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Bove I, Pangal DJ, Ruzevick JJ, Cheok S, Amar A, Mack W, Ference ED, Wrobel B, Swanson M, Hur K, Zada G. Anatomic Considerations Guiding Single Versus Multiportal Endoscopic Approaches for Resection of Juvenile Nasopharyngeal Angiofibroma: Cases Series With Graded Multicorridor Resections. Oper Neurosurg (Hagerstown) 2023; 25:150-160. [PMID: 37166983 DOI: 10.1227/ons.0000000000000709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/08/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Juvenile nasopharyngeal angiofibromas (JNAs) are characterized by expansive and destructive growth, often invading the midline/paranasal sinuses, pterygopalatine fossa, and infratemporal fossa and can extend into the orbit, cavernous sinus, or intracranially. OBJECTIVE To evaluete the major benefits of the extended endoscopic endonasal approach (EEA) for JNA resection as compared with more traditional and invasive transpalatal and transfacial approaches. When JNAs extend into lateral anatomic compartments, the optimal operative trajectory often requires additional approach strategies or surgical staging. METHODS We retrospectively reviewed 8 cases of large JNAs arising in symptomatic adolescent boys (University of Pittsburgh Medical Center Stages II, III, and V) and discuss anatomic and tumor considerations guiding the decision of a pure EEA vs combined EEA and sublabial transmaxillary approach (Caldwell-Luc). RESULTS A pure extended EEA was used in 6 JNA cases (UPMC Stages II-III); a multiportal EEA + Caldwell-Luc maxillotomy was used in 2 cases. One of the 2 patients (UPMC Stage V) previously treated with multiportal EEA + Caldwell-Luc maxillotomy underwent staged left temporal/transzygomatic craniotomy, obtaining gross total resection. Seven patients ultimately underwent complete removal without recurrence. One patient with a small residual JNA (UPMC II) underwent stereotactic radiosurgery without progression to date. CONCLUSION JNAs with lateral extension into the infratemporal fossa often benefited from additional lateral exposure using a Caldwell-Luc maxillotomy. Cases with significant skull base and/or dural involvement may undergo staged surgical treatment; temporalis + transzygomatic craniotomy is often useful for second-stage approaches for residual tumor in these lateral infratemporal or intracranial regions. SRS should be considered for residual tumor if additional surgery is not warranted.
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Affiliation(s)
- Ilaria Bove
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Dhiraj J Pangal
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jacob J Ruzevick
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Stephanie Cheok
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Arun Amar
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - William Mack
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Elisabeth D Ference
- USC Caruso Department of Otolaryngology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Bozena Wrobel
- USC Caruso Department of Otolaryngology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Mark Swanson
- USC Caruso Department of Otolaryngology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Kevin Hur
- USC Caruso Department of Otolaryngology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California, USA
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A radioanatomical study of 3rd segment terminal branches of the maxillary artery in the pterygopalatine fossa. Sci Rep 2023; 13:3401. [PMID: 36854685 PMCID: PMC9975186 DOI: 10.1038/s41598-023-29975-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/14/2023] [Indexed: 03/02/2023] Open
Abstract
This study describes the clinical anatomical topography and relationship of the terminal branches of the maxillary artery to the bony wall of the maxillary sinus in the pterygopalatine fossa (PPF) to estimate the bleeding risk during surgical interventions. Using contrasted computer tomography records, (i) the route of the maxillary artery in the infratemporal fossa, (ii) the number of the arteries in the critical PPF surgery plane, (iii) the diameter of the largest artery in the area and (iv) its relation to the posterior wall of the maxillary sinus were examined. Furthermore, measurements were extended with (v) the minerality of the bony posterior wall of the maxillary sinus on bone-window images. For statistical analyses Student's t- and Fisher-test were applied. 50 patients (n = 50, 100 cases including both sides) were examined in this study. The maxillary artery reached the pterygomaxillary fissure on the lateral side of the lateral pterygoid muscle in 56% of the cases (n = 32), in 37% (n = 23) on its medial side and in 7% (n = 4) on both sides. The number of arteries at the level of the Vidian canal in the PPF varied between 1 and 4 with a median of 2. The diameter of the biggest branch was 1.2-4.7 mm, the median diameter was 1.90 mm. In 41% (n = 30) of the cases the biggest artery directly contacted the posterior wall of the maxillary sinus, and the mineral density of the posterior wall was decreased in 14.3% (n = 12) of all investigated cases. The present description and statistical analysis of the vasculature of the PPF optimizes operative planning-like clip size or the type and direction of the surgical approach-in this hidden and deep head/neck region.
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Giorgianni A, Molinaro S, Agosti E, Terrana AV, Vizzari FA, Arosio AD, Pietrobon G, Volpi L, Turri-Zanoni M, Craparo G, Piacentino F, Castelnuovo P, Baruzzi FM, Bignami M. Twenty Years of Experience in Juvenile Nasopharyngeal Angiofibroma (JNA) Preoperative Endovascular Embolization: An Effective Procedure with a Low Complications Rate. J Clin Med 2021; 10:jcm10173926. [PMID: 34501374 PMCID: PMC8432214 DOI: 10.3390/jcm10173926] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasal cavity that predominantly affects young boys. Surgical removal remains the gold standard for the management of this disease. Preoperative intra-arterial embolization (PIAE) is useful for reductions in intraoperative blood loss and surgical complications. In our series of 79 patients who underwent preoperative embolization from 1999 to 2020, demographics, procedural aspects, surgical management and follow-up outcome were analyzed. Embolization was performed in a similar fashion for all patients, with a superselective microcatheterization of external carotid artery (ECA) feeders and an injection of polyvinyl alcohol (PVA) particles, followed, in some cases, by the deployment of coils . Procedural success was reached in 100% of cases, with no complications such as bleeding or thromboembolic occlusion, and surgical intraoperative blood loss was significantly decreased. In conclusion, PIAE is a safe and effective technique in JNA treatment, minimizing intraoperative bleeding.
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Affiliation(s)
- Andrea Giorgianni
- Neuroradiology Unit, ASST Sette Laghi-Circolo Hospital, 21100 Varese, Italy; (A.G.); (A.V.T.); (F.A.V.); (F.M.B.)
| | - Stefano Molinaro
- Neuroradiology Unit, ASST Sette Laghi-Circolo Hospital, 21100 Varese, Italy; (A.G.); (A.V.T.); (F.A.V.); (F.M.B.)
- Correspondence:
| | - Edoardo Agosti
- Department of Biotechnology and Life Sciences, Division of Neurosurgery, University of Insubria, 21100 Varese, Italy;
| | - Alberto Vito Terrana
- Neuroradiology Unit, ASST Sette Laghi-Circolo Hospital, 21100 Varese, Italy; (A.G.); (A.V.T.); (F.A.V.); (F.M.B.)
| | - Francesco Alberto Vizzari
- Neuroradiology Unit, ASST Sette Laghi-Circolo Hospital, 21100 Varese, Italy; (A.G.); (A.V.T.); (F.A.V.); (F.M.B.)
| | - Alberto Daniele Arosio
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, 21100 Varese, Italy; (A.D.A.); (M.T.-Z.); (P.C.)
- Department of Surgical Specialities, Division of Otorhinolaryngology, ASST Sette Laghi-Circolo Hospital, 21100 Varese, Italy
| | - Giacomo Pietrobon
- Department of Head and Neck Surgery and Otorhinolaryngology, European Institute of Oncology IRCCS, 20122 Milano, Italy;
| | - Luca Volpi
- Department of Otorhinolaryngology, ASST Lariana, University of Insubria, 22100 Como, Italy; (L.V.); (M.B.)
- Department of Surgery, ASST Lariana, University of Insubria, 22100 Como, Italy
| | - Mario Turri-Zanoni
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, 21100 Varese, Italy; (A.D.A.); (M.T.-Z.); (P.C.)
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, 21100 Varese, Italy
| | - Giuseppe Craparo
- Diagnostic and Interventional Neuroradiology Unit, ARNAS Civic Hospital, 90127 Palermo, Italy;
| | | | - Paolo Castelnuovo
- Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, 21100 Varese, Italy; (A.D.A.); (M.T.-Z.); (P.C.)
- Department of Surgical Specialities, Division of Otorhinolaryngology, ASST Sette Laghi-Circolo Hospital, 21100 Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, 21100 Varese, Italy
| | - Fabio Massimo Baruzzi
- Neuroradiology Unit, ASST Sette Laghi-Circolo Hospital, 21100 Varese, Italy; (A.G.); (A.V.T.); (F.A.V.); (F.M.B.)
| | - Maurizio Bignami
- Department of Otorhinolaryngology, ASST Lariana, University of Insubria, 22100 Como, Italy; (L.V.); (M.B.)
- Department of Surgery, ASST Lariana, University of Insubria, 22100 Como, Italy
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