 patients had a combination of direct puncture embolization and TAE. Polyvinyl alcohol particles were the most used embolization material (n = 264, 80.0%). The most common reported time to surgery was 24 to 48 hours (n = 8, 57.1%). Pooled results showed an embolization complication proportion of 3.16% (95% confidence interval [CI]: 0.96-6.60) (n = 354), a surgical complication proportion of 4.96% (95% CI: 1.90-9.37) (n = 415), and a recurrence proportion of 6.30% (95% CI: 3.01-10.69) (n = 415).

CONCLUSION

The current data on JNA embolization parameters and their effect on surgical outcomes remains too heterogenous to provide expert recommendations. Future studies should use uniform reporting to allow for more robust comparisons of embolization parameters, which, in turn, may lead to optimized patient outcomes.

MRI features of sinonasal tract angiofibroma/juvenile nasopharyngeal angiofibroma: Case series and systematic review

BACKGROUND AND PURPOSE

To comprehensively summarize the radiological characteristics of sinonasal tract angiofibroma (STA) (commonly known as juvenile nasopharyngeal angiofibroma).

METHODS

Forty-four lesions from 41 cases provided by 33 study articles identified through a systematic review and 13 lesions from 13 cases from our institution associated with patients with STA who underwent MRI were included in the review study, carried out by two board-certified experienced radiologists.

RESULTS

The study participants were all male patients with a mean age of 15.6 years at the time of diagnosis. All of them presented with nasal cavity lesions (100%), predominantly in the nasopharynx (98.2%). The sphenopalatine foramen/pterygopalatine fossa was involved in 76.0%, and compressive shift of the posterolateral wall of the maxillary sinus was present in more than half (57.9%). T2-weighted imaging signal intensity was heterogeneous with mixed high and iso intensities as compared to skeletal muscle (100%). T1-weighted imaging showed partial high signal intensity in 61.1% of the cases. Flow void and intense enhancement were present in almost all cases. Cystic/nonenhancement changes on contrast-enhanced MRI were relatively common (40.8%). The mean apparent diffusion coefficient value (2.07 × 10-3  mm2 /second) and some quantitative dynamic contrast-enhanced MRI parameters were high. There was a significant difference in the frequency of residual/recurrent lesions based on the presence of MRI findings of skull base invasion (p = .017) and intracranial extension (p = .003).

CONCLUSIONS

We summarized the MRI findings of STA that can facilitate timely diagnosis and appropriate management.

Vascular Control in Nose and Paranasal Sinus Tumours

Effective management of Tumors of Nose and Paranasal Sinuses (PNS) require adequate vascular control of the vessels supplying the tumor to facilitate complete removal and to reduce the complications. To emphasize the role of prior control of feeding vessels in reducing intraoperative blood loss, achieving bloodless fields for endoscopic excision and in facilitating complete excision of tumors of Nose and PNS. A prospective study of 23 patients who were operated for various tumors of Nose and PNS by either Endoscopic or Open approaches for which intraoperative control of the feeding vessels was done based on the Radiological findings. The mean average blood loss was 280 ml and mean Operating time for Endoscopic approach was less than 2 h. All the patients were stable postoperatively and none of the patients had worrisome intraoperative hemorrhage or required multiple blood transfusions. All the patients had complete removal of the tumor. Prior identification of all the vessels that supply the tumor and planning to control them before manipulating the tumor always gives us good results. Tumors supplied by single vessel can be controlled by Embolization or intraoperative clamping, when the tumor is supplied by multiple vessels or when it is not possible to access the vessel by the size of the tumor, Temporary Clamping of the main vessel is a definitive alternative.

Endoscopic, endoscopic-assisted and open approaches in the treatment of juvenile angiofibroma: what has been new in the past decade (and 1586 cases)?

PURPOSE

Juvenile angiofibroma (JA) is a benign, but locally invasive tumor of the nasopharynx. Surgical resection of JA is performed through endoscopic (EA), endoscopic-assisted (EAA), or open approaches (OA). The management of these tumors is constantly evolving. We aimed to compare the surgical efficiency and morbidity of EA, EAA, and OA in JA treatment by conducting a systematic review of the literature published over the last 10 years.

METHODS

A systematic review of the English literature on surgical cases of JA published between 2012 and 2022 was performed. Eligible articles were analyzed for individual patient data (IPD) and aggregate patient data (APD). The primary predictor variable was the surgical approach. The primary outcome variable was recurrence rate.

RESULTS

The search retrieved 75 articles reporting 1586 JA surgical cases; 129 in IPD, and 1457 in APD data sets. Within the IPD data set, recurrence rates were significantly lower in cases completed by EA than that by OA (p < 0.05). There was no significant difference in recurrence rates between the EA and EAA groups (p > 0.05). EAA had a lower recurrence rate than that of OA (p < 0.05). For the APD data set, the recurrence rate following EA was significantly lower than that following OA (p < 0.05). There was no significant difference in recurrence between the EA and EAA groups (p > 0.05), and between the EAA and OA groups (p > 0.05).

CONCLUSIONS

EA represents the method of choice for mild and moderately advanced JA. EAA and OA still play important roles in the treatment of advanced-stage JA.

Endoscopic Modified Denker's Approach for the Treatment of Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma is a benign vascular lesion with propensity of bony erosion leading to skull base involvement and intracranial extension. It involves multiple compartments which are difficult to access surgically. With surgical expertise endoscopic resection of angiofibroma has become the preferred choice of surgical management. This article presents our experience with endoscopic approach for angiofibroma and establishes the modified Denker's procedure as a effective approach for removal of tumor. A prospective case study was done on 25 cases of juvenile nasopharyngeal angiofibroma treated surgically by endonasal endoscopic modified Denker's approach in the department of ENT at BJ Medical College, Ahmedabad over a period of 4 years from January 2015 to January 2019. This technique was used up to Fisch stage 3b with extension up to infratemporal fossa. Using this technique no major recurrence or major morbidity was observed and did not produce any late serious complications. The endoscopic technique allows the surgeon to achieve an extensive exposure of the sinuses and control of the sphenopalatine and internal maxillary arteries without the risk of palatal dysfunction, oronasal fistula, or facial scarring. In addition, the modified Denkers approach can be an effective and less mutilating technique in managing recurrences.

Glomus Tumor of the Pterygopalatine Fossa: A Rare Case Report

The pterygopalatine fossa (PPF) is a challenging space and pathological processes in this anatomical space are uncommon. This report presents a case of glomus tumor right PPF in a 65 years old female patient who underwent tumor removal by endoscopic transnasal-transmaxillary approach with preoperative selective embolization of the right internal maxillary artery.

Incidental finding of juvenile angiofibroma from pre-orthodontic radiographs: two case reports and a literature review

This case series presents two asymptomatic cases of juvenile angiofibroma which were initially incidentally identified in pre-orthodontic radiographs. Juvenile angiofibroma is an uncommon, locally aggressive benign, vascular neoplasm with invasive growth patterns. Due to the hypervascularity of these tumours, there are biopsy associated risks and multi-slice computed tomography, magnetic resonance imaging and angiography are usually employed for diagnosis. Early pre-symptomatic identification of this lesion facilitates early management and limiting potential life-threatening complications. This highlights the importance of thorough interpretation of dental radiographs, including the evaluation of structures which are not in the primary region of interest. © 2022 Australian Dental Association.

Preoperative emobilisation of juvenile nasopharyngeal angiofibroma

INTRODUCTION

Juvenile nasopharyngeal angiofibroma(JNA) are highly vascular benign tumours originating in the sphenopalatine fossa and may extend to the pterygopalatine fossa, paranasal sinuses, and nasal cavity. The management of JNA has evolved greatly with development of endoscopy. Treatment modality has changed from open approach to endoscopic approach due to various advantages offered by the endoscopic approach. Bleeding during the surgery can compromise the exposure and surgical excision of JNA endoscopically. There have been many techniques to decrease intraoperative bleeding including external carotid ligation, hypotensive anaesthesia and more recently embolization of the feeding vessels. Embolization of the tumour has made the endoscopic excision of JNA easier because of less bleeding. This study was taken to find out the outcomes of surgical excision of JNA after embolization.

METHODOLOGY

We retrospectively reviewed 22 histopathological proven JNA cases that underwent preoperative embolization followed by resection during the period of June 2015 to December 2020 in our tertiary care hospital. From the records demographic, clinical, radiological imaging (CECT nose and PNS), angiographic, pre-operative embolization and operative details were evaluated.

RESULT

In the present study a total of 22 cases of angiofibroma were taken up for surgical excision after embolization. A complete endonasal endoscopic resection could be done in 21/22 cases with average operative time of 141 minutes (80 minutes-190 minutes range). The mean blood loss during surgery was 1163 ml (Range 500 ml- 1900 ml). In 7/22 (31.81%) subjects required intraoperative blood transfusion. No perioperative surgical complications occurred.

CONCLUSION

Endoscopic excision of JNA has now become the primary operative technique and pre operative embolization in such cases can reduce the intraoperative time, blood loss and tumour relapse rate. It is a relatively safe procedure in a hand of an expert and must be done where ever available.

Sinonasal Symptom Outcomes following Endoscopic Anterior Cranial Base Surgery in the Pediatric Population

Objective This study aimed to evaluate the impact of endoscopic anterior cranial base (ACB) surgery on sinonasal symptoms in the pediatric population utilizing the Sino-Nasal Outcome Test (SNOT)-22 questionnaire.

Design This is a retrospective review.

Setting The study was conducted at a tertiary academic medical center.

Participants Thirty-four consecutive patients, age 6 to 17 years, M:F 14:20, who underwent endoscopic ACB surgery from July 2008 to August 2019. Ten patients had baseline and a minimum of two subsequent postoperative SNOT-22 questionnaires available for analysis.

Main Outcome Measures Baseline and postoperative SNOT-22 scores were compared. The mean change from baseline sinonasal symptom scores in the pediatric and historical adult cohorts was compared.

Results The mean baseline SNOT-22 score for our 10 patient cohort was 0.46 out of 5 for each of the first 10 sinonasal-specific questions. This worsened to 1.69 at 1 month and returned to near baseline, 0.7, at 3 months postoperatively. The mean quality-of-life score improved to 0.91 at 1 month and 0.6 at 3 months postoperatively. The mean change from baseline for the following items: need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable were similar to those in our historical adult cohort at 3 months postoperatively.

Conclusion Endoscopic ACB surgery in the pediatric population results in increased sinonasal symptom morbidity in the early postoperative period; however, symptoms return to near baseline by ∼3 months, and quality-of-life scores progressively improve in the postoperative period. These trends were similar to those seen in our historic adult cohort.

Multidisciplinary management of juvenile nasopharyngeal angiofibroma

Background

Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign, but the locally aggressive, vascular tumor that occurs almost exclusively in young men. Although this tumor accounts for only about 0.5% of head and neck tumors, it is by far the most common benign nasopharyngeal neoplasm. It is presented typically with epistaxis, obstructive symptoms, and chronic otomastoiditis. The examination of this tumor reveals pale reddish-blue mass. The tumor is seen on imaging as vividly augmenting soft-tissue mass centered on the sphenopalatine foramen. The treatment of choice is usually surgical resection; either open or endoscopic. Pre-operative embolization is usually done to help with hemostasis. We aim to address the efficiency and the safety of endovascular modality in JNA.

Methods

In the period between January 2012 to December 2017, 20 male patients with age ranging from 6 to 20 years were referred to the Endovascular Unit, at Departments of Neurosurgery in Sohag, Alexandria, and Tanta University Hospitals with JNF. Preoperative trans-arterial embolization was done, followed by endoscopic surgical resection by our ENT surgeons. All patients were subjected to clinical and radiological Imaging evaluation pre embolization, post embolization, and post endoscopic resection. All patients had clinical and radiological follow-ups for at least 1 year.

Results

20 male patients with JNA underwent preoperative super-selective trans-arterial embolization. The average age at presentation was 13 years. All patients underwent successful embolization with total obliteration of vascular blush of the tumor in 15 patients, and near-total obliteration of blush in 5 patients. The dramatic effect of preoperative embolization was observed on limiting intraoperative blood loss (average 200 ml) and decreasing the time of surgery (average 2.5 h). There was no permanent morbidity or mortality related to either embolization or endoscopic resection in all patients.

Conclusions

Trans-arterial embolization is strongly recommended in patients with JNA, it offers a good assist to the surgeon, reduces blood loss, decreases the amount of transfusion, improves the degree of resection, reduces operative time, and decreases the incidence of recurrence.

Juvenile Angiofibroma: What Is on Stage?

OBJECTIVES/HYPOTHESIS

The aim of the present study is to validate and compare four of the most widely used staging systems for juvenile angiofibroma on a homogeneous cohort of patients.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective review of patients treated with endoscopic or endoscopic-assisted surgical resection between 1999 and 2020 was carried out. Each case was classified according to the following staging systems: Andrews-Fisch (1989), Radkowski (1996), University of Pittsburgh Medical Center (2010), and Janakiram (2017). Spearman's rank correlation test and areas under the curve of receiver operator curves were used to assess the correlation between outcomes of interests (blood loss, surgical time, need for transfusion, and persistence of disease) and stage of disease.

RESULTS

Seventy-nine patients were included, with a median follow-up time of 25 months (range 12-127 months). Median surgical time was 217 minutes (range 52-625). Median blood loss was 500 mL (range 40-5200) and 27 patients (34.2%) required blood transfusions. Seven patients (8.9%) showed persistence of disease. All classification systems showed a similar association with blood loss, surgical time, persistence of disease, and need for transfusion.

CONCLUSIONS

Involvement of the infratemporal fossa and intracranial extension was identified as red flags for surgical planning and preoperative counseling, as associated with increased risk for transfusion and persistent/recurrent disease, respectively. No classification system was found to be better than the others in predicting the most important outcomes. Therefore, the simplest and most easily applicable system would be the preferred one to be used in clinical practice.

LEVEL OF EVIDENCE

Level 4 case series Laryngoscope, 2021.

Preoperative Embolization of Fisch Grades II-IVa Juvenile Nasopharyngeal Angiofibromas: Transarterial Embolization in the Age of Onyx

Objective

The current mainstay treatment for juvenile nasopharyngeal angiofibromas (JNAs) is surgical resection, but embolization of primary feeding arteries through endovascular transarterial and direct tumoral puncture embolizations with various agents has been described. We describe a single institutional experience with JNA embolization utilizing Onyx (Medtronic, Dublin, Ireland).

Methods

A retrospective records review was performed to identify patients who underwent embolization for devascularization of Fisch grades II-IVa JNA (tumor extension beyond the sphenopalatine region) before surgical resection between 2010 and 2019. Fluoroscopy time, grade, intraoperative blood loss, and clinical follow-up data were compiled. Tumor devascularization percentage was calculated using ImageJ software (public domain, BSD-2) by measuring the ratio of preoperative and postoperative embolization tracing.

Results

Five consecutive patients (ages 12-16 years [average 14 years]; all male) with JNAs underwent preoperative transarterial embolizations performed under general anesthesia. All patients presented with epistaxis; two also presented with headaches. Fisch grades were II in two patients, IIIa in two, and IVa in one. The patient with the grade IVa lesion underwent direct transtumoral puncture and Onyx embolization. The mean percentage of all tumor devascularizations postembolization was 86.0±9.7%.Complete resection 24-48 hours postembolization was obtained for grades II and IIIa lesions with <700 mL blood loss. No embolization-related complications and no clinical sequelae were present in the five cases after embolization.

Conclusion

In our experience, Onyx embolization of JNAs was safely conducted with adequate tumor penetration beyond the sphenopalatine region through transarterial routes.

Crescentic postinfectious glomerulonephritis in an adult patient with juvenile nasopharyngeal angiofibroma

Crescentic glomerulonephritis is usually associated with an acute nephritic syndrome with rapidly declining renal function. Postinfectious cases usually have a higher possibility of recovery. Juvenile nasopharyngeal angiofibroma (JNA) is a rare, locally aggressive tumour affecting mostly young men. A 28-year-old man presented with recurrent JNA initially excised 2 years prior. The patient was initially managed as a case of airway obstruction and pneumonia. He developed tea-coloured urine, oedema and acute kidney failure requiring dialysis while awaiting surgery. Urine and immunological studies (low C3, negative antineutrophil cytoplasmic antibody and antinucleosomal antibody and high antistreptolysin O) suggested a nephritic aetiology. Nasopharyngeal swab cultures of the mass revealed gram-negative organisms. Kidney biopsy showed diffuse proliferative glomerulonephritis compatible with a postinfectious glomerulonephritis with 77% cellular crescents. The mass was excised with histopathology consistent with JNA. The patient was eventually discharged off dialysis.

Juvenile nasopharyngeal angiofibroma-20 years of experience in endoscopic treatment

INTRODUCTION

Juvenile nasopharyngeal angiofibroma is a rare, benign tumor; however, it shows local aggression and leads to profuse nosebleeds. &lt;br/&gt;Aim: The aim of the study is to present 20 years of experience in endoscopic treatment of this tumor. &lt;br/&gt;Material and methods: The material covers 71 patients treated in the years 1985-2019 at the Department of Otolaryngology and Laryngological Oncology in Poznań. In these patients, either the classic external approach, or the double approach - external with the use of endoscopes, or only the endoscopic approach was used. In the entire population, external surgeries were performed in 37 patients, double access in 8 and endoscopic access in 26 patients. &lt;br/&gt;Results: Complete resection of the tumor was achieved in 51 patients (72%). The remaining 20 patients (28%) had a residual or recurrent tumor and all of these patients underwent reoperation.&lt;br/&gt; Conclusions: The endoscopic approach with the use of various optics and navigation allows for the removal of not only small tumors but also much more advanced ones. Pre-operative evaluation of imaging results is extremely important to avoid incomplete tumor removal. Individual development of an operating strategy, a wide range of optics and various surgical methods, and especially endoscopic ones, are the guarantee of therapeutic success.

[Current perspectives on imaging and treatment of juvenile angiofibromas : A review]

CLINICAL ISSUE

Juvenile angiofibroma is a benign tumor, whose surgical treatment may be complicated due to intraoperative hemorrhage. The tumors appear as well circumscribed, reddish masses, which often extend into the complete nasal cavity and nasopharynx.

STANDARD RADIOLOGICAL METHODS

Diagnosis is based on computed tomography (CT) and magnetic resonance imaging (MRI) with angiography to identify supplying blood vessels.

STANDARD TREATMENT

Open resection.

INNOVATION IN TREATMENT

The endoscopic endonasal resection is the therapy of choice and may be combined with open surgery after endovascular embolization. Radiation or hormone therapy are alternatives for patients with very advanced tumors or high surgical morbidity. Depending on location and age of the patients, residual tumors after surgery can be watched only or treated with radiotherapy.

PERFORMANCE

Preoperative endovascular embolization lowers intraoperative blood loss by about 70%, induces tumor shrinkage, and facilitates resection. The endonasal approach will lower the peri- and postoperative morbidity.

RECOMMENDATION

An endonasal approach combined with preoperative endovascular embolization should be preferred over open resection, but requires expertise as well as modern endoscopy and navigation equipment. MRI follow-ups should be performed regularly until after puberty. Recurrence after puberty is very uncommon.

Midfacial degloving for juvenile angiofibroma: A case-series of 21 adult males: An alternative to the endoscopic approach and when it should be considered

OBJECTIVES

To describe the midfacial degloving approach and compare the varying surgical approaches to juvenile angiofibromas. To demonstrate the efficacy of midfacial degloving in treating large juvenile angiofibromas in a unique patient cohort.

DESIGN

A retrospective case-series between 2006 and 2019.

SETTING

All patient care was undertaken at a regional skull base referral centre.

PARTICIPANTS

Twenty-one male patients with a median age of 18 (range 16-45 years).

MAIN OUTCOME MEASURES

Presenting symptoms, imaging, stage, age at operation, residual disease, estimated blood loss and operative time were all recorded. Postoperative outcomes included complications, length of stay and recurrence.

RESULTS

The median surgical time was 105 minutes (range 55-219 minutes), median estimated blood loss 600 mls (range 150-900 mls) and median length of stay was 4 days (range 2-13 days.). Complications included two episodes of epistaxis, one requiring packing and one return to theatre. 14% (3/21) of patients had residual disease, none requiring further treatment and one patient had recurrence.

CONCLUSIONS

MFD for JNA in our series resulted in low recurrence rate and no progression of residual disease. The approach has been successful in our cohort of patients and is an option in males over the age of 16 years, with JA extending beyond the nasopharynx and sinuses, involving the infratemporal fossa, cavernous sinus or orbital region.

Plasma ablation-assisted endoscopic excision versus traditional technique of endoscopic excision of juvenile nasopharyngeal angiofibroma

BACKGROUND

Juvenile nasopharyngeal angiofibroma is the vascular and locally aggressive tumor of the posterior nares and nasopharynx. Endoscopic excision is the preferred surgical modality in early Radkowski stages. The prime challenge is intraoperative bleeding. Literature is in favor of the use of plasma ablation to overcome surgical challenges.

OBJECTIVE

To evaluate the effectiveness of plasma ablation technique in the surgical management of juvenile nasopharyngeal angiofibroma.

MATERIALS AND METHODS

The current study recruited 36 patients of clinico-radiologically diagnosed cases of primary JNA of stage I and II (Modified Radkowski). In prospective arm, 18 consecutive patients were recruited, who underwent plasma ablation assisted endoscopic excision. In retrospective arm, 18 consecutive patients who underwent excision by traditional endoscopic instruments in the past two years, were recruited. Both the groups were compared for baseline characteristics, intraoperative blood loss, duration of surgery, length of hospital stay, and recurrence rates.

RESULTS

The use of plasma ablation decreased overall blood loss by 338 ml (mean difference) which was not statistically significant (p = 0.26). On subgroup analysis, the use of plasma ablation significantly decreased mean blood loss (648 ml, p = 0.046) and duration of surgery (83 min, p < 0.001) in patients who underwent embolization. No statistically significant difference was noted between two groups in length of hospital stay (p = 0.36) and recurrence rates (p = 0.64).

CONCLUSION

Plasma ablation is an effective technique available to decrease blood loss and duration of surgery during endoscopic excision of post embolized stage I and II patients of JNA.

Early Postoperative Magnetic Resonance in the Diagnosis of Persistent Juvenile Angiofibroma

OBJECTIVES/HYPOTHESIS

Despite improvements in the treatment of juvenile angiofibroma (JA), the rate of persistence (pJA) is still not negligible. In the present study, we assessed the value of early postoperative magnetic resonance imaging (MRI) in depicting unintentional pJAs and designed a MRI-driven decisional flow-chart for pJA management and follow-up.

STUDY DESIGN

Observational study.

METHODS

Patients undergoing early postoperative MRI after endoscopic resection of JA in the Unit of Otorhinolaryngology - ASST Spedali Civili, University of Brescia from 2007 to 2017 were enrolled. MRI was defined as negative or positive based on defined radiological criteria. The diagnostic performance of MRI was evaluated.

RESULTS

The analysis included 26 patients, with a mean age of 16.5 years (range, 11-25). Early MRI was negative for pJA in 21 (80.8%) patients and positive in five (19.2%). No patient with a negative finding was found positive at subsequent follow-up MRIs. The accuracy of a positive finding was confirmed by pathologic examination (three cases) or follow-up MRIs (two cases). The diagnostic performance of MRI was excellent with sensitivity and specificity of 100%. An MRI-driven flow-chart for pJA management and follow-up was designed.

CONCLUSIONS

Early postoperative MRI demonstrated a high diagnostic accuracy in the detection of unintentional pJA. Our MRI-driven strategy and decisional flow-chart could aid in the decision-making process in the management of pJA and definition of postoperative surveillance.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2436-E2441, 2021.

Combined endoscopic and transoral resection of a high-staged juvenile nasopharyngeal angiofibroma: A pictorial essay

Juvenile nasopharyngeal angiofibromas (JNAs) are highly vascular and benign tumors that can expand into the skull base. Delay of treatment can result in intracranial invasion, requiring extensive open approaches such as a facial translocation, maxillary swing, or an orbitozygomatic craniotomy. We describe a single-stage, combined endoscopic and transoral approach on a 14-year-old male with extensive high-stage dumbbell-shaped JNA involving the infratemporal fossa, orbit, buccal space, and intracranial extension into Meckel's cave. Successful resection of the tumor and good postoperative outcome was achieved. A transoral approach allowed for greater access to the infratemporal fossa, where endonasal resection was not possible, allowing for improved visualization, greater traction, and dissection. In select highly staged JNAs with significant lateral extension and intracranial involvement, successful and complete resection may be accomplished with this combined approach. Utilization of this approach avoids the morbidity of more invasive open approaches.

Clinical Practice Guideline: Nosebleed (Epistaxis)

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Solitary fibrous tumors of the head and neck region revisited: a single-institution study of 20 cases and review of the literature

A solitary fibrous tumor (SFT) is a rare, NAB2-STAT6 fusion gene-associated mesenchymal neoplasm. It most commonly arises in the pleural site, but it can occur at many other sites, and rarely also in the head and neck (H&N) region. STFs may show many growth patterns and therefore can be easily mistaken for other more common H&N spindle cell or epithelial lesions. In this study, we present our experience in the diagnosis of 20 cases of SFT in the H&N region and discuss their most notable mimickers. In all cases, STAT6 expression was found positive by immunohistochemistry, and the NAB2-STAT6 fusion was confirmed by next-generation sequencing. Three major fusion variants were detected: NAB2ex2-STAT6int1 (5/20, 25%), NAB2ex6-STAT6ex16 (4/20, 20%), and NAB2ex4-STAT6ex2 (3/20, 15%). Clinical follow-up was available for 16 patients (median follow-up time: 84 months). One patient with a morphologically malignant SFT experienced multiple local recurrences, followed by dissemination into the lungs and meninges. This malignant SFT also displayed an aberrant FLI1 expression, which was not previously reported in SFT cases. We also summarize findings from 200 cases of SFT of the H&N region, which included cases from our study, and from previous studies that reported on the fusion status of the STAT6 gene. The results suggest that metastatic disease developed only in cases with STAT6 variants that included the DNA-binding domain (STAT6-full variants), which contradicts expectations from previous reports and deserves further investigation.

A Rarely Seen Mass of Nasal Cavity: Seromucinous Hamartoma

Seromucinous hamartoma (SH) is a rarely seen benign polypoid mass of the sinonasal tract. Although the most common presentation symptom is nasal obstruction, most of the patients are asymptomatic. In this paper, the authors present an additional case of SH and discuss its differential diagnosis. A 34-year-old male patient presented with progressive nasal obstruction and serous nasal discharge for several months. A well-defined polypoid mass was detected in the left nasal cavity during the endoscopic assessment. Preoperative biopsy was reported as benign polypoid lesion. The mass was resected via transnasal endoscopic approach and final pathological examination was notified as SH.The SH is an uncommon tumor, originates from nasal septum in the most cases and presents as a well-circumscribed polypoid mass. Radiological imaging modalities and biopsy should be performed to distinguish from the sinonasal malignancies. Complete surgical excision is recommended treatment and recurrence is almost never.

Soft Tissue Special Issue: Fibroblastic and Myofibroblastic Neoplasms of the Head and Neck

Fibroblastic and myofibroblastic neoplasms of the head and neck encompass a group of rare tumor types with often overlapping clinicopathologic features that range in biologic potential from benign to overtly malignant. Even neoplasms with no metastatic potential may provide significant therapeutic challenges in this region due to the unique anatomy of the head and neck. This review will cover the following entities, highlighting important clinical aspects of each neoplasm and then focusing on their characteristic histomorphology, immunophenotype, and molecular alterations: nodular and cranial fasciitis, fibrous hamartoma of infancy, nasopharyngeal angiofibroma, nuchal-type and Gardner fibromas, desmoid fibromatosis, dermatofibrosarcoma protuberans and giant cell fibroblastoma, solitary fibrous tumor, inflammatory myofibroblastic tumor, low-grade myofibroblastic sarcoma, infantile fibrosarcoma, low-grade fibromyxoid sarcoma, and sclerosing epithelioid fibrosarcoma. While some of these neoplasms characteristically arise in the head and neck, others are rarely described in this anatomic region and may therefore be particularly difficult to recognize. Distinction between these entities, however, is crucial, particularly as the molecular pathogenetic basis for these neoplasms are being rapidly elucidated, in some instances allowing for targeted therapeutic approaches.

Juvenile Nasopharyngeal Angiofibroma Outcomes and Cost: Analysis of the Kids’ Inpatient Database

Objective:

To report trends in Juvenile Nasopharyngeal Angiofibroma (JNA) hospitalizations and identify key factors affecting treatment outcomes and cost of care in JNA patients.

Methods:

The Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database was queried for all cases of JNA between the years of 1997 and 2016. Key factors extracted were patient demographics, geographic region, hospital size, teaching status, elective admissions, and number of diagnoses and procedures performed during the hospitalization. These elements were correlated to length of stay (LOS) and cost-per-day (CPD) using a multiple linear regression (MLR). Regional variation in JNA diagnosis and changes in LOS and CPD trends over time were also analyzed.

Results:

A total of 614 JNA patients were hospitalized in this time period, with a majority of patients identifying as male (98%) and Caucasian/White (55%). The average LOS has decreased by 0.14 day per year since 1997 ( P = .0034) whereas the CPD has steadily increased by $2 380 per year ( P < .001). MLR analysis revealed that while holding all other factors constant, patients who stayed at teaching hospitals had an increased LOS of 1.7 days ( P = .026), but paid $11 961 less per day ( P = .05). Regional variation in CPD was found in the Northeast region, where hospitalizations were more expensive by $9 801 per day compared to the South ( P = .017).

Conclusion:

These results indicate hospital characteristics, such as teaching status and geographic region, may predict differences in JNA outcomes and cost. Healthcare providers should be cognizant of these variations to ensure optimal patient outcomes and expenditures.

The endoscopic endonasal approach for the treatment of juvenile angiofibromas

BACKGROUND AND OBJECTIVES

Juvenile angiofibroma (JA) is a benign tumour, for which the treatment of choice is surgery. It may be associated with significant morbidity because of its anatomical location and its locally destructive growth pattern. Severe haemorrhage constitutes a high risk in JA and its surgical management can be complex. The management of JA remains a challenge. The objective of this study was to review a series of patients with JA treated via the endonasal/endoscopic approach.

MATERIAL AND METHODS

Medical records of patients operated for JA were reviewed.

MAIN OUTCOME MEASURES

tumour stage, intraoperative blood loss, complications and persistence/recurrence rates.

RESULTS

A total of 30 male patients and one female were included. The mean age was 17 years. Using the Radkowski classification, one JA was classified as stage I, 5 stage IIA, 9 stage IIB, 4 stage IIC, 10 stage IIIA and 2 stage IIIB. Thirty-nine percent of the JA was classified as advanced stage JA (IIIA and IIIB). The mean blood loss was 1.156mL Except in one case, no significant complications were observed. Tumour persistence/recurrence was observed in 2 JA (6%), at the end of the follow-up. Mean postoperative follow-up time was 86 months.

CONCLUSIONS

This retrospective study supports the notion that endonasal endoscopic approaches for a JA are a feasible option associated with good long-term results.

Transoral Finger-Retraction for Endonasal Endoscopic Resection of Masseteric and Buccal Space Lesions

Lesions involving the masseteric and buccal spaces have traditionally required transoral or transcervical approaches. Herein, the authors describe the successful endonasal endoscopic resection of a juvenile nasopharyngeal angiofibroma (JNA) with significant extension into the masseteric and buccal spaces facilitated by transoral finger retraction. Juvenile nasopharyngeal angiofibromas are hypervascular tumors originating in the pterygopalatine fossa (PPF) with complex relationships to skull base and orbital structures. Endoscopic approaches have allowed for resection of JNAs with excellent visualization and without traditional transfacial approaches, decreasing morbidity and reducing incidence of facial deformity with similar outcomes as open approaches. While the endonasal endoscopic approach to the masseteric and buccal spaces is unconventional, encapsulated tumors in these regions can be delivered into the nasal cavity through the maxilla and PPF with the use of transoral finger-retraction. The authors present a case of a 10-year-old male referred to their tertiary care center with left-sided epistaxis, nasal obstruction, and facial swelling. Imaging demonstrated a vascular lesion in the PPF involving the left nasal cavity and paranasal sinuses, with extension into left middle cranial fossa, infratemporal fossa, orbit, and deep spaces of the neck including the masticator, masseteric, and buccal spaces. The patient underwent preoperative embolization and endoscopic endonasal surgical resection with transoral finger-retraction without complication. Transoral finger-retraction represents a supplemental technique that allows for encapsulated lesions involving the masseteric and buccal spaces to be delivered into the nasal cavity for endoscopic resection in a safe and effective fashion, preventing the need for transfacial incisions.

The risk factors for residual juvenile nasopharyngeal angiofibroma and the usual residual sites

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Implication of embolization in residual disease in lateral extension of juvenile nasopharyngeal angiofibroma

A few studies have reported incomplete resection of juvenile nasopharyngeal angiofibroma (JNA) following embolization. The likely effects of embolization, viz. shrinkage/reduced tensile strength may have increased the fragility of tumour, leaving remnants postoperatively particularly across hour-glass constriction of sphenopalatine foramina. This paper describes the likelihood of residual disease being left following embolization and hence the importance of extended surgery for complete excision.

Recurrence Rate after Endoscopic vs. Open Approaches for Juvenile Nasopharyngeal Angiofibroma: A Meta-analysis

Context  The effect on recurrence rate between patients with juvenile nasopharyngeal angiofibroma (JNA), treated by an endoscopic versus open approach, has not been well established. Objective  A meta-analysis of the available literature concerning recurrence rate in patients who underwent surgery for JNA. Methods  A retrospective meta-analysis of studies analyzing recurrence rate after endoscopic or open surgery for patients with JNA was performed using the DerSimonian-Laird random-effects method. English and non-English articles were reviewed using Embase, Medline, and Cochrane databases. Results  Among nine studies, including 362 patients from 1981 to 2015, with a mean follow-up of 49.4 months, a total of 89 patients (24.5%) had recurrence. Our analysis revealed a total effect size of -0.16 in favor of endoscopic approach (-0.25 to -0.06, CI [confidence interval] 95%). When analyzing tumor by stage (Radkowski's IA-IIIB n  = 299), the endoscopic approach proved to be superior independent of tumor stage (2 vs. 17% for tumors stage IA-IIA, and 26 vs. 32% for tumor stage IIB-IIIB for endoscopic and open approaches respectively; p  < 0.05). The endoscopic approach has a statistical significant lower recurrence rate in patients without intracranial compromise when compared with the open approach (13 vs. 28%; p  < 0.02). No statistical difference was seen in patients with intracranial compromise ( p  = 0.5) Conclusion  The use of an endoscopic approach to treat JNA has a significantly lower recurrence rate when compared with open approaches. Independent of disease stage, an endoscopic approach should be the standard of care to surgically treat JNA. For cases with intracranial compromise, either approach can be used for surgical resection.

A case of nasopharyngeal angiofibroma removed using a minimally invasive endoscopic endonasal technique

Nasopharyngeal angiofibroma is a rare head and neck tumor characterized by hypervascularity. With the development of various surgical devices and hemostatic agents, endoscopic endonasal surgery for nasopharyngeal angiofibroma, which is characterized by significant intraoperative bleeding, has become possible. We describe our experiences performing an effective endoscopic endonasal removal of a nasopharyngeal angiofibroma without embolization, using advanced devices and hemostatic agents. A 21-year-old male patient presented with massive epistaxis. The characteristic findings of angiofibroma were confirmed by computed tomography scan and nasal endoscopy. Navigation-guided endoscopic endonasal surgery was performed, and complementary devices and products were used to effectively remove the mass. Development of navigation, endoscopes, tissue handling devices, and hemostatic agents has enabled effective endoscopic endonasal removal of nasopharyngeal angiofibroma without embolization.

Endoscopic Resection of Pediatric Skull Base Tumors: An Evidence-Based Review

Objectives  To perform a systematic review examining experiences with endoscopic resection of skull base lesions in the pediatric population, with a focus on outcomes, recurrence, and surgical morbidities. Methods  PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases were evaluated. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool, Grades of Recommendation, Assessment, Development and Evaluation (GRADE), and Methodological Index for Non-Randomized Studies (MINORS) criteria. Patient characteristics, pathology, site of primary disease, presenting symptoms, stage, procedure specific details, and complications were evaluated. Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines. Results  Ninety-three studies met criteria for inclusion, encompassing 574 patients with skull base tumors. The GRADE and MINORS criteria determined the overall evidence to be moderate quality. The most common benign and malignant pathologies included juvenile nasopharyngeal angiofibromas ( n  = 239) and chondrosarcomas ( n  = 11) at 41.6 and 1.9%, respectively. Of all juvenile nasopharyngeal angiofibroma tumors, most presented at stage IIIa and IIIb (25.8 and 27.3%, respectively). Nasal obstruction (16.5%) and headache (16.0%) were common symptoms at initial presentation. Surgical approaches included endoscopic endonasal ( n  = 193, 41.2%) and endoscopic extended transsphenoidal ( n  = 155, 33.1%). Early (< 6 weeks) and late (>6 weeks) complications included cerebrospinal fluid leak ( n  = 36, 17.3%) and endocrinopathy ( n  = 43, 20.7%). Mean follow-up time was 37 months (0.5-180 months), with 86.5% showing no evidence of disease and 2.1% having died from disease at last follow-up. Conclusion  Endoscopic skull base surgery has been shown to be a safe and effective method of treating a variety of pediatric skull base tumors. If appropriately employed, the minimally invasive approach can provide optimal results in the pediatric population.

Morbidity and Volumetric Progression in Juvenile Nasopharyngeal Angiofibroma in a Long-Term Follow-Up

Objective  We compare the open and transnasal approaches for the excision of juvenile nasopharyngeal angiofibromas regarding the rate of morbidity, and residual tumor and its symptomatic recurrence over time. In addition, we present volumetric measurements of juvenile nasopharyngeal angiofibromas over time. Methods  All surgically treated patients of our institution were reviewed back to 1969 for type of surgery, residual tumor by magnetic resonance imaging (MRI)-based volumetry, recurrence, and morbidity. We performed a prospective clinical and radiological follow-up on reachable patients. Results  In total, 40 patients were retrievable from our records. We were able to follow up on 13 patients after a mean of 15.7 years since surgery (range: 1-47 years). Patients operated by the open approach had a higher rate of postoperative complications and thus a higher morbidity than endoscopic patients (4/4 vs 3/9; p  = 0.007), although tumor sizes were equal among groups ( p  = 0.12). Persisting tumor was noted in 3/4 and 4/9 ( p  = 0.56) patients, respectively. The corresponding mean volumes of residual tumors were 16.2 ± 14.4 cm ³ and 10.8 ± 6.6 cm ³ ( p  = 0.27). No progression could be noted in endoscopically treated patients ( p  = 0.24, mean time between scans 2 years). Conclusions  Our analysis shows that the endoscopic approach results in less morbidity. The open approach does not guarantee freedom from persisting tumor tissue. Age seems to be a most important risk factor for the conversion of an asymptomatic persistence into a symptomatic recurrence.

Atypical angiofibroma in a patient with compromised general health: A case report

Introduction

The nasopharyngeal angiofibroma (NA) is a benign tumor that originates from the pterygopalatine fossa and extends to the adjacent anatomical structures and affects frequently young individuals. The basic treatment for NA is surgical resection, but in some cases the tumor is surgically inaccessible.

Case presentation

We describe the case of a 45-year-old male with respiratory difficulty after the appearance of a soft palate lesion. The clinical appearance of NA was not specific.

Discussion

There are still discussions about the best therapeutic strategy and controversies about performing incisional biopsy. To our knowledge, this is the first report of a NA in an adult patient in which the general health conditions prevented the therapeutic approach, besides the extension of the lesion and its complications.

Conclusion

Our case shows that NA may reach high proportions and its involvement in older patients should be considered. In this report, we showed the limitation of the therapeutic strategy for advanced cases of NA.

•

A 45-year-old man with soft palate injury and respiratory distress.

•

Imaging examination showed involvement of the nasal cavity, nasopharynx and soft palate.

•

Initially, an intraoral incisional biopsy was performed under general anesthesia.

•

Surprisingly it was a nasopharyngeal angiofibroma.

•

General health status and extent of the lesion limited therapeutic intervention.

Long-term neurological morbidity following endoscopic transnasal resection of juvenile angiofibroma

OBJECTIVES/HYPOTHESIS

Although transnasal endoscopic resection (TER) of juvenile angiofibroma (JA) is unquestionably less invasive than traditional external approaches, several endonasal and neurovascular structures are sacrificed during the procedure. The aim of this study was to evaluate long-term neurological morbidity and related quality of life following TER of JA.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients who underwent TER for JA at the Unit of Otorhinolaryngology-Head and Neck Surgery of the University of Brescia from 1994 to 2016 were contacted to know their availability to undergo a battery of tests aimed to assess lacrimal secretion (Schirmer test), impairment of sensitive nerves (electrophysiological threshold test), and impact on quality of life of tearing reduction and sensitivity impairment with the Ocular Surface Disease Index (OSDI) and visual analogue scale (VAS) (0-10), respectively.

RESULTS

Thirteen patients were included. Mean follow-up was 77 months (range, 19-156 months). The median Schirmer test value was 5.5 mm and 28.5 mm for the treated and untreated sides, respectively (P = .003). Analysis of sensitivity revealed significant impairment only in the hard palate. The mean OSDI score was 6.8 (normal). The mean values of the VAS scores for hard palate, buccal mucosa, gum, and premaxillary skin were 1.7, 1.7, 1.2, and 2.3, respectively.

CONCLUSIONS

TER for JA can result in objective reduction of lacrimal secretion and sensitivity impairment; nevertheless, their impact on quality of life is negligible. The predictable neurological morbidity of TER should be discussed during preoperative counseling.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2184-2188, 2019.

Management of Epistaxis in Children and Adolescents: Avoiding a Chaotic Approach

This article provides an organized foundation that facilitates the management of acute epistaxis and an understanding of features that merit further diagnostic workup. Prompt management, including measures such as holding pressure and using nasal packing, takes precedence over comprehensive diagnostic workup. Severe, recurrent, and posteriorly based bleeds should prompt consideration of alternate interventions and expert consultation.

Hypoxia-Inducible Factor-1α (HIF-1α) Expression on Endothelial Cells in Juvenile Nasopharyngeal Angiofibroma: A Review of 70 cases and Tissue Microarray Analysis

OBJECTIVE

To examine the expression of hypoxia-inducible factor-1α (HIF-1α) and its related molecules (cellular repressor of E1A-stimulated genes [CREG], osteopontin [OPN], proto-oncogene tyrosine-protein kinase Src [c-Src], and vascular endothelial growth factor [VEGF]) in juvenile nasopharyngeal angiofibroma (JNA) and explore the correlation between clinical prognosis and HIF-1α expression.

METHODS

The study performed a retrospective review of the clinical records of patients with JNA treated between 2003 and 2007. Specimens were analyzed by immunohistochemistry for HIF-1α, CREG, OPN, c-Src, and VEGF expression, and microvessel density (MVD) was assessed by tissue microarray. The correlation between expression levels and clinicopathological features including age, tumor stage, intraoperative blood loss, and recurrence was analyzed.

RESULTS

HIF-1α, CREG, OPN, c-Src, and VEGF were upregulated in endothelial cells (ECs) of patients with JNA, and strong correlations in the expression of these molecules were observed. HIF-1α expression was higher in young patients ( P = .032) and in recurrent cases ( P = .01). Survival analysis showed that low HIF-1α levels in ECs predicted longer time to recurrence (log rank test P = .006). Receiver operating characteristic curve analysis showed that HIF-1α was a prognostic factor for recurrence (area under the curve = 0.690, P = .019). No correlation was found between the expression of molecules and Radkowski stage or intraoperative blood loss.

CONCLUSION

In cases of JNA treated surgically, HIF-1α expression in ECs is a useful prognostic factor for tumor recurrence.