Nasopharyngeal Angiofibroma-changing Trends in the Management

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.

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

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

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

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Surprisingly it was a nasopharyngeal angiofibroma.

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

Juvenile nasopharyngeal angiofibroma surgical treatment in paediatric patients

INTRODUCTION AND OBJECTIVES

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Juvenile Nasopharyngeal Angiofibroma: Combined Approach for Excision, Transpalatal and Endoscopic; A New Perspective

Juvenile angiofibroma is a rare, highly vascular, histologically benign but locally invasive tumour, affecting predominantly male adolescents. To describe our experience in diagnosis of angiofibroma and treatment by combined endoscopic and transpalatal route. We analysed a case series of 50 patients of nasopharyngeal angiofibroma in Fisch stages I and II who presented at our institute during a period of four years 2011-2014, their clinical presentation, their treatment by combined transpalatal and endoscopic approach, intraoperative and post operative course, complications and tumour recurrence. Patients were aged 8-26 years. All patients were treated surgically by combined approach endoscopic and transpalatal. The mean operation time was 90 min, and the mean bleeding volume was 300 ml. Only 8 % patients came with recurrence and only 10 % came with palatal perforation (fistula formation). With gratifying results we advocate this novel technique for the treatment of early to intermediate JNA.

Juvenile Nasopharyngeal Angiofibroma: A Rise in Incidence

Juvenile nasopharyngeal angiofibroma is a very rare, highly vascular, uncapsulated and locally invasive tumor. Recently a changing trend has been seen in its epidemiology, pathogenesis, diagnosis, medical management, pre-operative care, surgical management and post-operative care including radiotherapy. Study the changing trend basically in the north-eastern region of south-east Asia and its prospects. Retrospective study of patients presenting with JNA between the study period of 6 months (October 2014-March 2015) in the, Department of Otolaryngology and Head and Neck Surgery, Assam Medical College, Dibrugarh, Assam, India. Incidence in comparison to previous studies has increased. Eight patients were treated in the study period. Different approaches were used. Mean age of presentation was 18 years and more than 75 % of them were either Stage III or Stage IV. Different approaches like transpalatine, transpalatine along with transnasal, lateral rhinotomy and endoscopic surgery were used. The recurrence rate was 12.5 %. Surgery by transpalatine approach should be the choice of treatment. Endoscopic resection should be only used for Stage I or Stage II disease.

Microspheres embolization of juvenile nasopharyngeal angiofibroma in an adult

INTRODUCTION

Juvenile nasopharyngeal angiofibroma (JNA) is a benign though locally aggressive, highly vascular tumor primarily affecting adolescent males which has traditionally posed a significant intraoperative challenge during its resection due to the high risk of uncontrollable hemorrhage. Pre-operative angiographic embolization of the major feeding vessels to the tumor has become a valuable, even necessary, tool in the surgical treatment of these lesions.

PRESENTATION OF CASE

Our patient was a 32-year-old man with a chief complaint of recurrent left-sided epistaxis for one year, brisk and continuous for ten days prior to presentation, subsequently found to have a 4 cm vascular skull base tumor causing mild expansion of the pterygopalatine fossa. The patient underwent pre-operative embolization utilizing 300–500 micrometer microspheres injected into the ipsilateral maxillary artery. The following day, the patient underwent definite Stereotactical surgical resection of his JNA tumor. Estimated blood loss during the operation was 50 mL, and the patient was discharged the same day.

DISCUSSION

Juvenile nasopharyngeal angiofibromas pose a significant bleeding risk for the surgeon due to their highly vascular nature. Pre-operative embolization of juvenile nasopharyngeal angiofibromas can reduce intraoperative blood loss while lessening the risk of massive hemorrhage, shortening operation times, increasing intra-operative visibility, and allowing for easier resection of lesions.

CONCLUSION

Pre-operative embolization of JNA is a safe, effective method to prevent against the risk of massive, sometimes fatal, hemorrhage that occurs with these highly vascular tumors.

Two types of lateral extension in juvenile nasopharyngeal angiofibroma: diagnostic and therapeutic management

Juvenile nasopharyngeal angiofibroma is a benign, locally aggressive nasopharyngeal tumor. Apart from anterior lateral extension to the pterygopalatine fossa, it may spread laterally posterior to the pterygoid process, showing posterior lateral growth pattern, which is less common and more difficult to identify during surgery. We analyzed the routes of lateral spread, modalities useful in its diagnosis, the incidence of lateral extension and its influence on outcomes of surgical treatment. The records of 37 patients with laterally extending JNA treated at our institution between 1987 and 2011 were retrospectively evaluated. Computed tomography was performed in all patients and magnetic resonance imaging in 17 (46 %) patients. CT and MRI were evaluated to determine routes and extension of JNA lateral spread. Anterior lateral extension to the pterygopalatine fossa occurred in 36 (97 %) patients and further to the infratemporal fossa in 20 (54 %) patients. In 16 (43 %) cases posterior lateral spread was observed: posterior to the pterygoid process and/or between its plates. The recurrence rate was 29.7 % (11/37). The majority of residual lesions was located behind the pterygoid process (7/11). Recurrent disease occurred in 3/21 patients with anterior lateral extension, in 7/15 patients with both types of lateral extensions and in 1 patient with posterior lateral extension. JNA posterior lateral extension may spread behind the pterygoid process or between its plates. The recurrence rate in patients with anterior and/or posterior lateral extension is significantly higher than in patients with anterior lateral extension only. Both CT and MRI allow identification of the anterior and posterior lateral extensions.