Preoperative angiography and external carotid artery embolization of juvenile nasopharyngeal angiofibromas in a tertiary referral paediatric centre

Case of giant juvenile angiofibroma resected by external incision with temporary double balloon occlusion of the internal carotid artery by intraoperative endovascular treatment

We report the first case of a juvenile nasal angiofibroma (JNA) fed by multiple arteries from the internal carotid artery (ICA), removed without complications by temporarily blocking the ICA with two balloons. An early adolescent with JNA underwent preoperative embolisation of feeding arteries arising from the external carotid artery (ECA) (University of Pittsburgh Medical Centre classification IV). Endoscopic resection was attempted once but discontinued due to massive bleeding (7000 mL). 17 months later, the JNA had grown to fill both nasal cavities. Repeated preoperative embolisation of the feeders from the ECA was performed, followed by surgery combined with endoscopic and external incision. Intraoperatively, two balloons were inserted into the right ICA, which were inflated at the proximal and distal sites of the feeder vessels to cut-off blood flow to the tumour. The tumour was almost completely resected with 6270 mL of blood loss and no postoperative neurological deterioration.

Juvenile Nasopharyngeal Angiofibroma: Outcomes Analysis Based Upon Hospital Volume

OBJECTIVE

To evaluate the management of juvenile nasopharyngeal angiofibroma (JNA) from a national perspective with outcomes comparison based on hospital volume.

STUDY DESIGN

Ten-year Pediatric Health Information Systems (PHIS) data analysis.

METHODS

The PHIS database was queried for the diagnosis of JNA. Data regarding demographics, surgical approach, embolization, length of stay, charges, readmission, and revision surgery was collected and analyzed. Hospitals were classified as low volume if fewer than 10 cases and high volume if greater than or equal to 10 cases during the study period. A random effects model compared outcomes based on hospital volume.

RESULTS

A total of 287 JNA patients were identified with a mean age of 13.8 (± 2.7) years. Nine hospitals were classified as high volume, accounting for a total of 121 patients. The mean length of hospitalization, blood transfusion rate, and 30-day readmissions did not differ significantly by hospital volume. Patients cared for at high-volume institutions were less likely to require postoperative mechanical ventilation (8.3% vs. 25.0%; adjusted RR = 0.32; 95% CI 0.14-0.73; p < 0.01) or return to the operating room for residual disease than patients admitted to low-volume hospitals (7.4% vs. 20.5%; adjusted RR = 0.38; 95% CI 0.18-0.79; p = 0.01).

CONCLUSIONS

The management of JNA is complex from both an operative and perioperative management standpoint. Over the past decade, nearly half (42.2%) of JNA patients have been managed at nine institutions in the United States. These centers have significantly lower rates of postoperative mechanical ventilation and the need for revision surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3216-3220, 2023.

Application of Digital Subtraction Angiography in Predicting the Outcomes of Intraoperative Hemorrhage of Juvenile Nasopharyngeal Angiofibroma

OBJECTIVE

Juvenile nasopharyngeal angiofibroma (JNA) is a very rare hemorrhagic vascular tumor that predominantly affects adolescent boys. The tumor is relatively large when detected, and the risk of intraoperative bleeding is high. We aimed to examine factors associated with intraoperative blood loss in JNA surgery.

METHODS

Thirteen patients with JNA who underwent surgery at the Jikei University Hospital between 2009 and 2020 were retrospectively reviewed, and factors associated with blood loss were examined by single regression analysis.

RESULTS

The mean age was 20.8 ± 7.7 years. Preoperative angiographic images were evaluated in 9 of the 13 cases. The 6 patients with the largest bleeding volumes, all had residual nutrient vessels from the internal carotid artery (ICA), with an average number of 2.5 vessels. The mean blood loss of patients with residual nutrient vessels from the ICA was 3037 ± 2568 mL. Single regression analysis of bleeding volume against the number of remaining nutrient vessels from the ICA and the total peak contrast density of nutrient vessels (Cmax) standardized by region of interest showed that the coefficient was positive (P < 0.05 for both), confirming a significant correlation between the 2, respectively.

CONCLUSIONS

The amount of bleeding significantly correlated with the number of remaining nutrient vessels from the ICA after preoperative embolization and with the total Cmax/region of interest. The ability to predict the amount of preoperative blood loss using this study will facilitate proposals for external incisions in patients with JNA.

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.

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.

Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management

BACKGROUND

Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas.

METHODS

We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension.

AIMS

Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery.

RESULTS

Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes.

CONCLUSIONS

The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

Embolization in Juvenile Nasopharyngeal Angiofibroma Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare outcomes of juvenile nasopharyngeal angiofibroma (JNA) resection between embolized and non-embolized cohorts, and between transarterial embolization (TAE) and direct puncture embolization (DPE).

DATA SOURCES

Per PRISMA guidelines, PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched for publications prior to or in 2021.

MATERIALS AND METHODS

Original English manuscripts investigating the resection of JNA with and without preoperative embolization were included. Embolization type, recurrence rate, complication rates, blood loss, and transfusions were extracted. Risk of bias was assessed by the Risk of Bias in Non-randomized Studies-of Interventions method.

RESULTS

There were 61 studies with 917 patients included. Preoperative embolization was performed in 79.3% of patients. Of those embolized, 75.8% (N = 551) underwent TAE and 15.8% (N = 115) underwent DPE. JNA recurrence in embolized patients was lower than in non-embolized patients (9.3% vs. 14.4%; odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.35, 1.06). DPE resulted in lower rates of disease recurrence (0% vs. 9.5%; OR: 0.066, 95% CI: 0.016, 0.272) and complications (1.8% vs. 21.9%; OR: 0.07, 95% CI: 0.02, 0.3) than TAE. A random effects Bayesian model was performed to analyze the difference in mean blood loss in 6 studies that included both embolized and non-embolized patients. This analysis showed a mean reduction in blood loss of 798 mL in the embolized group.

CONCLUSIONS

We found embolization decreases blood loss in JNA resection. DPE led to improved recurrence and complication rates when compared to TAE, but future prospective studies are needed to further evaluate which embolization technique can optimize outcomes in JNA.

LEVEL OF EVIDENCE

NA Laryngoscope, 2023.

Multidiscipline management of giant reccurent nasopharyngeal angiofibroma which extends to paranasal sinuses, orbita, and intracranial in adult

Nasopharyngeal angiofibroma (NA) is a benign, slowly growing tumour that affects males in their early puberty, and rarely men over 25 years of age. There was an interesting case of a giant recurrent NA in a 62-year-old male, which is challenging to manage due to wide tumour expansion to paranasal sinuses, orbital and intracranial. In cases of large angiofibromas disease, preoperative embolization should be performed to prevent profuse bleeding. Wide expansion of NA can cause post extirpation large defects of the tumour so that optimal defect closure techniques are needed to restore the aesthetics and function of the disturbed organs. This case's diagnosis and management of this disease was carried out by multidisciplinary discussion, and surgical extirpation of the joint tumour was performed in Dr. Soetomo General Academic Teaching Hospital. The tumour was removed by medial maxillectomy with an extended Killian right lateral rhinotomy approach followed by tumour defects reconstruction. The follow up showed that there were still tumour residue and suspicious intracranial abscess, but the patient had no complaint during follow-up for ten months after surgery.

•

Nasopharyngeal angiofibroma (NA) is a benign but locally aggressive tumor and rarely appears in adults. Although it is rare, NA should not be disregarded in elderly patients. Histopathological tests showed different results before surgery.

•

The surgical technique chosen is embolization, MMRL and facial reconstruction through joint surgery ORL-HNS, Ophthalmologist, Neurosurgeon, and Plastic Reconstructive & Aesthetic Surgeon because of the large size of the tumor and has spread aggressively to the intracranial and many blood vessels involved.

•

The result concluded a benign mesenchymal spindle tumour with a differential diagnosis of solitary fibrous tumour, neurofibroma cellular schwannoma, and angiofibroma. The patient was advised to undergo an immunohistochemical examination to establish a tumour diagnosis, but this was not done due to constraints on equipment and family considerations related to the Covid-19 pandemic.

•

Evaluation of the results of surgery and recurrence events has been carried out for 10 months postoperatively and there are no complaints and the patient can carry out activities as usual.

Twenty Years of Experience in Juvenile Nasopharyngeal Angiofibroma (JNA) Preoperative Endovascular Embolization: An Effective Procedure with a Low Complications Rate

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.

Pre-Operative Embolisation of an Aberrant Pharyngeal Arterial Branch Arising From the Internal Carotid Artery and Contributing Significantly to the Supply of a Large Juvenile Nasopharyngeal Angiofibroma

Preoperative embolisation of juvenile nasopharyngeal angiofibromas (JNAs) is a well-established treatment that reduces intraoperative blood loss and improves surgical outcomes. While the bulk of arterial supply to the tumour is derived from the external carotid system, some degree of contribution from the internal carotid artery (ICA) is common. ICA branch embolisation in this setting has previously been avoided due to concerns over ischaemic neurological complications, possibly contributing to the increased intraoperative blood loss observed in patients with tumours with ICA supply. There is a marked paucity of reports of embolisation of ICA branches supplying JNA in the medical literature. We present a case of successful embolisation of an aberrant pharyngeal branch of the ascending pharyngeal artery arising from the proximal cervical ICA, which was making a significant contribution to tumour blood supply in a male adolescent with a very large JNA.

Two rare cases of sinonasal vascular malformation in the pediatric population

Vascular malformations presenting in the nasal cavity and paranasal sinuses are rare. Differentiating benign vascular malformations of the sinonasal cavity from other pathologic entities can be challenging and the role of preoperative angiography and embolization is not well defined. We present two unique cases of large pediatric sinonasal vascular malformations and describe their presentation, diagnosis and subsequent management. Both patients underwent embolization of the ipsilateral arterial supply followed by successful and complete endonasal surgical excision. This report provides description of management of the very rare occurrence of sinonasal vascular malformation in two adolescents.

Embolization of Internal Carotid Artery Branches in Juvenile Nasopharyngeal Angiofibroma

OBJECTIVE

Preoperative embolization of juvenile nasopharyngeal angiofibroma (JNA) is usually performed by the occlusion of branches of the external carotid artery (ECA). However, a significant proportion of JNAs also receive blood from the internal carotid artery (ICA). The objective of this study was to report on the feasibility and clinical impact of superselective embolization of ICA branches in complex cases of JNA.

METHODS

This was a single-center retrospective study of all patients operated on for JNA between 2000 and 2018. The patients treated with embolization of branches of the ICA were identified. The results in terms of complications, intraoperative blood loss, and rate of residual disease were analyzed and compared to those of a control group of patients treated only with embolization of ECA branches and matched by age, stage, angiographic pattern, surgical approach, and previous surgery.

RESULTS

Ninety-two patients were included. Embolization of branches of the ICA was attempted in 14 cases of advanced or recurrent tumors and was ultimately possible in nine cases. There were no complications after embolization. The mean intraoperative blood loss was 1428 mL. Residual disease was found in three cases (33%). There was no significant difference compared with the control group (mean intraoperative blood loss = 1355 mL, residual disease = 4 (44%); all P > .05).

CONCLUSION

In this retrospective study, we report the feasibility of superselective embolization of ICA branches in selected cases of JNA. There was no observed benefit of this technique in terms of intraoperative bleeding or decreased risk of residual disease.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E775-E780, 2021.

The role of diagnostic and interventional radiology in juvenile nasopharyngeal angiofibroma: A case report and literature review

Juvenile Nasopharyngeal Angiofibroma is a rare and locally aggressive benign tumor. It is characterized by high vascularization leading to spontaneous bleeding or massive hemorrhage. We reported a case of 13 years old boy with a swollen at the right face, nasal congestion, recurrent nose bleeding, hyposmia, headache, breathing difficulty, and a nasopharyngeal mass at CT scan. Angiography examination showed a highly vascularized mass which was successfully occluded through preoperative embolization procedures. It is suggested that imaging modalities is not only playing an important role in diagnostic process, but also as an adjunct treatment approach in patient with Juvenile Nasopharyngeal Angiofibroma.

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.

Efficacy and safety of preoperative internal maxillary arterial embolization with gelfoam for nasopharyngeal angiofibroma

PURPOSE

To investigate the efficacy and safety of preoperative internal maxillary arterial embolization with gelfoam particles in patients with nasopharyngeal angiofibroma.

MATERIALS AND METHODS

We retrospectively reviewed a total of 27 consecutive patients with pathologically confirmed nasopharyngeal angiofibroma from August 2006 to September 2018. Of the 27 enrolled patients, 10 patients received surgical excision alone; 17 patients received preoperative internal maxillary arterial embolization followed by surgical excision. Embolic agents were gelfoam particles.

RESULTS

The mean volume of intro-operative blood loss was 385.3 ml in patients with preoperative arterial embolization, which was significantly lower than 1215.0 ml in the patients without preoperative arterial embolization (P < 0.001). The mean surgical time was shorter in patients with preoperative arterial embolization than in the patient without preoperative arterial embolization, but the difference had no statistical significance (205.0 vs 264.5 min, P = 0.064). Neurological complications such as facial palsy or vision loss or hemiplegia were not observed in patients with preoperative arterial embolization.

CONCLUSION

Internal maxillary artery embolization with gelfoam particles suffices to provide an effective and safe adjuvant procedure for surgical excision of nasopharyngeal angiofibroma.

Preoperative transcatheter arterial embolization using a gelatin sponge for head and neck tumors

Purpose: To evaluate the usefulness of preoperative transcatheter arterial embolization using a gelatin sponge for hypervascular head and neck tumors to reduce intraoperative blood loss (IBL).　　　　 Material and methods: Nineteen patients underwent preoperative transcatheter arterial embolization for hypervascular head and neck tumors using a gelatin sponge. The technical success rate, devascularization rate, IBL, and complications were evaluated. Angiography images obtained before and after preoperative embolization were compared in all patients, and the devascularization rate was assessed from the relative reduction rate of contrast agent volumes. Results: The technical success rate was 100%. The median devascularization rate was 95% (range, 75-100%). The median period between embolization and surgical resection was one day (range, 1-12 days). The median IBL was 122 ml (range, 0-3780 ml). Blood transfusions were required in three cases, and their IBL and devascularization rates were 850, 1959, and 3780 ml, and 75%, 90%, and 80%, respectively. There was a complication of cerebral embolism in one out of 19 cases (5%). Conclusions: Preoperative transcatheter arterial embolization using a gelatin sponge was feasible and may contribute to decreasing IBL.

Management and Outcome in Patients with Advanced Juvenile Nasopharyngeal Angiofibroma

Objective  To report the management outcome in a series of patients with advanced juvenile nasopharyngeal angiofibroma (JNA). Design  Retrospective study. Setting  Tertiary care teaching hospital. Participants  Forty-five patients classified as Radkowski stage IIIA or IIIB who presented to us over the past 10 years. Main Outcome Measures  Surgical approaches used and disease free outcomes in patients with advanced JNA. Results  Surgical access for the extracranial component included open (41.9%) and expanded endonasal approaches (58.1%). Craniotomy (16.3%), endoscopy-assisted open approach (7%), or expanded endonasal approach (20.9%) was performed to excise the skull base or intracranial component. Follow up ranged from 4 to 96 months (mean, 20.3 months). Of 35 patients who underwent imaging at the first postoperative follow up, 25 (71.4%) had negative scans. Three symptomatic patients with residual disease underwent endoscopic excision and had negative scans thereafter. Of two others who had radiation therapy, one was disease free and the other lost to follow up. Five others had stable, residual disease. Three patients (8.6%) with recurrent disease underwent surgical excision, of whom two had minimal, stable residual disease. At the last follow-up, 27 (77.1%) patients had negative scans, and 7 (20%) had stable residual disease with one (2.9%) patient lost to follow-up. Conclusions  Advanced JNA may be successfully treated in most cases with expanded endonasal/endoscopy assisted ± craniotomy approach after appropriate preoperative evaluation. At follow-up, only symptomatic patients or those with enlarging residue require treatment; periodic imaging surveillance is adequate for those with stable disease.

Four-dimensional CT angiography (4D-CTA) in the evaluation of juvenile nasopharyngeal angiofibromas: comparison with digital subtraction angiography (DSA) and surgical findings

OBJECTIVES

To explore the value of four-dimensional CT angiography (4D-CTA) in the preoperative evaluation of juvenile nasopharyngeal angiofibromas (JNAs) using 320-row volume CT.

METHODS

4D-CTA and DSA data of 18 patients with histopathologically proven JNAs were retrospectively reviewed. The location, extent, feeding vessels and stage of JNAs were assessed by two radiologists independently and blindly. The agreements between both reviewers and between 4D-CTA and surgical findings for assessing the above indicators were analysed, respectively. The radiation dose and the number of feeding arteries between 4D-CTA and digital subtraction angiography (DSA) were also compared.

RESULTS

4D-CTA showed high diagnostic consistency with surgical pathology for JNAs with consistent rates of 96.2 and 100% in both reviewers, respectively. The effective dose of 4D-CTA was significantly less than that of DSA (p < 0.001). Good agreements between 4D-CTA and surgical findings and between the two reviewers were found in the assessment of the location, extent and stage of JNAs. 4D-CTA showed that 15 lesions were supplied strictly by the external carotid artery circulation and 3 by the external and internal carotid artery supply, which was in accordance with DSA. There were no significant differences in the main arterial feeder number obtained by 4D-CTA and DSA between different observers (all p > 0.05).

CONCLUSIONS

4D-CTA can provide a reliable preoperative diagnosis and assessment of JNAs, which is useful for determining the surgical strategy and management of this condition.

Imaging of Paranasal Sinuses and Anterior Skull Base and Relevant Anatomic Variations

This article reviews the normal anatomy and variants of the anterior skull base and sinonasal cavities that are relevant to endoscopic sinus and skull base surgery. Radiologists should be aware of sinonasal anatomy that can be impediments to surgical access and increase risk of vascular or cranial nerve injury during surgery. Imaging features of the paranasal sinuses and anterior skull base pathologies are also discussed.

Strategies for Improving Visualization During Endoscopic Skull Base Surgery

The nasal cavity has a robust vascular supply, and bleeding is a primary obstacle to the minimally invasive skull base technique. Venous bleeding, including the cavernous sinus, can be managed with various techniques using hemostatic materials and pressure. A thorough understanding of the skull base vascular anatomy is vital for avoiding injury to major arteries and having confidence to control venous bleeding to optimize the endoscopic view and tumor resection.

Transarterial embolization in the management of intractable epistaxis: the angiographic findings and results based on etiologies

CONCLUSIONS

Transarterial embolization (TAE) appears to be a safe and effective treatment for patients with intractable epistaxis, despite different etiologies or angiography findings. Idiopathic epistaxis is prone to present with negative angiographic findings.

OBJECTIVE

To retrospectively evaluate the safety and effectiveness of TAE for intractable epistaxis, and focus on the factors of etiology and angiographic findings.

MATERIALS AND METHODS

From March 2008 to December 2014, the data of 43 patients with intractable bleeding undergoing TAE were reviewed. The outcomes of interventional therapy were assessed according to different etiology (malignant or benign disease) and angiographic finding (positive or negative angiogram).

RESULTS

Positive angiographic findings were found in 11 of 12 cases with malignant diseases and 22 of 31 cases with benign diseases, respectively (p = 0.237). Among the 10 cases with negative angiographic findings, the negative angiography rate of idiopathic epistaxis was higher than that of epistaxis with definite etiology (p = 0.003). Bleeding was controlled successfully in all of the 43 patients after embolization. During the mean follow-up period of 24.0 ± 16.7 months, five patients relapsed. No significant difference was found in recurrence rates between malignant and benign diseases or between positive and negative angiography (p = 0.241, p = 0.704, respectively).

Juvenile Nasal Angiofibromas: A Comparison of Modern Staging Systems in an Endoscopic Era

Objectives To compare the clinical utility of four juvenile nasal angiofibroma (JNA) staging systems in a large cohort of patients. Design Retrospective case series. Setting Tertiary referral academic center. Participants Pediatric patients undergoing surgical resection of JNAs between January 2008 and June 2015. Main Outcome Measures Intraoperative blood loss and transfusions, number of staged operations, postoperative residual disease, and recurrent disease. Results In total, 34 patients were identified; all underwent preoperative embolization followed by surgery. Of the 34 patients, 33 (97%) underwent an exclusively endoscopic surgical approach, with 6 (18%) requiring planned staged operations. Ten (29%) patients had residual disease and three (9%) required further surgical resection. Using the area under the curve (AUC) of receiver operating characteristic curves, the University of Pittsburgh Medical Center (UPMC) staging system was most predictive of patients who required staged procedures, received intraoperative transfusions, and had residual postoperative disease (AUC: 0.89, 0.88, 0.86, respectively). Conclusions The UPMC JNA staging system accounts for both route of skull base extension and tumor vascularity, which are two important tumor attributes in the age of preoperative embolization and endoscopic endonasal surgery. The UPMC staging system is a reliable modern staging system that closely reflects prognostic information and aids in surgical planning.

Juvenile Nasopharyngeal Angiofibroma: Magnetic Resonance Imaging Findings

Purpose:

Juvenile nasopharyngeal angiofibroma (JNA) is a rare tumor that exhibits a predictable spreading pattern. Radiologist’s prior knowledge on the tumor’s characteristics aids in establishing a diagnosis. We aimed to report the characteristic Magnetic Resonance Imaging (MRI) findings and the spread patterns of JNA.

Materials and methods:

We retrospectively evaluated the MRI findings and extension pathways of 6 cases of JNA.

Results:

The patients’ age ranged from 8 to 16 years and all patients were male. The tumors were classified according to the Onerci system. Tumors were largely isointense to muscle on T1-weighted images and hyperintense on T2-weighted images. All lesions had internal signal-void regions and all exhibited intense enhancement after IV contrast injection. Diffusion restriction was not an associated feature. ADC values for these tumors were high. The evaluation of the available MR angiography studies of three patients showed the blood supply to the tumor to be mainly from the internal maxillary branch of the external carotid artery. In all patients, the diagnosis was based on MR images and a surgical excision was planned.

Conclusion:

The diagnosis can be established based on the characteristic imaging findings and the clinical history without performing a biopsy.

Endoscopic Radiofrequency Ablation–Assisted Resection of Juvenile Nasopharyngeal Angiofibroma

Objectives

To evaluate the feasibility of radiofrequency surgical instrumentation for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and to test the hypothesis that endoscopic radiofrequency ablation–assisted (RFA) resection will have superior intraoperative and/or postoperative outcomes as compared with traditional endoscopic (TE) resection techniques.

Study Design

Case series with chart review.

Setting

Two tertiary care pediatric hospitals.

Subjects and Methods

Twenty-nine pediatric patients who underwent endoscopic transnasal resection of JNA from January 2000 to December 2014.

Results

Twenty-nine patients underwent RFA (n = 13) or TE (n = 16) JNA resection over the 15-year study period. Mean patient age was not statistically different between the 2 groups ( P = .41); neither was their University of Pittsburgh Medical Center classification stage ( P = .79). All patients underwent preoperative embolization. Mean operative times were not statistically different ( P = .29). Mean intraoperative blood loss and the need for a transfusion were also not statistically different ( P = .27 and .47, respectively). Length of hospital stay was not statistically different ( P = .46). Recurrence rates did not differ between groups ( P = .99) over a mean follow-up period of 2.3 years.

Conclusion

There were no significant differences between RFA and TE resection in intraoperative or postoperative outcome parameters.

The Endovascular Treatment of Epistaxis

Epistaxis or nosebleed is relatively common in the general population. Depending on the location of the bleeding in the nasal cavity, epistaxis can be divided in two types: anterior or posterior type. The anterior type is far more frequent, often self-limiting and, if needed, is relatively easy treatable. Posterior type epistaxis is rare and more likely to require medical attention. The cornerstone of the conservative therapy of posterior epistaxis is nasal packing. Only in patients with persistent or recurrent epistaxis, endovascular intervention or surgery is indicated. Both treatment options have a similar success and complication rate, but endovascular treatment, if feasible, has several advantages above surgical treatment. The choice of procedure should be made on a patient-to-patient basis, taking several parameters into account. In this pictorial essay we present an overview of the relevant radiological anatomy and a review of various causes of epistaxis, with the emphasis on the endovascular treatment.

Bilateral, independent juvenile nasopharyngeal angiofibroma: case report

Background:

Juvenile nasopharyngeal angiofibroma is a benign, vascular tumour that primarily occurs in adolescent males. Despite its benign nature, aggressive growth patterns can cause potential life-threatening complications. Juvenile nasopharyngeal angiofibroma is normally unilateral, originating from the sphenopalatine artery, but bilateral symptoms can occur if a large tumour extends to the contralateral side of the nasopharynx. This paper presents the first reported case of true bilateral extensive juvenile nasopharyngeal angiofibroma involving clinically challenging pre-surgical planning and surgical strategy.

Case report:

A 21-year-old male presented with increasing bilateral nasal obstruction and discharge. Examination revealed tumours bilaterally and imaging demonstrated non-contiguous tumours. Pre-operative angiography showed strictly ipsilateral vascular supplies requiring bilateral embolisation. Radical removal performed as one-step, computer-assisted functional endoscopic sinus surgery was performed. The follow-up period was uncomplicated.

Conclusion:

This case illustrates the importance of suspecting bilateral juvenile nasopharyngeal angiofibroma in patients presenting with bilateral symptoms. Our management, including successful pre-operative planning, enabled one-step total removal of both tumours and rapid patient recovery.

Combined percutaneous and transarterial devascularisation of juvenile nasopharyngeal angiofibroma with protection of internal carotid artery: A modification of the technique

Juvenile nasal angiofibroma (JNA) is a hypervascularised, benign, but locally aggressive tumour that grows in the posterior, upper part of the nasal cavity and invades surrounding anatomical structures. The treatment of choice is surgical removal, but complete resection of the tumour can be hampered because of profuse perioperative bleeding. Preoperative embolisation of the tumour has been proposed as an effective method for prevention of perioperative bleeding, thereby shortening of the time of the operation. In this report of five cases, we describe successful preoperative devascularisation of the tumour by applying a modified method of direct intratumoural injection of the liquid embolic agent Onyx combined with protection of the internal carotid artery. The control of bleeding during the embolisation and occlusion of the maxillary or sphenopalatine artery was achieved by using a bi-luminal balloon catheter. Such use of the dual-lumen catheter in treatment of JNA has not been reported so far in the medical literature.

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.