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Endoscopic, endoscopic-assisted and open approaches in the treatment of juvenile angiofibroma: what has been new in the past decade (and 1586 cases)? Eur Arch Otorhinolaryngol 2023; 280:2081-2089. [PMID: 36683103 DOI: 10.1007/s00405-023-07824-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/14/2022] [Indexed: 01/24/2023]
Abstract
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.
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Behera G, Gupta V, Mishra UP, Tandon A. Extra Nasopharyngeal Angiofibroma Arising From Oropharynx: A Clinical Report. Indian J Otolaryngol Head Neck Surg 2022; 74:4646-4648. [PMID: 36742930 PMCID: PMC9895626 DOI: 10.1007/s12070-021-02956-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023] Open
Abstract
Angiofibroma arising from sites other than nasopharynx is rare and termed as Extra nasopharyngeal angiofibroma (ENA). ENAs commonly arise from nasal septum, maxillary sinus, and inferior turbinate. But angiofibroma arising from oropharynx have not been frequently reported. We present here a case of middle-aged male who presented with a large pedunculated oropharyngeal mass attached to palatopharyngeal fold. Endoscopic radiofrequency assisted transoral excision of mass was done. Histopathological features were consistent with angiofibroma arising from oropharynx. Patient recovered well with no evidence of recurrence till 18 months of follow up. In this report, we have tried to emphasize the diagnostic workup for oropharyngeal mass. This report also provides an insight into the clinical and pathological behavior of extra nasopharyngeal angiofibroma.
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Affiliation(s)
- Ganakalyan Behera
- Department of Otorhinolaryngology-Head and Neck Surgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh 462020 India
| | - Vikas Gupta
- Department of Otorhinolaryngology-Head and Neck Surgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh 462020 India
| | - Utkal Priyadarshi Mishra
- Department of Otorhinolaryngology-Head and Neck Surgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh 462020 India
| | - Ashwani Tandon
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh 462020 India
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Manogaran RS, Mathialagan A, Singh V, Mishra P, Jain R, Keshri A. Role of Transarterial Angiography with Embolization in Deciding Surgical Approach to Juvenile Nasopharyngeal Angiofibroma: A Step-Ladder Approach. J Neurol Surg B Skull Base 2021; 82:547-555. [PMID: 34513561 DOI: 10.1055/s-0040-1715594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 06/21/2020] [Indexed: 10/23/2022] Open
Abstract
Objective This study was aimed to understand the usefulness of transarterial angiography and embolization in management of juvenile nasopharyngeal angiofibroma (JNA) and to apply the information obtained to stage the disease, select appropriate surgical approach, predict intraoperative bleeding, and prognosticate the disease. Study Design This study represents a retrospective review of the patients of JNA with major focus on transarterial angiography and embolization findings and its clinical and surgical implications. Setting The study conducted at a tertiary-care super-specialty referral center. Participants Forty-two patients who had undergone transarterial angiography and embolization followed by surgery over the period of 5 years from July 2015 till February 2019 were participated in this study. Main Outcome Measures Tumor vascular pattern based on transarterial angiography, staging of the disease based on extent and vascular supply, surgical approach selected, and prognosticating the disease were determined from this study. Conclusion Transarterial angiography with embolization becomes a prudent preoperative investigation for management of JNA. It provides a complete three-dimensional map of the tumor with stage-specific vascular pattern, reduces vascularity of the tumor, and predicts the sites from where bleeding can occur intra operatively. Thus, it helps in choosing the appropriate surgical approach aiding in complete tumor removal with minimal bleeding.
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Affiliation(s)
- Ravi S Manogaran
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arulalan Mathialagan
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vivek Singh
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhaker Mishra
- Department of Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajat Jain
- Division of Neuro-otology, Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Keshri
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Adham M, Hajarani K, Rachmadi L, Suroyo I. Bilateral juvenile nasopharyngeal angiofibroma: A rare case report. ACTA OTO-LARYNGOLOGICA CASE REPORTS 2021. [DOI: 10.1080/23772484.2021.1914060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Marlinda Adham
- Oncology Division, Department of Otorhinolaryngology Head and Neck Surgery, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Kartika Hajarani
- Department of Otorhinolaryngology Head and Neck surgery, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Lisnawati Rachmadi
- Pathology Anatomy Department, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Indrati Suroyo
- Faculty of Medicine, Radiology Department, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
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Kairo AK, Kumar R, Sharma SC. Can palatovaginal canal be the site of origin of juvenile nasopharyngeal angiofibroma? Med Hypotheses 2020; 144:110300. [PMID: 33254490 DOI: 10.1016/j.mehy.2020.110300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/13/2020] [Accepted: 09/19/2020] [Indexed: 11/19/2022]
Abstract
Juvenile nasopharyngeal angiofibroma (JNA) is the most common benign tumor of the nasopharynx. For reasons unknown, this tumor is found almost always in male population. However, site of origin of JNA is still an enigma. Previously, JNA was considered to arise from the superior aspect of sphenopalatine foramen. Over last decade, the vidian canal was considered to be the more specific and likely site of origin. However, based on our observations, we believe this hypothesis to be anomalous as it does not explain major blood supply, pattern of skull base erosion in early stage of tumor and newer studies on electron microscopic and immunopathological findings. To explain these anomalies, we hypothesize the site of origin to be palato-vaginal canal.
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Affiliation(s)
- A K Kairo
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - R Kumar
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - S C Sharma
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
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Schreiber A, Ravanelli M, Ferrari M, Mattavelli D, Rampinelli V, Bolzoni Villaret A, Bertazzoni G, Tomasoni M, Gualtieri T, Zorza I, Farina D, Maroldi R, Nicolai P. Early Postoperative Magnetic Resonance in the Diagnosis of Persistent Juvenile Angiofibroma. Laryngoscope 2020; 131:E2436-E2441. [PMID: 33245803 DOI: 10.1002/lary.29293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/30/2020] [Accepted: 11/17/2020] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Alberto Schreiber
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.,Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Bolzoni Villaret
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giacomo Bertazzoni
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Cremona, Cremona, Italy
| | - Michele Tomasoni
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Tommaso Gualtieri
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Ivan Zorza
- Unit of Radiology, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Davide Farina
- Unit of Radiology, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, ASST Spedali Civili Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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9
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Recurrence Rate after Endoscopic vs. Open Approaches for Juvenile Nasopharyngeal Angiofibroma: A Meta-analysis. J Neurol Surg B Skull Base 2018; 80:577-585. [PMID: 31750043 DOI: 10.1055/s-0038-1676562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022] Open
Abstract
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.
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Schreiber A, Bertazzoni G, Ferrari M, Ravanelli M, Rampinelli V, Mattavelli D, El‐Naggar A, Nicolai P. Management of persistent juvenile angiofibroma after endoscopic resection: Analysis of a single institution series of 74 patients. Head Neck 2018; 41:1297-1303. [DOI: 10.1002/hed.25555] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/12/2018] [Accepted: 11/09/2018] [Indexed: 01/21/2023] Open
Affiliation(s)
- Alberto Schreiber
- Unit of Otorhinolaryngology – Head and Neck SurgeryUniversity of Brescia Brescia Italy
| | - Giacomo Bertazzoni
- Unit of Otorhinolaryngology – Head and Neck SurgeryUniversity of Brescia Brescia Italy
| | - Marco Ferrari
- Unit of Otorhinolaryngology – Head and Neck SurgeryUniversity of Brescia Brescia Italy
| | | | - Vittorio Rampinelli
- Unit of Otorhinolaryngology – Head and Neck SurgeryUniversity of Brescia Brescia Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology – Head and Neck SurgeryUniversity of Brescia Brescia Italy
| | - Ahmed El‐Naggar
- Unit of Otorhinolaryngology – Head and Neck SurgeryUniversity of Brescia Brescia Italy
- Unit of OtorhinolaryngologyTanta University Tanta Egypt
| | - Piero Nicolai
- Unit of Otorhinolaryngology – Head and Neck SurgeryUniversity of Brescia Brescia Italy
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Juvenile nasopharyngeal angiofibroma: a single centre's 11-year experience. The Journal of Laryngology & Otology 2018; 132:978-983. [DOI: 10.1017/s0022215118001779] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveThis study aimed to present the clinical features and surgical outcomes of juvenile nasopharyngeal angiofibroma patients who were surgically treated.MethodsThe medical records of 48 male patients histologically confirmed as having juvenile nasopharyngeal angiofibroma, who underwent transnasal endoscopic surgery between 2005 and 2016, were retrospectively reviewed.ResultsThe overall recurrence rate was 20.8 per cent; however, the recurrence rate differed significantly between patients diagnosed aged less than 14 years (34.7 per cent) and more than 14 years (8 per cent) (p < 0.05). Advanced-stage tumours (Radkowski stage of IIC or more, and Önerci stage of III or more) were more aggressive than earlier stage tumours (p < 0.05 and p < 0.01, respectively). Pre-operative embolisation significantly prolonged mean hospitalisation duration, but had no effect on intra-operative blood loss in patients with advanced-stage tumours (p < 0.001 and p = 0.09, respectively).ConclusionThe findings show that transnasal endoscopic surgery could be considered the treatment of choice for juvenile nasopharyngeal angiofibroma. Patients diagnosed when aged less than 14 years and those with advanced-stage tumours are at risk of recurrence, and should be monitored with extreme care.
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Mattavelli D, Rampinelli V, Ferrari M, Schreiber A, Guarneri B, Nicolai P. Long-term neurological morbidity following endoscopic transnasal resection of juvenile angiofibroma. Laryngoscope 2018; 129:2184-2188. [PMID: 30315581 DOI: 10.1002/lary.27466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2018] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Bruno Guarneri
- Unit of Electrophysiology, University of Brescia, Brescia, Italy
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Rupa V, Mani SE, Backianathan S, Rajshekhar V. Management and Outcome in Patients with Advanced Juvenile Nasopharyngeal Angiofibroma. J Neurol Surg B Skull Base 2018; 79:353-360. [PMID: 30009116 PMCID: PMC6043168 DOI: 10.1055/s-0037-1608658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/30/2017] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Vedantam Rupa
- Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India
| | | | | | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
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Cumulative sum analysis of the learning curve for endoscopic resection of juvenile nasopharyngeal angiofibroma. Surg Endosc 2018; 32:3181-3191. [PMID: 29368283 DOI: 10.1007/s00464-018-6035-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND To determine the learning curve with cumulative sum analysis for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and investigate whether the surgeon's expertise is a risk factor for recurrence. MATERIALS AND METHODS We reviewed the medical records of patients with JNA who underwent endoscopic or endoscopic-assisted surgery between 2006 and 2015. We used cumulative sum (Cusum) analysis to plot the learning curve for operation time versus chronological sequence, and verified the Cusum curve by risk-adjusted Cusum (RA-Cusum) analysis. We identified three phases of expertise. The recurrence rate was analyzed using the Kaplan-Meier method and log-rank tests. A multivariable Cox regression analysis was performed to identify the independent risk factors for recurrence. RESULTS We included 154 JNA patients with a median age of 16 years. The surgeon overcame the learning curve after case 80 with increasing surgical efficiency and competence. The learning curve plotted by Cusum analysis divided the cases into three phases: phase 1, accumulation of initial experience (cases 1-41); phase 2, further accumulation of experience (cases 42-117); and phase 3, mastering the procedure (cases 118-154). Pearson's χ2 tests showed that tumor stage (P = 0.021), blood loss (P = 0.001), operation time (P < 0.001), and phase (P < 0.001) were associated with recurrence. The log-rank test showed that time to recurrence was significantly shorter in phase 1 than in phases 2 and 3. Blood loss and phase were independently prognostic factors for time to recurrence, with P values of 0.023 and 0.009, respectively. The RA-Cusum analysis identified two inflection points of the curve at case 44 and 83, and verified the results of Cusum analysis. CONCLUSION Surgical experience and competence with endoscopic resection affect the recurrence rate in JNA patients. LEVEL OF EVIDENCE 4.
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Safadi A, Schreiber A, Fliss DM, Nicolai P. Juvenile Angiofibroma: Current Management Strategies. J Neurol Surg B Skull Base 2018; 79:21-30. [PMID: 29404237 DOI: 10.1055/s-0037-1615810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Juvenile angiofibroma (JA) is a benign, highly vascular tumor which is diagnosed on the basis of clinical and imaging features. It has a characteristic pattern of spread commonly involving the pterygopalatine fossa and pterygoid base. The mainstay of treatment is surgery, while radiotherapy is rarely used for the treatment of recurrent lesion. Endoscopic endonasal surgery is currently the treatment of choice for small to intermediate size JAs, and is feasible even for advanced lesions; however, this should only be practiced in well-experienced centers.
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Affiliation(s)
- Ahmad Safadi
- Department of Otorhinolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alberto Schreiber
- Department of Otorhinolaryngology - Head and Neck Surgery, Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Dan M Fliss
- Department of Otorhinolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Piero Nicolai
- Department of Otorhinolaryngology - Head and Neck Surgery, Spedali Civili of Brescia, University of Brescia, Brescia, Italy
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16
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Grachev NS, Vorozhtsov IN. [The transperygoid approach to the removal of a recurrent juvenile angiofibroma at the base of the skull without preoperative embolization]. Vestn Otorinolaringol 2017. [PMID: 28631685 DOI: 10.17116/otorino201782362-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors report a clinical case of successful elimination of a recurrent juvenile angiofibroma at the base of the skull (JAFBS) with the application of the optical navigation system and a cold plasma scalpel in the absence of preoperative embolization. It has been demonstrated using the proposed transperygoid approach to the extirpation of the tumour that a recurrent juvenile angiofibroma at the base of the skull can be efficiently removed by means of a modern minimally invasive and at the same time radical surgical method.
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Affiliation(s)
- N S Grachev
- Dmitry Rogahev National Research and Practical Centre for Pediatric Hematology, Oncology and Immunology, Moscow, Russia, 117997
| | - I N Vorozhtsov
- Dmitry Rogahev National Research and Practical Centre for Pediatric Hematology, Oncology and Immunology, Moscow, Russia, 117997
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17
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López F, Triantafyllou A, Snyderman CH, Hunt JL, Suárez C, Lund VJ, Strojan P, Saba NF, Nixon IJ, Devaney KO, Alobid I, Bernal-Sprekelsen M, Hanna EY, Rinaldo A, Ferlito A. Nasal juvenile angiofibroma: Current perspectives with emphasis on management. Head Neck 2017; 39:1033-1045. [PMID: 28199045 DOI: 10.1002/hed.24696] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/03/2016] [Accepted: 12/06/2016] [Indexed: 12/12/2022] Open
Abstract
Juvenile angiofibroma is an uncommon, benign, locally aggressive vascular tumor. It is found almost exclusively in young men. Common presenting symptoms include nasal obstruction and epistaxis. More advanced tumors may present with facial swelling and visual or neurological disturbances. The evaluation of patients with juvenile angiofibroma relies on diagnostic imaging. Preoperative biopsy is not recommended. The mainstay of treatment is resection combined with preoperative embolization. Endoscopic surgery is the approach of choice in early stages, whereas, in advanced stages, open or endoscopic approaches are feasible in expert hands. Postoperative radiotherapy (RT) or stereotactic radiosurgery seem valuable in long-term control of juvenile angiofibroma, particularly those that extend to anatomically critical areas unsuitable for complete resection. Chemotherapy and hormone therapy are ineffective. The purpose of the present review was to update current aspects of knowledge related to this rare and challenging disease. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1033-1045, 2017.
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Affiliation(s)
- Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Universidad de Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias and CIBERONC, Spain
| | - Asterios Triantafyllou
- Pathology Department, Liverpool Clinical Laboratories, Liverpool, UK.,School of Dentistry, University of Liverpool, Liverpool, UK
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer L Hunt
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Carlos Suárez
- Universidad de Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias and CIBERONC, Spain
| | - Valerie J Lund
- Professorial Unit, Ear Institute, University College London, London, UK
| | - Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, The Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Iain J Nixon
- Departments of Surgery and Otolaryngology, Head and Neck Surgery, Edinburgh University, Edinburgh, UK
| | | | - Isam Alobid
- Department of Otolaryngology, Hospital Clinic, University of Barcelona Medical School, Barcelona, Spain
| | - Manuel Bernal-Sprekelsen
- Department of Otolaryngology, Hospital Clinic, University of Barcelona Medical School, Barcelona, Spain
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group
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18
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Efficacy of Preoperative Transcatheter Arterial Embolization for Nasopharyngeal Angiofibroma: A Comparative Study. Cardiovasc Intervent Radiol 2017; 40:836-844. [DOI: 10.1007/s00270-017-1587-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
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19
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Benign Primary Neoplasms. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0138-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Janakiram TN, Sharma SB, Panicker VB. Endoscopic Excision of Non-embolized Juvenile Nasopharyngeal Angiofibroma: Our Technique. Indian J Otolaryngol Head Neck Surg 2016; 68:263-9. [PMID: 27508124 DOI: 10.1007/s12070-016-1013-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/05/2016] [Indexed: 11/25/2022] Open
Abstract
To approach Juvenile nasopharyngeal angiofibroma extending to the sphenoid sinus, pterygoid wedge and minimal involvement of the pterygopalatine fossa (Radkowski Stage 2 A) with an endoscopic technique without embolization with no recurrence and minimal morbidity and mortality. This is a retrospective, descriptive study based on the medical records of 15 patients with histologically confirmed JNA who underwent endoscopic binostril four handed endoscopic excision in our centre without embolisation between 2010 and 2015. All 15 patients were young males with a mean age of 14.13 years who underwent endoscopic excision of JNA without embolisation. Nasal obstruction (100 %) and epistaxis (100 %) were the most common symptoms. Average surgery length was 1 h 41 min. Mean blood loss was 67.2 ml and none of patients required blood transfusion. All patients had crusting and septal defect postoperatively, only 3 (20 %) had synechiae. Mean hospitalization time was 3.66 days. 2 (13.33 %) of our patients had a residual tumor and one (6.66 %) had a relapse in pterygoid wedge. There were no cases of death or significant morbidity. The follow up period was 1 year. Endoscopic endo nasal bi nostril four handed technique can achieve complete resection without embolization in case of small to medium sized JNA s in the hands of an experienced surgeon with minimal blood loss, low rates of recurrence and morbidity.
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Hardillo JAU, Vander Velden LA, Knegt PP. Denker Operation is an Effective Surgical Approach in Managing Juvenile Nasopharyngeal Angiofibroma. Ann Otol Rhinol Laryngol 2016; 113:946-50. [PMID: 15633895 DOI: 10.1177/000348940411301202] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article presents our experience with the various surgical approaches for angiofibroma and establishes the Denker procedure as an effective approach for removal of the tumor. The medical records of 29 patients treated between the years 1981 and 2001 were examined. The clinical extent of the tumor, the surgical approach, complications, and recurrences were evaluated. The surgical approaches used before 1992 consisted of the transnasal, transpalatal, and combined transnasal-transpalatal ones. Although no major recurrence or major morbidity was observed, late complications occurred, such as persistent palatal fistula in 3 patients who underwent operation via a transpalatal approach, and an unsightly scar with lacrimal duct stenosis in 2 patients who underwent operation via a combined transnasal-transpalatal approach. From 1992 onward, the above-mentioned surgical approaches were replaced with the Denker and midfacial degloving techniques, which proved to be just as effective in removing the tumor and did not produce late complications. According to our experience, the Denker approach is effective for angiofibromas confined to the nasal cavity and nasopharynx with small extensions in the infratemporal fossa. On the other hand, large tumor extension in the infratemporal fossa can be effectively approached in combination with a midfacial degloving technique.
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Affiliation(s)
- Jose Angelito U Hardillo
- Department of Otorhinolaryngology--Head and Neck Surgery, Erasmus Medical Center--University Medical Center Rotterdam, Rotterdam, the Netherlands
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22
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In defence of transpalatal, transpalatal-circumaxillary (transpterygopalatine) and transpalatal-circumaxillary-sublabial approaches to lateral extensions of juvenile nasopharyngeal angiofibroma. The Journal of Laryngology & Otology 2016; 130:462-73. [DOI: 10.1017/s0022215116000773] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Juvenile nasopharyngeal angiofibroma often presents with lateral extensions. In countries with limited resources, selection of a cost-effective and least morbid surgical approach for complete excision is challenging.Methods:Sixty-three patients with juvenile nasopharyngeal angiofibroma, with lateral extensions, underwent transpalatal, transpalatal-circumaxillary (transpterygopalatine) or transpalatal-circumaxillary-sublabial approaches for resection. Clinico-radiological characteristics, tumour volume and intra-operative bleeding were recorded.Results:The transpalatal approach was suitable for extensions involving medial part of pterygopalatine fossa; transpalatal-circumaxillary for extensions involving complete pterygopalatine fossa, with or without partial infratemporal fossa; and transpalatal-circumaxillary-sublabial for extensions involving complete infratemporal fossa, even cheek or temporal fossa up to zygomatic arch. Haemorrhage was greatest with the transpalatal-circumaxillary-sublabial approach, followed by transpalatal approach and transpalatal-circumaxillary approach (1212, 950 and 777 ml respectively). Tumour size (volume) was greatest with the transpalatal-circumaxillary approach, followed by transpalatal-circumaxillary-sublabial approach and transpalatal approach (40, 34 and 29 mm3). There was recurrence in three cases and residual disease in two cases. Long-term morbidity included small palatal perforation (n = 1), trismus (n = 1) and atrophic rhinitis (n = 2).Conclusion:These modified techniques, performed with endoscopic assistance under hypotensive anaesthesia, without embolisation, offer a superior option over other open procedures with regard to morbidity and recurrences.
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23
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Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
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Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
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25
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Thakar A, Hota A, Bhalla AS, Gupta SD, Sarkar C, Kumar R. Overt and occult vidian canal involvement in juvenile angiofibroma and its possible impact on recurrence. Head Neck 2015; 38 Suppl 1:E421-5. [DOI: 10.1002/hed.24012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 11/24/2014] [Accepted: 01/06/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- Alok Thakar
- Department of Otolaryngology and Head and Neck Surgery; All India Institute of Medical Sciences; New Delhi
| | - Ashutosh Hota
- Department of Otolaryngology and Head and Neck Surgery; All India Institute of Medical Sciences; New Delhi
| | - Ashu Seth Bhalla
- Department of Radiodiagnosis; All India Institute of Medical Sciences; New Delhi
| | | | - Chitra Sarkar
- Department of Pathology; All India Institute of Medical Sciences; New Delhi
| | - Rakesh Kumar
- Department of Otolaryngology and Head and Neck Surgery; All India Institute of Medical Sciences; New Delhi
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26
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Naraghi M, Saberi H, Mirmohseni AS, Nikdad MS, Afarideh M. Management of advanced intracranial intradural juvenile nasopharyngeal angiofibroma: combined single-stage rhinosurgical and neurosurgical approach. Int Forum Allergy Rhinol 2015; 5:650-8. [PMID: 25778926 DOI: 10.1002/alr.21507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/12/2015] [Accepted: 01/20/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although intracranial extension of juvenile nasopharyngeal angiofibroma (JNA) occurs commonly, intradural penetration is extremely rare. Management of such tumors is a challenging issue in skull-base surgery, necessitating their removal via combined approaches. In this work, we share our experience in management of extensive intradural JNA. METHODS In a university hospital-based setting of 2 tertiary care academic centers, retrospective chart of 6 male patients (5 between 15 and 19 years old) was reviewed. Patients presented chiefly with nasal obstruction, epistaxis, and proptosis. One of them was an aggressive recurrent tumor in a 32-year-old patient. All cases underwent combined transnasal, transmaxillary, and craniotomy approaches assisted by the use of image-guided endoscopic surgery, with craniotomy preceding the rhinosurgical approach in 3 cases. RESULTS Adding a transcranial approach to the transnasal and transmaxillary endoscopic approaches provided 2-sided exposure and appreciated access to the huge intradural JNAs. One postoperative cerebrospinal fluid leak and 1 postoperative recurrence at the site of infratemporal fossa were treated successfully. Otherwise, the course was uneventful in the remaining cases. CONCLUSION Management of intracranial intradural JNA requires a multidisciplinary approach of combined open and endoscopic-assisted rhinosurgery and neurosurgery, because of greater risk for complications during the dissection. Carotid rupture and brain damage remain 2 catastrophic complications that should always be kept in mind. A combined rhinosurgical and neurosurgical approach also has the advantage of very modest cosmetic complications.
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Affiliation(s)
- Mohsen Naraghi
- Department of Otorhinolaryngology-Head and Neck Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Otolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Rhinology Research Society, Tehran, Iran
| | - Hooshang Saberi
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Sadat Mirmohseni
- Otolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Rhinology Research Society, Tehran, Iran
| | - Mohammad Sadegh Nikdad
- Otolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Rhinology Research Society, Tehran, Iran
| | - Mohsen Afarideh
- Otolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Rhinology Research Society, Tehran, Iran
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Sun X, Guo L, Wang H, Yu H, Wang J, Meng X, Liu Z, Liu J, Hu L, Li H, Wang D. The presence of tumor-infiltrating IL-17-producing cells in juvenile nasopharyngeal angiofibroma tumor microenvironment is a poor prognostic factor. Am J Otolaryngol 2014; 35:582-8. [PMID: 25014998 DOI: 10.1016/j.amjoto.2014.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 05/26/2014] [Accepted: 06/02/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor histologically, it demonstrates aggressive propensity of locally destructive growth causing bone erosion. The patients with JNA remain high recurrence rate after surgical excision. Th17 cells secrete the proinflammatory cytokine interleukin-17 (IL-17), and play an important role in carcinogenesis and tumor progression. So far, no studies have focused on the significance of IL-17-producing cells in the JNA tumor microenvironment. The current study was designed to investigate the localization and level of tumor-infiltrating IL-17-producing cells in JNA microenvironment. The presence and number of IL-17-producing cells were further analyzed for a possible association with clinicopathological features and disease outcome. MATERIALS AND METHODS Immunohistochemistry was used to analyze the expression of IL-17 in a tissue microarray from 70 patients with JNA and 10 control subjects. Correlations between the levels of IL-17 expression and clinicopathologic variables, as well as tumor recurrence, were assessed. RESULTS In vessels, the IL-17-producing cells were identified in pericytes and irregular smooth muscle cells, but the matured vascular endothelial cells showed no IL-17 reactivity. The expression of IL-17 in stromal cells was concentrated in the less differentiated and plump cells that contained a central hypochromatic nucleus and single small nucleolus. Chi-square test showed that tumor stage (p=0.09), operation history (p=0.828), operation approach (p=0.159), and volume of intraoperative hemorrhage (p=0.352) were not associated with the expression of IL-17 in JNA patients. However, intratumoral IL-17-producing cells were negatively associated with patient's age (p=0.004). Furthermore, we found that patients with extensive infiltration of IL-17-producing cells had significantly higher recurrence rates than those with less infiltration of IL-17-producing cells (p=0.028). Log rank analysis showed that JNA patients with high levels of IL-17 had significantly shorter disease free survival (DFS) than those with low levels of IL-17 (p=0.004). Univariate Cox regression analysis suggested that IL-17 and patient's age were significantly associated with DFS. Multivariate analysis indicated that high infiltration with IL-17-producing cells was associated with poor DFS. Of all clinicopathological features, IL-17 level was an independent factor predicting the patient's prognosis. CONCLUSION In JNA patients, a high level of IL-17-producing cells was negatively associated with patient's age. Patients with extensive infiltration of IL-17-producing cells had significantly higher tumor recurrence rates. High infiltration of IL-17-producing cells in JNA microenvironment is an independent poor prognostic factor for shorter disease-free survival. Future studies further focusing on the role of IL-17 may provide more promising therapeutic methods for extensive JNA tumors.
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Sun X, Guo L, Wang J, Wang H, Liu Z, Liu J, Yu H, Hu L, Li H, Wang D. Prognostic value of matrix metalloproteinase 9 expression in patients with juvenile nasopharyngeal angiofibroma: tissue microarray analysis. Int J Pediatr Otorhinolaryngol 2014; 78:1232-8. [PMID: 24969348 DOI: 10.1016/j.ijporl.2014.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 03/30/2014] [Accepted: 04/01/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Although JNA is a benign neoplasm histopathologically, it has a propensity for locally destructive growth and remains a higher postoperative recurrence rate. The aim of this study was to analyze the expression and localization of MMP-9 in JNA using tissue microarray to elucidate its correlation with clinicopathological features and recurrence. MATERIALS AND METHODS The expression of MMP-9 was assessed by immunohistochemistry in a tissue microarray from 70 patients with JNA and 10 control subjects. Correlation between the levels of MMP-9 expression and clinicopathologic variables, as well as tumor recurrence, were analyzed. RESULTS MMP-9 was detected in perivascular and extravascular less differentiated cells and stromal cells of patients with JNA but not in the matured vascular endothelial cells of these patients. The presence of MMP-9 expression in JNA was correlated with patient's age (p=0.001). Spearman correlation analysis suggested that high expression of MMP-9 in JNA had negative correlation with patient's age (r=-0.412, p<0.001). The recurrence rate in JNA patients with high MMP-9 expression was significantly higher than those with low MMP-9 expression (p=0.002). In multivariate and ROC curve analysis, MMP-9 was a good prognostic factor for tumor recurrence of JNA. CONCLUSION Higher MMP-9 expression is a poor prognostic factor for patients with JNA who have been surgically treated.
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Affiliation(s)
- Xicai Sun
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Limin Guo
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jingjing Wang
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhuofu Liu
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Juan Liu
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huapeng Yu
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Li Hu
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Han Li
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Dehui Wang
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
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Szymańska A, Szymański M, Czekajska-Chehab E, Szczerbo-Trojanowska M. Invasive growth patterns of juvenile nasopharyngeal angiofibroma: radiological imaging and clinical implications. Acta Radiol 2014; 55:725-31. [PMID: 24132768 DOI: 10.1177/0284185113506189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Juvenile nasopharyngeal angiofibroma is a benign lesion with locally aggressive nature. Knowledge of its typical growth patterns is crucial for precise preoperative staging and adequate preoperative patient counseling. This pictorial essay focuses on characteristic radiological features and paths of invasive growth of this rare tumor. Also, the impact of accurate preoperative evaluation of tumor extensions on surgical planning and results of treatment are discussed.
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Affiliation(s)
- Anna Szymańska
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
| | - Marcin Szymański
- Department of Otolaryngology, Medical University of Lublin, Poland, Lublin
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Szymańska A, Szymański M, Czekajska-Chehab E, Szczerbo-Trojanowska M. Two types of lateral extension in juvenile nasopharyngeal angiofibroma: diagnostic and therapeutic management. Eur Arch Otorhinolaryngol 2014; 272:159-66. [PMID: 24599598 PMCID: PMC4282713 DOI: 10.1007/s00405-014-2965-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 02/18/2014] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Anna Szymańska
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Jaczewskiego 8, 20-954, Lublin, Poland,
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Ballah D, Rabinowitz D, Vossough A, Rickert S, Dunham B, Kazahaya K, Cahill A. Preoperative angiography and external carotid artery embolization of juvenile nasopharyngeal angiofibromas in a tertiary referral paediatric centre. Clin Radiol 2013; 68:1097-106. [DOI: 10.1016/j.crad.2013.05.092] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 04/09/2013] [Accepted: 05/22/2013] [Indexed: 11/29/2022]
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Iovanescu G, Ruja S, Cotulbea S. Juvenile nasopharyngeal angiofibroma: Timisoara ENT Department's experience. Int J Pediatr Otorhinolaryngol 2013; 77:1186-9. [PMID: 23732022 DOI: 10.1016/j.ijporl.2013.04.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 04/24/2013] [Accepted: 04/27/2013] [Indexed: 11/20/2022]
Abstract
UNLABELLED Juvenile nasopharyngeal angiofibroma is a histologically benign, but very aggressive and destructive tumor found exclusively in young males. The management of juvenile nasopharyngeal angiofibroma has changed in recent years, but it still continues to be a challenge for the multidisciplinary head and neck surgical team. OBJECTIVE The purpose of this study was to review a series of 30 patients describing the treatment approach used and studying the outcome of juvenile nasopharyngeal angiofibroma in the ENT Department Timisoara, Romania for a period of 30 years. METHODS The patients were diagnosed and treated during the years 1981-2011. All patients were male. Tumors were classified using Radkowski's staging system. Computed tomography and magnetic resonance imaging allowed for accurate diagnosis and staging of the tumors. Biopsies were not performed. Surgery represented the gold standard for treatment of juvenine nasopharyngeal angiofibroma. All patients had the tumor removed by an external approach, endoscopic surgical approach not being employed in this series of patients. RESULTS All patients were treated surgically. Surgical techniques performed were: Denker-Rouge technique in 13 cases (43.33%), paralateronasal technique in 7 cases (23.33%), retropalatine technique in 5 cases (16.66%) and transpalatine technique in 5 cases (16.66%). No preoperative tumor embolization was performed. The recurrence rate was 16.66%. The follow-up period ranged from 1 year to 12 years. CONCLUSIONS Management of juvenile nasopharyngeal angiofibroma remains a surgical challenge. Clinical evaluation and surgical experience are very important in selecting the proper approach. A multidisciplinary team, with an experienced surgeon and good collaboration with the anesthesiologist are needed for successful surgical treatment.
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Affiliation(s)
- Gheorghe Iovanescu
- Department of Otolaryngology, Victor Babes University of Medicine and Pharmacy Timisoara, Romania.
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Succo G, Gisolo M, Crosetti E, Bergui M, Danesi G. Spontaneous ICA rupture: a severe late complication after giant nasopharyngeal angiofibroma resection. Int J Pediatr Otorhinolaryngol 2013; 77:581-4. [PMID: 23312351 DOI: 10.1016/j.ijporl.2012.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 12/16/2012] [Accepted: 12/18/2012] [Indexed: 11/15/2022]
Abstract
Juvenile nasopharyngeal angiofibroma (JNA) is a benign vascular tumor occurring in young males. Surgery for giant JNA is a complex procedure, with a high risk of major complications. We report a rare case of massive epistaxis in a 15-year-old boy resulting from spontaneous rupture of the intracavernous tract of the internal carotid artery 20 days after resection of a giant JNA by midface degloving. The event was managed by an emergency arteriography with coils selectively deployed to occlude the vessel and to stop hemorrhage. This treatment has been shown to be effective in producing immediate hemostasis and stable long-term occlusion.
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Affiliation(s)
- G Succo
- ENT Department, S Luigi Gonzaga Hospital, University of Turin, Turin, Italy
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Boghani Z, Husain Q, Kanumuri VV, Khan MN, Sangvhi S, Liu JK, Eloy JA. Juvenile nasopharyngeal angiofibroma: A Systematic Review and Comparison of Endoscopic, Endoscopic-Assisted, and Open Resection in 1047 Cases. Laryngoscope 2013; 123:859-69. [DOI: 10.1002/lary.23843] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 09/12/2012] [Accepted: 10/03/2012] [Indexed: 11/07/2022]
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Wang JJ, Sun XC, Hu L, Liu ZF, Yu HP, Li H, Wang SY, Wang DH. Endoglin (CD105) expression on microvessel endothelial cells in juvenile nasopharyngeal angiofibroma: tissue microarray analysis and association with prognostic significance. Head Neck 2013; 35:1719-25. [PMID: 23471755 DOI: 10.1002/hed.23210] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2012] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The purpose of this study was to examine endoglin (CD105) expression on microvessel endothelial cells (ECs) in juvenile nasopharyngeal angiofibroma (JNA) and its relationship with recurrence. METHODS Immunohistochemistry was performed to detect CD105 expression in a tissue microarray from 70 patients with JNA. Correlation between CD105 expression on microvessel ECs and clinicopathological features, as well as tumor recurrence, were analyzed. RESULTS Immunohistochemistry revealed CD105 expression on ECs but not in stroma of patients with JNA. Chi-square analysis indicated CD105-based microvessel density (MVD) was correlated with JNA recurrence (p = .013). Univariate and multivariate analyses determined that MVD was a significant predictor of time to recurrence (p = .009). The CD105-based MVD was better for predicting disease recurrence (AUROC: 0.673; p = .036) than other clinicopathological features. CONCLUSIONS MVD is a useful predictor for poor prognosis of patients with JNA after curative resection. Angiogenesis, which may play an important role in the occurrence and development of JNA, is therefore a potential therapeutic target for JNA.
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Affiliation(s)
- Jing-Jing Wang
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
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Panda NK, Gupta G, Sharma S, Gupta A. Nasopharyngeal Angiofibroma-changing Trends in the Management. Indian J Otolaryngol Head Neck Surg 2012; 64:233-9. [PMID: 23998026 PMCID: PMC3431533 DOI: 10.1007/s12070-011-0338-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 11/09/2011] [Indexed: 11/26/2022] Open
Abstract
Juvenile nasopharyngeal angiofibroma is a rare high-risk tumor of adolescent males. To present the experience of managing extensive angiofibroma at a single institution. A retrospective analysis of patients with nasopharyngeal angiofibroma between 1980 and 2009. 150 patients have been included in the analysis. The patients have been divided into two groups depending on diagnostic and therapeutic protocols into two groups. A 1980-1990 and B from 1990 to 2009. The disease pattern, surgical approaches and outcome in the two groups have been analyzed. Surgery has been the main modality for management of this tumor. Preoperative embolization and open surgical approaches results in less blood loss and favourable outcome.
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Affiliation(s)
- Naresh K. Panda
- Department of Otolaryngology and Head & Neck surgery, PGIMER, Chandigarh, 160012 India
| | - Gaurav Gupta
- Department of Otolaryngology and Head & Neck surgery, PGIMER, Chandigarh, 160012 India
| | - Suresh Sharma
- Department of Otolaryngology and Head & Neck surgery, AIIMS, New Delhi, India
| | - Ashok Gupta
- Department of Otolaryngology and Head & Neck surgery, PGIMER, Chandigarh, 160012 India
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Cloutier T, Pons Y, Blancal JP, Sauvaget E, Kania R, Bresson D, Herman P. Juvenile Nasopharyngeal Angiofibroma. Otolaryngol Head Neck Surg 2012; 147:958-63. [DOI: 10.1177/0194599812454394] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective The aim of this study was to review recent management of juvenile nasopharyngeal angiofibroma (JNA) in our institution during the past 10 years and to analyze the shift in surgical paradigm based on the rate of endoscopic approach and Radkowski staging. Study Design Case series with chart review. Setting The study was conducted from April 2000 to August 2010 in a tertiary care university hospital (Lariboisière, Paris, France). Subjects and Methods All patients referred for a JNA were included in the study. Medical files and imaging data were retrospectively analyzed. Surgical management was then evaluated for 2 different periods (group 1, n = 31, consecutive patients operated on from April 2000 to June 2005, and group 2, n = 41, from July 2005 to August 2010). Results Seventy-two patients were operated on, with a mean age of 16.25 years (range, 9-33 years). The rate of the endoscopic approach was significantly higher in group 2 than in group 1 (82.9% vs 45%). Rates of recurrence and complications were similar. Recurrences (ie, residual disease growing and treated by redo) were noted in 6 cases or 8.3% (group 1, n = 3; group 2, n = 3; P > .05). Conclusion Progress in skull base anatomy, instrumentation, cameras, and surgical strategy allows for expansion of the indications for endoscopic removal of JNA. This approach may have a better outcome in terms of blood loss, hospital stay, and local sequelae. Still, an external approach should be considered only for selected cases due to massive intracranial extension or optic nerve or internal carotid artery entrapment by the tumor.
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Affiliation(s)
- Tam Cloutier
- Head and Neck Surgery Department, Hôpital Lariboisière, Paris, France
| | - Yoann Pons
- Head and Neck Surgery Department, Hôpital Lariboisière, Paris, France
| | | | | | - Romain Kania
- Head and Neck Surgery Department, Hôpital Lariboisière, Paris, France
| | - Damien Bresson
- Neurosurgery Department, Hôpital Lariboisière, Paris, France
| | - Philippe Herman
- Head and Neck Surgery Department, Hôpital Lariboisière, Paris, France
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Abstract
More than 70 benign and malignant sinonasal tumours and tumour-like conditions have been described. However, sinonasal tumours are rare, and sinonasal cancers comprise only 3% of all head and neck cancers and 1% of all malignancies, with a peak incidence in the 5th to 7th decades and with a male preponderance. The early symptoms and imaging findings of sinonasal tumours are similar to rhinosinusitis with runny and stuffy nose, lacrimation and epistaxis and therefore neglected both by the patients and doctors. When late symptoms such as anosmia, visual disturbances, cranial neuropathy (Cn II, IV, V, VI) or facial swelling appear, the patient is referred to sinonasal endoscopy or imaging. At the time of correct diagnosis more than half of the tumours have reached an advanced stage with a poor prognostic outcome. Even if imaging is performed in the early stages, a radiologist inexperienced with sinonasal anatomy and tumour features may easily interpret early signs of a malignant tumour as rhinosinusitis or a lesion that does not require follow-up. This article presents the imaging findings in some of the most common benign and malignant sinonasal tumours, and the TNM classification and staging of sinonasal carcinomas.
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Blount A, Riley KO, Woodworth BA. Juvenile nasopharyngeal angiofibroma. Otolaryngol Clin North Am 2012; 44:989-1004, ix. [PMID: 21819885 DOI: 10.1016/j.otc.2011.06.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Juvenile nasopharyngeal angiofibromas (JNAs) are rare, benign, highly vascular, locally aggressive tumors that primarily affect male adolescents. Historical treatment of these neoplasms has been primarily surgical. In the past decade, endoscopic resection of JNAs has become a viable and promising surgical treatment option. Endoscopic resection has many advantages over traditional open techniques, including better cosmesis, decreased blood loss, shortened hospital stays, and equivalent or improved recurrence rates. Emerging endoscopic technology continues to push the boundaries of resection of skull base tumors and will no doubt become the surgical treatment of choice for most JNAs in the near future.
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Affiliation(s)
- Angela Blount
- Division of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, 563 Boshell Building, 1530 3rd Avenue South, Birmingham, AL 35294-0012, USA
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Abstract
Juvenile angiofibroma is a rare benign lesion originating from the pterygopalatine fossa with distinctive epidemiologic features and growth patterns. The typical patient is an adolescent male with a clinical history of recurrent epistaxis and nasal obstruction. Although the use of nonsurgical therapies is described in the literature, surgery is currently considered the ideal treatment for juvenile angiofibroma. Refinement in preoperative embolization has provided significant reduction of complications and intraoperative bleeding with minimal risk of residual disease. During the last decade, an endoscopic technique has been extensively adopted as a valid alternative to external approaches in the management of small-intermediate size juvenile angiofibromas. Herein, we review the evolution in the management of juvenile angiofibroma with particular reference to recent advances in diagnosis and treatment.
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Singh R, Hazarika P, Nayak D, Balakrishnan R, Pillai S, Hazarika M. Role of Le Fort type I osteotomy approach in juvenile nasopharyngeal angiofibroma. Int J Oral Maxillofac Surg 2011; 40:1271-4. [DOI: 10.1016/j.ijom.2011.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 04/06/2011] [Accepted: 05/18/2011] [Indexed: 10/17/2022]
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Liu ZF, Wang DH, Sun XC, Wang JJ, Hu L, Li H, Dai PD. The site of origin and expansive routes of juvenile nasopharyngeal angiofibroma (JNA). Int J Pediatr Otorhinolaryngol 2011; 75:1088-92. [PMID: 21719122 DOI: 10.1016/j.ijporl.2011.05.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Revised: 05/26/2011] [Accepted: 05/30/2011] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Juvenile nasopharyngeal angiofibroma (JNA) is a rare vascular tumor of the nasopharynx occurring in young males. The aim of this study was attempt to find out the site of origin and the common expansion routes of JNA. METHODS The CT examinations of 46 untreated patients with histologically proven JNA were retrospectively analyzed. Evidence of tumor spreading of the locations are those following CT characteristics: (a) expansion and/or erosion of bony wall; (b) obliteration of normal fatty planes. In addition, three dimensional reconstruction technology was used to make further study. RESULTS The pterygoid canal was affected in all untreated cases and therefore was considered as the origin of JNA. Nineteen patients' tumors (41.3%) originated from the front part of pterygoid canal and the other 27 ones (58.7%) from the post part of pterygoid canal. Pterygoid canal, choanae and nasal cavity are the three most common sites of JNA. CONCLUSION The possible site of origin is pterygoid canal. After originating from this point, the tumor will invade sphenopalatine foramen, sphenoid sinus and pterygopalatine fossa first, and then into adjacent structure through aforementioned three sites.
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Affiliation(s)
- Zhuo-fu Liu
- ENT Department of Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
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Fyrmpas G, Konstantinidis I, Constantinidis J. Endoscopic treatment of juvenile nasopharyngeal angiofibromas: our experience and review of the literature. Eur Arch Otorhinolaryngol 2011; 269:523-9. [DOI: 10.1007/s00405-011-1708-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 07/04/2011] [Indexed: 11/25/2022]
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El Sharkawy AA, Elmorsy SM. Transnasal endoscopic management of recurrent juvenile nasopharyngeal angiofibroma. Int J Pediatr Otorhinolaryngol 2011; 75:620-3. [PMID: 21397958 DOI: 10.1016/j.ijporl.2011.01.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 01/19/2011] [Accepted: 01/21/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to present our experience with definitive endoscopic surgical management of the recurrent juvenile nasopharyngeal angiofibroma. STUDY DESIGN Retrospective study. SETTING Tertiary care centre. MATERIALS AND METHODS This study includes 13 male adolescence patients with recurrent nasopharyngeal angiofibroma who received treatment at our centre between 2005 and 2010. The patient age ranged from 12 to 21 years (mean age, 15.7 years). Endoscopic two surgeons' technique had been used. Follow up MRI every four months. RESULTS Complete removal of the recurrent tumor was achieved in 10 cases. Three patients had incomplete removal with further recurrences. These recurrences were two in lateral wall of the sphenoid sinus (2 patients), and soft palate (one patient). CONCLUSION Recurrent JNAs are residual disease resulting from incomplete removal of the primary tumor. Transnasal endoscopic sinus surgery is an effective method for treating recurrent JNA. Follow up is essential and integral point in management of JNAs.
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Renkonen S, Häyry V, Heikkilä P, Leivo I, Haglund C, Mäkitie AA, Hagström J. Stem cell-related proteins C-KIT, C-MYC and BMI-1 in juvenile nasopharyngeal angiofibroma--do they have a role? Virchows Arch 2010; 458:189-95. [PMID: 21113618 DOI: 10.1007/s00428-010-1010-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 11/03/2010] [Accepted: 11/07/2010] [Indexed: 01/11/2023]
Abstract
Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular tumour, occurring almost exclusively in adolescent males. Histogenesis of JNA remains unclear, two optional theories proposing either fibrous or vascular tissue as the tissue of origin. Stem cell-related proteins have been discussed to possibly participate in the growth of these tumours. In our study, we reviewed retrospective clinicopathological data of 26 JNA patients. By immunohistochemistry, we investigated the cellular distribution and expression levels of stem cell-related proteins C-KIT, C-MYC and BMI-1 and their correlation with cell and vessel density of the tumour. Contrary to earlier reports, we detected C-KIT expression in addition to stromal cells also in endothelial cells. The C-KIT expression was more dominant in slit vessels than large vessels. A significant correlation was found between endothelial immunoexpression of C-KIT and cellular density of the tumour. C-MYC and BMI-1 expression was detected in stromal cells only. Due to our finding of C-KIT expression in both stromal and endothelial cells and the strong correlation between the endothelial C-KIT expression and cellular density, we suggest that, besides the stromal tissue, the vascular component might take part in the neoplastic growth of JNA.
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Affiliation(s)
- Suvi Renkonen
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Renkonen S, Hagström J, Vuola J, Niemelä M, Porras M, Kivivuori SM, Leivo I, Mäkitie AA. The changing surgical management of juvenile nasopharyngeal angiofibroma. Eur Arch Otorhinolaryngol 2010; 268:599-607. [PMID: 20848119 DOI: 10.1007/s00405-010-1383-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 09/02/2010] [Indexed: 11/28/2022]
Abstract
The management of juvenile nasopharyngeal angiofibroma (JNA) has changed during the last decades but it still continues to be a challenge for the multidisciplinary head and neck surgical team. The aim of this study was to review the used treatment approach and outcome of JNA in a single institution series of 27 patients diagnosed and treated during the years 1970-2009. All patients were male, with the median age of 17 years (range 11-33 years). Surgery was used as the primary treatment in every case. Surgical approaches varied, transpalatal approach (N = 14) being the most common approach used in this series. During the last decade various other techniques were applied, including endoscopic (N = 3) resection. Two patients were additionally treated with antiangiogenic agents and one patient with stereotactic radiotherapy. The primary recurrence rate was 37% and it seemed to correlate with vascular density of tumour and the surgical approach used. We suggest that the management of JNA should be planned by an experienced head and neck surgeon, as part of a multidisciplinary team, preferably in a tertiary referral setting, and the recent development of the available therapies should be taken into account to minimise the risk of recurrence.
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Affiliation(s)
- Suvi Renkonen
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Central Hospital and University of Helsinki, P.O. Box 220, 00029, Helsinki, Finland
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Nicolai P, Villaret AB, Farina D, Nadeau S, Yakirevitch A, Berlucchi M, Galtelli C. Endoscopic surgery for juvenile angiofibroma: a critical review of indications after 46 cases. Am J Rhinol Allergy 2010; 24:e67-72. [PMID: 20338105 DOI: 10.2500/ajra.2010.24.3443] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND At present, transnasal endoscopic surgery is considered a viable option in the management of small-intermediate size juvenile angiofibromas (JAs). The authors critically review their 14-year experience in the management of this lesion to refine selection criteria for an endoscopic approach. METHODS From January 1994 to May 2008, 46 patients were treated by a pure endoscopic resection after vascular embolization (87%). The lesions were classified according to Andrews (Andrews JC, et al., The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach, Laryngoscope 99:429-437, 1989) and Onerci (Onerci M, et al. Juvenile nasopharyngeal angiofibroma: A revised staging system, Rhinology 44:39-45, 2006) staging systems. All patients were followed by regular endoscopic and magnetic resonance imaging (MRI) examinations. RESULTS Lesions were classified as follows: stage I, n = 5; stage II, n = 24; stage IIIa, n = 14; stage IIIb, n = 3 according to Andrews classification system; stage 1, n = 9; stage II, n = 12; stage III, n = 26 according to Onerci's system. Unilateral blood supply was detected in 39 (85%) cases. Feeding vessels from the internal carotid artery (ICA) were also reported in 14 (30%) patients. Intraoperative blood loss ranged from 250 to 1300 mL (mean, 580 mL). In four (8.7%) cases, suspicious residual disease was detected by MRI. In one patient, a 1-cm persistent lesion was endoscopically removed because septoplasty was required and a slight increase in size was noticed. The other three lesions, all located in the root of the pterygoid plate, are nearly stable in size and are currently under MRI follow-up. CONCLUSION The improvement of surgical instrumentation and the experience acquired during a 14-year period have contributed to expanding the indications for endoscopic surgery in the management of JAs. Even stage III lesions may be successfully managed, unless the ICA is encased or if it provides an extensive blood supply. An external approach may be required when critical structures such as the ICA, cavernous sinus, or optic nerve are involved by lesions that are persistent after previous treatment; such a situation may prevent safe and radical dissection with a pure endoscopic approach. Better understanding of the factors influencing the growth of residual lesions is needed to differentiate those requiring re-treatment from those which can be simply observed.
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Affiliation(s)
- Piero Nicolai
- Department of Otorhinolaryngology, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy.
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Hodges JM, McDevitt AS, El-Sayed Ali AI, Sebelik ME. Juvenile nasopharyngeal angiofibroma: current treatment modalities and future considerations. Indian J Otolaryngol Head Neck Surg 2010; 62:236-47. [PMID: 23120720 PMCID: PMC3450247 DOI: 10.1007/s12070-010-0073-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Juvenile angiofibroma (JNA) is a relatively uncommon, highly vascular and benign tumor that presents most commonly in adolescent males. Symptoms may persist from months to years and often times, these tumors are asymptomatic until they increase and encroach on critical structures. Because of technological advances both in surgery and radiology, management of JNA patients has been refined. With the advent of more sophisticated capabilities such as CT, MRI, intensity-modulated radiation therapy (IMRT), stereotactic guidance systems as well as advanced embolization techniques, these tumors can be diagnosed and managed more effectively.Patients with juvenile angiofibroma (JNA) are typically silent for years and often present with epistaxis, nasal obstruction, facial numbness, rhinorrhea, ear popping, sinusitis, cheek swelling, visual changes and headaches. In addition to these symptoms, up to one-third of patients with this condition may present with proptosis or other orbital involvement, which are late symptoms and findings.Most physicians agree that surgery is the primary treatment modality for the early-stage disease process. However, controversy arises regarding the best treatment when a patient presents with more locally advanced disease involving widespread cranial-based extension or intracranial involvement which may necessitate a combination of treatment modalities including surgery and postoperative radiation.With the advancement of endoscopic surgery, there have been a number of cases reporting the value of its use. The purpose of this review, however, will address not only endoscopic alternatives, but will discuss other treatment options as reported in the literature. Robotic surgery of the skull base for JNA is something to expect for the future.Finally, with the advent of IMRT and an image-guided robotic radiotherapy delivery system, some researchers speculate that this will result in less objections for radiation in general and certainly less reservations for the use radiotherapy in certain circumstances, i.e. patient refusal of surgery or extensive non-resectable or recurrent JNA tumors.
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Affiliation(s)
- John M. Hodges
- Division of Otolaryngology, VA Medical Center — Memphis, University of Tennessee, Department of Otolaryngology Head and Neck Surgery, Memphis, TN USA
| | | | | | - M. E. Sebelik
- Dept of Otolaryngology Head and Neck Surgery VA Medical Center, Memphis, University of Tennessee, Memphis, TN USA
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Lee JT, Keschner DB, Kennedy DW. Endoscopic resection of juvenile nasopharyngeal angiofibroma. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.otot.2010.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Effect of embolisation on endoscopic resection of angiofibroma. The Journal of Laryngology & Otology 2010; 124:631-5. [DOI: 10.1017/s0022215109992726] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjective:To determine the effect of embolisation on endoscopic resection of angiofibroma.Subjects and method:A partially blinded trial was undertaken. Twenty-three patients with angiofibroma (nine embolised and 14 not embolised) underwent endoscopic resection between January 2007 and August 2008 in two tertiary referral centres. Demographic data were collected, the pre-operative tumour extent was assessed by computed tomography, and tumours were staged according to their computed tomography appearance (Radkowski scale). In addition, we evaluated the duration of surgery, amount of haemorrhage, blood pressure during surgery, duration of hospitalisation, complications of surgery and embolisation, cost of treatment, and number of post-operative recurrences, as well as the angiographic characteristics in the embolisation group.Results:There was no significant difference between the general characteristics of both groups. At the end of the study period, we could find no significant difference between the two groups regarding haemorrhage, number of recurrences or complications. The only significant difference was cost of treatment, which was significantly higher in the embolisation group.Conclusion:Endoscopic resection is a feasible and safe method for angiofibroma surgery. The current evidence does not support obligatory embolisation in every case of endoscopic angiofibroma resection.
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