Resection of juvenile angiofibroma using the Le Fort I approach

Long-term use of Le Fort I osteotomy for the management of nasopharyngeal rhinosporidiosis: A case series

Rhinosporidiosis is a rare, chronic, granulomatous infection of the mucous membranes that mainly involves the nose and nasopharynx; it occasionally involves the pharynx, conjunctiva, larynx, trachea and, rarely, the skin. The characteristic clinical features of this disease include the formation of painless polyps in the nasal mucosa or the nasopharynx that bleed easily on touch. At our center, excision of the lesion with a Le Fort I osteotomy is carried out in patients (1) in whom two or more previous attempts at excision of biopsy-proven rhinosporidiosis arising from the nasal mucosa was carried out or (2) in whom the rhinosporidiosis arises from the nasophayrngeal mucosa and/or extranasal sites. In this article we retrospectively present 7 cases in which, according to our inclusion criteria, complete excision of the lesion was carried out with a Le Fort I osteotomy. Excellent visualization of the entire maxillary and ethmoidal air cells after the down-fracture of the maxilla helped in the total removal of the lesions. Most of these lesions had multiple points of origin through the nasal, maxillary, and ethmoidal mucosa; the excellent visualization enabled direct cauterization of all these points of origin. The mean follow-up period was 7.96 years, and all patients were disease-free by the time the study was prepared. This article presents details of the treatment protocol and technique followed at our center for the treatment of nasopharyngeal rhinosporidiosis and the details of long-term follow-up. Through this study we hope to prove the efficacy of Le Fort I osteotomy in the definitive management of nasopharyngeal rhinosporidiosis.

Transoral “Adenoidectomy” Excision of Juvenile Nasopharyngeal Angiofibromas

Objectives:

We describe a minimally invasive technique for excision of selected juvenile nasopharyngeal angiofibromas (JNAs) using indirect visualization of the nasopharynx.

Methods:

An observational case series with follow-up of 9 months to 3 years was performed. The subjects included 4 teenage boys with early-stage nasopharyngeal angiofibromas. The intervention included computed tomography, magnetic resonance imaging, angiography and embolization, tumor excision, pathologic examination, and follow-up. The outcome measures included blood loss, perioperative morbidity, and surgical cure.

Results:

Four teenage boys underwent excision of early stage JNAs — 3 with preoperative embolization. The JNAs were excised under indirect mirror guidance with an adenoid curette and the nasopharynx packed. Residual tumor was removed endoscopically. The operative time was less than 1 hour in each case, and blood loss was less than 100 mL. All 4 boys are free of disease.

Conclusions:

With the advent of refined imaging techniques and relatively safe preoperative embolization, minimally invasive approaches to JNA excision have been advocated. Endoscopic transnasal piecemeal excision is feasible but time-consuming. Transoral avulsion of the tumor mass by adenoidectomy techniques combined with endoscopic removal of tumor remnants from the pterygopalatine fossa allows complete, controlled surgical excision with minimal blood loss.

Resection of a juvenile nasoangiofibroma by Le Fort I osteotomy: Experience with 40 cases

PURPOSE

The aim of this study was to determine the rate of success and complications of juvenile nasoangiofibroma resection by Le Fort I osteotomy.

MATERIAL AND METHODS

Data were obtained from the medical records of 40 patients with a diagnosis of juvenile nasoangiofibroma confirmed by anatomopathological examination. All tumors were resected by Le Fort I osteotomy between 1983 and 2010. The data obtained were gender, age, symptoms, sites of invasion, preoperative embolization, routes of surgical access, duration of surgery, complications, need for transfusion, relapses, and follow-up time.

RESULTS

All patients were male, ranging in age from 7 to 27 years. The most common symptom was nasal obstruction, and central nervous system (CNS) invasion was present in 27.5% of cases. Craniotomy was associated with Le Fort I osteotomy in only one case. The mean duration of surgery was 216 min. Complications occurred in 15% of cases, with intraoperative bleeding being the most frequent one. Relapses occurred in 5% of cases. The mean follow-up was 48.8 months.

CONCLUSION

Exclusively surgical treatment by Le Fort I access proved to be a safe and effective method for the treatment of nasoangiofibromas, permitting the removal of tumors even in patients with extension to the CNS, with a low rate of complications and relapses.

Le Fort I osteotomy for extensive juvenile nasopharyngeal angiofibroma: a retrospective study

INTRODUCTION

Juvenile nasopharyngeal angiofibroma (JNA) is a rare, nonencapsulated, benign neoplasm typically diagnosed in adolescent boys. Surgery is the usual treatment modality for JNA. The optimal surgical procedure should allow maximal exposure of the tumor for complete excision with minimum morbidity. One possible surgical approach is Le Fort I maxillary osteotomy. The aim of this study was to review our experience with the Le Fort I osteotomy and to investigate the feasibility of this approach for extensive JNA invaded into pterygopalatine and infratemporal fossae.

METHODS

We retrospectively studied patients who had undergone JNA resection via the Le Fort I osteotomy approach from July 2000 to September 2007, considering tumor location and size, complications, and tumor recurrence associated with the surgical approach.

RESULTS

Six patients of JNA (all boys; mean age, 15.5 years) were identified through the chart review. All the angiofibromas had extended into the pterygomaxillary space and infratemporal fossa. The mean follow-up for this cohort was 50.1 months. No intraoperative and postoperative complications were noted, except for slight diplopia in one patient due to injury of the left medial rectus muscle. There were no cases of tumor recurrence that could be attributed to the procedure.

CONCLUSION

Our experience suggests that the Le Fort I osteotomy approach is a useful technique for the removal of extensive JNA invaded into pterygopalatine and infratemporal fossae. It has distinct advantages over traditional anterior or lateral approaches, providing a more direct vision, improved exposure, and cosmesis.

Critical look at the surgical approaches of nasopharyngeal angiofibroma excision and "total maxillary swing" as a possible alternative

OBJECTIVES

We critically analyzed different surgical approaches used for the excision of nasopharyngeal angiofibroma (NPA) at our hospital in a 10-year period and proposed "total maxillary swing" as a possible alternative approach.

METHODS

Retrospective review of the clinical and operative records was done regarding 39 cases of NPA that were surgically managed from 1995 to 2005. The duration of the surgical procedures, amount of blood loss and transfusion, time to recurrence, frequency of recurrence, functional and cosmetic deformity, and complications of all surgical procedures were thoroughly analyzed. These parameters were compared with total maxillary swing, a new approach recently being used by us, for the one-time excision of NPA.

RESULTS

A total of 61 operations including revision surgeries for recurrences were done in the 39 cases of NPA. Conventional surgical approaches were performed in 37 cases, and the total maxillary swing approach was used in 2 cases. This new approach provided a wider surgical exposure for complete tumor resection and better hemostasis without any recurrence or major functional deformity, which were seen with some of the conventional approaches.

CONCLUSIONS

We found total maxillary swing to be a relatively safe alternate approach for the resection of NPA. We removed the entire tumors in a wider surgical field under the microscope with reduced blood loss and minimal complications or chance of recurrences.

Management Dilemmas in the Treatment and Follow-Up of Advanced Juvenile Nasopharyngeal Angiofibroma

Advanced juvenile nasopharyngeal angiofibroma (JNA) (i.e. disease with intracranial extension) is reportedly uncommon. The optimum management form of such a clinical situation currently remains controversial. This review, of the recent English published literature, discusses the common JNA classification systems advocated, shows the advantages and disadvantages of surgical approaches used (both open, endoscopic or combined), and re-evaluates the current role of radiotherapy (for initial management or treatment of residual/recurrent disease). We also discuss the typical presentation of these patients, the role of pre-operative embolization, as well as surgical techniques to minimize recurrence, and advocate a post-treatment follow-up protocol.

Angiofibroma: an outcome review of conventional surgical approaches

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasopharynx, and for its treatment, many surgical approaches have been recommended. However, selecting the appropriate one for the tumor in an advanced stage is still controversial. In this study, we evaluate the rate of recurrence of JNA and its relationship to the preoperative stage as well as various surgical approaches. Thirty-seven patients with pathologically proven JNA were retrospectively analyzed. For each patient, data were obtained regarding the primary extension, various surgical approaches and rate of recurrence. Seven patients were in stage III with intracranial extensions. Two of these patients had symptomatic recurrence that needed surgery. Three of them were disease free, and in two cases residues were demonstrated that were asymptomatic and were chosen only to be observed. Among different surgical approaches used, the transpalatal resulted in 1 recurrence out of 14 patients treated with this approach when the lesion was limited to the nasal cavity, nasopharynx and paranasal sinuses (stage I). No recurrence was observed with the use of this approach with lesions with minimal extension to the pterygopalatine fossa (stage IIA). But among three patients with intracranial extension who were treated with this approach, two resulted in symptomatic recurrence; however, using the Lefort I surgical technique, no evidence of recurrence was observed in the two patients in stage III who were treated with this approach. Involvement of the orbit, middle cranial fossa and base of the pterygoid by the primary JNA results in a higher incident of recurrent tumor. Among different surgical techniques, the lowest recurrence rate is seen either in the transpalatal approach when the tumor is limited to the nasopharynx with extension to the nasal cavity or paranasal sinuses or with the Lefort I approach when skull base invasion is present.

Recent advances in the treatment of juvenile angiofibroma

PURPOSE OF REVIEW

Juvenile nasopharyngeal angiofibroma is a rare vascular tumor almost exclusive to the nasopharynx of adolescent males. Traditionally, juvenile nasopharyngeal angiofibroma has been treated surgically using open surgical approaches and has been associated with frustratingly high recurrence rates. This article reviews recent contributions to the study and treatment of this disease. In particular, advances in minimally invasive endoscopic resection of juvenile nasopharyngeal angiofibroma are evaluated.

RECENT FINDINGS

The growth patterns of juvenile nasopharyngeal angiofibroma are evaluated. Young age does not appear to correlate with more aggressive disease. The major recent advance in the treatment of juvenile nasopharyngeal angiofibroma has been the application of endoscopic endonasal surgery to the treatment of select tumors. This article reviews the indications and inclusion criteria recently put forth to help select patients for this minimally invasive approach. In properly selected patients with Radkowski stage I and II lesions, recurrence rates range between 0 and 7%. Advanced lesions continue, in most cases, to require open approaches, some of which are also presented.

SUMMARY

With proper patient selection, endoscopic resection of juvenile nasopharyngeal angiofibroma is feasible and may be preferable to traditional open approaches. Results suggest that after endonasal resection, disease recurrence is low. Most larger lesions, especially those with intracranial spread, continue to require open approaches for complete resection.