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Gupta DP, Gupta S, Shreevidya SR. Endoscopic Modified Denker's Approach for the Treatment of Juvenile Nasopharyngeal Angiofibroma. Indian J Otolaryngol Head Neck Surg 2022; 74:921-928. [PMID: 36452834 PMCID: PMC9702475 DOI: 10.1007/s12070-020-01984-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022] Open
Abstract
Juvenile nasopharyngeal angiofibroma is a benign vascular lesion with propensity of bony erosion leading to skull base involvement and intracranial extension. It involves multiple compartments which are difficult to access surgically. With surgical expertise endoscopic resection of angiofibroma has become the preferred choice of surgical management. This article presents our experience with endoscopic approach for angiofibroma and establishes the modified Denker's procedure as a effective approach for removal of tumor. A prospective case study was done on 25 cases of juvenile nasopharyngeal angiofibroma treated surgically by endonasal endoscopic modified Denker's approach in the department of ENT at BJ Medical College, Ahmedabad over a period of 4 years from January 2015 to January 2019. This technique was used up to Fisch stage 3b with extension up to infratemporal fossa. Using this technique no major recurrence or major morbidity was observed and did not produce any late serious complications. The endoscopic technique allows the surgeon to achieve an extensive exposure of the sinuses and control of the sphenopalatine and internal maxillary arteries without the risk of palatal dysfunction, oronasal fistula, or facial scarring. In addition, the modified Denkers approach can be an effective and less mutilating technique in managing recurrences.
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Affiliation(s)
- Devang P. Gupta
- Department of E.N.T, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat India
| | - Shalu Gupta
- Department of E.N.T, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat India
| | - S. R. Shreevidya
- Department of E.N.T, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat India
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Machado A, Briner HR, Schuknecht B, Simmen D. Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall. Rhinology 2021; 59:475-480. [PMID: 34428266 DOI: 10.4193/rhin21.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip. METHODOLOGY Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the 'shoulder' of the inferior turbinate and the pyriform aperture. RESULTS The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78 ± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the 'shoulder' of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides. CONCLUSIONS We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.
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Affiliation(s)
- A Machado
- Department of Otolaryngology, Centro Hospitalar Universitario do Porto, Porto, Portugal; Faculdade de Ciencias da Saude, Universidade da Beira Interior, Covilha, Portugal
| | - H R Briner
- ORL-Zentrum - Otorhinolaryngology and Facial Plastic Surgery, Hirslanden Klinik, Zurich, Switzerland
| | - B Schuknecht
- Medizinisch Radiologisches Institut, Zurich, Switzerland
| | - D Simmen
- ORL-Zentrum - Otorhinolaryngology and Facial Plastic Surgery, Hirslanden Klinik, Zurich, Switzerland
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Transoral Finger-Retraction for Endonasal Endoscopic Resection of Masseteric and Buccal Space Lesions. J Craniofac Surg 2019; 30:800-802. [PMID: 30614990 DOI: 10.1097/scs.0000000000004931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Lesions involving the masseteric and buccal spaces have traditionally required transoral or transcervical approaches. Herein, the authors describe the successful endonasal endoscopic resection of a juvenile nasopharyngeal angiofibroma (JNA) with significant extension into the masseteric and buccal spaces facilitated by transoral finger retraction. Juvenile nasopharyngeal angiofibromas are hypervascular tumors originating in the pterygopalatine fossa (PPF) with complex relationships to skull base and orbital structures. Endoscopic approaches have allowed for resection of JNAs with excellent visualization and without traditional transfacial approaches, decreasing morbidity and reducing incidence of facial deformity with similar outcomes as open approaches. While the endonasal endoscopic approach to the masseteric and buccal spaces is unconventional, encapsulated tumors in these regions can be delivered into the nasal cavity through the maxilla and PPF with the use of transoral finger-retraction. The authors present a case of a 10-year-old male referred to their tertiary care center with left-sided epistaxis, nasal obstruction, and facial swelling. Imaging demonstrated a vascular lesion in the PPF involving the left nasal cavity and paranasal sinuses, with extension into left middle cranial fossa, infratemporal fossa, orbit, and deep spaces of the neck including the masticator, masseteric, and buccal spaces. The patient underwent preoperative embolization and endoscopic endonasal surgical resection with transoral finger-retraction without complication. Transoral finger-retraction represents a supplemental technique that allows for encapsulated lesions involving the masseteric and buccal spaces to be delivered into the nasal cavity for endoscopic resection in a safe and effective fashion, preventing the need for transfacial incisions.
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Kim SM, Paek SH, Lee JH. Infratemporal fossa approach: the modified zygomatico-transmandibular approach. Maxillofac Plast Reconstr Surg 2019; 41:3. [PMID: 30687683 PMCID: PMC6331346 DOI: 10.1186/s40902-018-0185-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/18/2018] [Indexed: 11/28/2022] Open
Abstract
Background The infratemporal fossa (ITF) is an anatomical lateral skull base space composed by the zygoma, temporal, and the greater wing of the sphenoid bone. Due to its difficult approach, surgical intervention at the ITF has remained a heavy burden to surgeons. The aim of this article is to review basic skull base approaches and ITF structures and to avoid severe complications based on the accurate surgical knowledge. Methods A search of the recent literature using MEDLINE (PubMed), Embase, Cochrane Library, and other online tools was executed using the following keyword combinations: infratemporal fossa, subtemporal fossa, transzygomatic approach, orbitozygomatic approach, transmaxillary approach, facial translocation approach, midface degloving, zygomatico-transmandibular approach, and lateral skull base. Aside from our Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial, there have been very few randomized controlled trials. The search data for this review are summarized based on the authors’ diverse clinical experiences. Results We divided our results based on representative skull base approaches and the anatomy of the ITF. Basic approaches to the ITF include endoscopic endonasal, transzygomatic, orbitozygomatic, zygomatico-transmandibular, transmaxillary, facial translocation, and the midfacial degloving approach. The borders and inner structures of the ITF (with basic lateral skull base dissection schemes) are summarized, and the modified zygomatico-transmandibular approach (ZTMA) is described in detail. Conclusions An anatomical basic knowledge would be required for the appropriate management of the ITF pathology for diverse specialized doctors, including maxillofacial, plastic, and vascular surgeons. The ITF approach, in conjunction with the application of microsurgical techniques and improved perioperative care, has permitted significant advances and successful curative outcomes for patients having malignancy in ITF.
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Affiliation(s)
- Soung Min Kim
- 1Oral and Maxillofacial Microvascular Reconstruction LAB, Ghana Health Service, Regional Hospital Sunyani, P.O. Box 27, Sunyani, Brong Ahafo Ghana.,2Department of Oral and Maxillofacial Surgery, Dental Research Institute, Clinical Trial Center and Oral Cancer Center, School of Dentistry, Seoul National University, Seoul, South Korea
| | - Sun Ha Paek
- 3Department of Neurosurgery, Hypoxia Ischemia Hypoxia Disease Institute, Cancer Research Institute, Seoul National University Medical College, Seoul, South Korea
| | - Jong Ho Lee
- 2Department of Oral and Maxillofacial Surgery, Dental Research Institute, Clinical Trial Center and Oral Cancer Center, School of Dentistry, Seoul National University, Seoul, South Korea
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de Almeida Vital JM, de Farias TP, Dias FL, de Oliveira JF, Miranda da Paixão JG, de Cavalcanti Siebra PJ, Lopes Moraes AR. Nasal Cavity Paraganglioma: Literature Review and Discussion of a Rare Case. Biomed Hub 2017; 2:1-15. [PMID: 31988909 PMCID: PMC6945913 DOI: 10.1159/000464099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 02/13/2017] [Indexed: 12/02/2022] Open
Abstract
Paragangliomas can be found from the skull base to the sacrum. Sinonasal paragangliomas are infrequent. A 16-year-old female reported spontaneous discrete bilateral epistaxis once a month beginning when she was 3 years of age. Computed tomography showed an expansive hypervascular mass occupying the right nasal cavity and nasopharynx. Sinonasal paragangliomas usually occur in middle-aged women. Radiologic investigation is essential for the diagnosis of sinonasal paragangliomas and evaluating extension of the lesion. Endoscopic and conventional approaches are effective, and preoperative embolization is paramount for reducing bleeding risk. Histopathological features cannot differentiate benign from malignant paragangliomas, and since metastasis may eventually occur, follow-up must be carried out for a long period of time.
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Affiliation(s)
| | - Terence Pires de Farias
- Department of Oncology, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil.,Department of Head and Neck Surgery, Pontíficia Universidade Católica of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernando Luiz Dias
- Department of Head and Neck Surgery, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil.,Department of Head and Neck Surgery, Pontíficia Universidade Católica of Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Clinical Surgery, Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | - Arli Regina Lopes Moraes
- Department of Head and Neck Surgery, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
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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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Khoueir N, Nicolas N, Rohayem Z, Haddad A, Abou Hamad W. Exclusive Endoscopic Resection of Juvenile Nasopharyngeal Angiofibroma. Otolaryngol Head Neck Surg 2013; 150:350-8. [DOI: 10.1177/0194599813516605] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To systematically review the exclusive endoscopic treatment of juvenile nasopharyngeal angiofibroma in the literature to define the clinical features in terms of staging and the treatment outcomes in terms of bleeding, recurrence, residual tumor, and complications. Data Sources Online databases, including PubMed and EMBASE, were used. Reference sections of identified studies were examined for additional articles. Review Methods The literature was searched by 2 reviewers with the following inclusion criteria: English or French language and exclusive endoscopic treatment of juvenile nasopharyngeal angiofibroma. We were only able to perform a meta-analysis on the categorical outcomes using DerSimonian and Laird random effects models. Results Ninety-two studies were included with a majority of retrospective studies (54/92; 58.6%). No randomized controlled trials were found. A total of 821 patients were identified. The Radowski classification was the most commonly used (29/92; 31.15%). The mean operative blood loss was 564.21 mL (minimum, 20 mL; maximum, 1482 mL). It was 414.6 mL (minimum, 20 mL; maximum, 1000 mL) and 774.2 mL (minimum, 228 mL; maximum, 1482 mL), respectively, in the group with and without embolization. No conclusion could be made because it was not stratified by tumor stage and because of the absence of randomized controlled trials. The random effect estimate of recurrence was 10% (95% confidence interval [CI], 8.3-11.7). It was 9.3% (95% CI, 7.2-11.5) for complications and 7.7% (95% CI, 5.4-10.1) for residual tumor. Conclusion The endoscopic treatment is an evolving modality. It is considered today the treatment of choice. A new classification system based on the endoscopic approach should be proposed in future studies.
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Affiliation(s)
- Nadim Khoueir
- Otolaryngology–Head and Neck Surgery, Hotel Dieu de France University Hospital, Saint Joseph University Medical School, Beirut, Lebanon
| | - Nicolas Nicolas
- Otolaryngology–Head and Neck Surgery, Hotel Dieu de France University Hospital, Saint Joseph University Medical School, Beirut, Lebanon
| | - Ziad Rohayem
- Otolaryngology–Head and Neck Surgery, Saint-Elizabeth Medical Center, Brighton, Massachusetts, USA
| | - Amine Haddad
- Otolaryngology–Head and Neck Surgery, Hotel Dieu de France University Hospital, Saint Joseph University Medical School, Beirut, Lebanon
| | - Walid Abou Hamad
- Otolaryngology–Head and Neck Surgery, Hotel Dieu de France University Hospital, Saint Joseph University Medical School, Beirut, Lebanon
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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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Abstract
BACKGROUND In the conventional technique of transpalatal approach, the palatal mucoperiosteum is incised and widely elevated and hard palate bone is removed in piece meal and discarded. These technique lead to complications, namely, temporary or permanent palatal fistula, palatal scarring leading to palatal disfiguration and velopharyngeal incompetence. In this article we describe a new technique of doing palatotomy to avoid these complications. METHODS A retrospective review of post-operative complications of 20 patients that underwent transpalatal approach by the conventional technique was performed. To avoid the complications encountered in these cases, a new approach was designed when the palatal mucoperiosteum on the pathological side was elevated partially, greater palatine artery was coagulated and palatal osteotomy was performed from the oral side. On the non-pathological side, hard palate was sectioned from the nasal side, thus preserving the ipsilateral palatal mucoperiosteum. The entire mucoperiosteum with attached hard palate was reflected orally as a single block which was pedicled on the greater palatine artery and palatal mucoperiosteum of the non-pathological side, thereby creating palatal osteo-mucoperiosteal flap. The flap was placed back at the end of the procedure. Eight patients were operated by this new technique. RESULTS All 20 patients operated by the conventional transpalatal approach developed post-operative complications. In the eight patients operated by the new technique, no post-operative complications were encountered after 2 years' follow-up. CONCLUSIONS We found palatal osteo-mucoperiosteal flap an easy and safe way of preserving the hard palate mucoperiosteum and bone with its vasculature resulting in quicker healing and minimal functional impairment.
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Affiliation(s)
- Siba P Dubey
- Department of Ear, Nose and Throat, Port Moresby General Hospital, Boroko, National Capital District 111, Papua, New Guinea.
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Yi ZX, Li ZC, Cheng JM, Zhang R, Lin C, Zhou AD, Fan ZM. Huge nasopharyngeal angiofibroma with intracranial extension: change in the dura mater and choice of surgical management. The Journal of Laryngology & Otology 2007; 121:1108-12. [PMID: 17295934 DOI: 10.1017/s0022215107005737] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractWe aimed to review (1) the imaging changes in the dura mater in cases of huge, lobulated juvenile nasopharyngeal angiofibroma, and (2) the choice of surgical management.Imaging from four cases of juvenile nasopharyngeal angiofibroma showed extrapharyngeal extension of the tumour. The sphenoid sinus, sella turcica and clivus were extensively eroded, and the tumour had spread deep into the cranial fossa. In three cases, intracranial exploration was performed to treat the intracranial tumour lobule. Subsequently, the tumours were removed using extracranial approaches. No perforation of the dura mater was found in these three cases, although the dura mater in the superior orbital fissure was congested, haemorrhagic and solid. Pre-operative imaging for two cases (i.e. the first operation for one and the second operation for the other) revealed no dura mater perforation. A transantral approach via a midfacial degloving incision was used to remove these tumours completely.We conclude that change in the dura mater is a crucial indication for the choice of management. If the dura mater is intact, a transantral approach via a midfacial degloving incision may remove the tumour successfully.
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Affiliation(s)
- Z X Yi
- Department of Otolaryngology-Head and Neck Surgery, First Affiliated Hospital of Fujian Medical University, Otolaryngology Institute of Fujian Province, Fuzhou, China.
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Douglas R, Wormald PJ. Endoscopic surgery for juvenile nasopharyngeal angiofibroma: where are the limits? Curr Opin Otolaryngol Head Neck Surg 2006; 14:1-5. [PMID: 16467630 DOI: 10.1097/01.moo.0000188859.91607.65] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article will examine recent publications on the endoscopic management of juvenile nasopharyngeal angiofibromas. RECENT FINDINGS The use of an endoscopic approach to resect small juvenile nasopharyngeal angiofibromas is supported by excellent results from a number of operative series published in recent years. Large juvenile nasopharyngeal angiofibromas continue to present a considerable surgical challenge, with most being resected by traditional open approaches. However, the results achieved after the endoscopic resection of large tumours have been reported for a small number of cases. This review focuses on the outcome of these cases, which would seem to compare favourably to open series, and the advances in instrumentation and techniques, that facilitate the endoscopic removal of large juvenile nasopharyngeal angiofibromas. SUMMARY Improvements in preoperative assessment and preparation, operative technique, and instrumentation potentially enable the endoscopic removal of most juvenile nasopharyngeal angiofibromas.
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Affiliation(s)
- Richard Douglas
- Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital, Woodville, Australia
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