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Felippu AWD, Fontes EB, Felippu AWD, Ellery BC, Oliveira ACSD, Guimarães AV, Cascio F, Felippu A. Juvenile Nasopharyngeal Angiofibroma: A Series of 96 Surgical Cases. Int Arch Otorhinolaryngol 2024; 28:e432-e439. [PMID: 38974625 PMCID: PMC11226290 DOI: 10.1055/s-0043-1777293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 10/15/2023] [Indexed: 07/09/2024] Open
Abstract
Introduction Juvenile nasopharyngeal angiofibroma (JNA) is a benign vascularized tumor that affects almost exclusively male adolescents. Surgery is the treatment of choice for JNA. Objectives The present study is a 42-year retrospective review of a series of JNA cases treated surgically without previous embolization. Methods The present is a retrospective, descriptive study based on medical records of 96 patients with JNA who underwent microscopic or endoscopic excision without previous embolization from 1978 to 2020 in a single institution. The patients were categorized according to the Andrews et al. stage, and data were collected on age, gender, tumor staging, surgical approach, affected side, and outcome. Results All patients were male, with an average age of 17 years. The predominant tumor stage consisted of type II, with 52.1%. A total of 33.3% of the patients were submitted to the microscopic technique and 66.7%, to the endonasal technique. The rate of intraoperative blood transfusion was of 17.7%. Conclusion The present study reinforces that resection of JNA in various stages is viable without previous artery embolization.
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Affiliation(s)
| | | | | | | | | | | | - Filippo Cascio
- Department of Otorhinolaryngology, Papardo Hospital, Messina, Italy
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2
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Diaz A, Wang E, Bujnowski D, Arimoto R, Armstrong M, Cyberski T, Nordgren R, Seal SM, Kass-Hout T, Roxbury C. Embolization in Juvenile Nasopharyngeal Angiofibroma Surgery: A Systematic Review and Meta-Analysis. Laryngoscope 2023. [PMID: 36789781 DOI: 10.1002/lary.30616] [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: 04/29/2022] [Revised: 01/18/2023] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE To compare outcomes of juvenile nasopharyngeal angiofibroma (JNA) resection between embolized and non-embolized cohorts, and between transarterial embolization (TAE) and direct puncture embolization (DPE). DATA SOURCES Per PRISMA guidelines, PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched for publications prior to or in 2021. MATERIALS AND METHODS Original English manuscripts investigating the resection of JNA with and without preoperative embolization were included. Embolization type, recurrence rate, complication rates, blood loss, and transfusions were extracted. Risk of bias was assessed by the Risk of Bias in Non-randomized Studies-of Interventions method. RESULTS There were 61 studies with 917 patients included. Preoperative embolization was performed in 79.3% of patients. Of those embolized, 75.8% (N = 551) underwent TAE and 15.8% (N = 115) underwent DPE. JNA recurrence in embolized patients was lower than in non-embolized patients (9.3% vs. 14.4%; odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.35, 1.06). DPE resulted in lower rates of disease recurrence (0% vs. 9.5%; OR: 0.066, 95% CI: 0.016, 0.272) and complications (1.8% vs. 21.9%; OR: 0.07, 95% CI: 0.02, 0.3) than TAE. A random effects Bayesian model was performed to analyze the difference in mean blood loss in 6 studies that included both embolized and non-embolized patients. This analysis showed a mean reduction in blood loss of 798 mL in the embolized group. CONCLUSIONS We found embolization decreases blood loss in JNA resection. DPE led to improved recurrence and complication rates when compared to TAE, but future prospective studies are needed to further evaluate which embolization technique can optimize outcomes in JNA. LEVEL OF EVIDENCE NA Laryngoscope, 2023.
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Affiliation(s)
- Ashley Diaz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Esther Wang
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Daniel Bujnowski
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Ryuji Arimoto
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Mikhayla Armstrong
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Thomas Cyberski
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Rachel Nordgren
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | - Stella M Seal
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Christopher Roxbury
- Department of Surgery, Section of Otolaryngology, University of Chicago Medicine, Chicago, Illinois, USA
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Scholfield DW, Clarke P. Midfacial degloving for juvenile angiofibroma: A case-series of 21 adult males: An alternative to the endoscopic approach and when it should be considered. Clin Otolaryngol 2020; 46:659-664. [PMID: 33370495 DOI: 10.1111/coa.13704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 07/20/2020] [Accepted: 12/06/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the midfacial degloving approach and compare the varying surgical approaches to juvenile angiofibromas. To demonstrate the efficacy of midfacial degloving in treating large juvenile angiofibromas in a unique patient cohort. DESIGN A retrospective case-series between 2006 and 2019. SETTING All patient care was undertaken at a regional skull base referral centre. PARTICIPANTS Twenty-one male patients with a median age of 18 (range 16-45 years). MAIN OUTCOME MEASURES Presenting symptoms, imaging, stage, age at operation, residual disease, estimated blood loss and operative time were all recorded. Postoperative outcomes included complications, length of stay and recurrence. RESULTS The median surgical time was 105 minutes (range 55-219 minutes), median estimated blood loss 600 mls (range 150-900 mls) and median length of stay was 4 days (range 2-13 days.). Complications included two episodes of epistaxis, one requiring packing and one return to theatre. 14% (3/21) of patients had residual disease, none requiring further treatment and one patient had recurrence. CONCLUSIONS MFD for JNA in our series resulted in low recurrence rate and no progression of residual disease. The approach has been successful in our cohort of patients and is an option in males over the age of 16 years, with JA extending beyond the nasopharynx and sinuses, involving the infratemporal fossa, cavernous sinus or orbital region.
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Affiliation(s)
- Daniel W Scholfield
- ENT Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Peter Clarke
- ENT Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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Uetz S, Crosby DL. Current Management of Juvenile Nasopharyngeal Angiofibroma. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00265-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Martinez-Monedero R, Danielian A, Angajala V, Dinalo JE, Kezirian EJ. Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals. Otolaryngol Head Neck Surg 2020; 163:892-905. [PMID: 32450783 DOI: 10.1177/0194599820924621] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals. DATA SOURCES Ovid Medline, Embase, and Cochrane Library. REVIEW METHODS A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions. RESULTS Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews. CONCLUSION Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.
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Affiliation(s)
- Rodrigo Martinez-Monedero
- USC Caruso Department of Otolaryngology-Head & Neck Surgery, Keck School of Medicine of USC, California, USA
| | - Arman Danielian
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Varun Angajala
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Jennifer E Dinalo
- Health Sciences Libraries, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Eric J Kezirian
- USC Caruso Department of Otolaryngology-Head & Neck Surgery, Keck School of Medicine of USC, California, USA
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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: 80] [Impact Index Per Article: 20.0] [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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Maroda AJ, Beckmann NA, Sheyn AM, Elijovich L, Michael LM, DiNitto JM, Rangarajan SV. Trimodal embolization of juvenile nasopharyngeal angiofibroma with intracranial extension. Int J Pediatr Otorhinolaryngol 2020; 130:109805. [PMID: 31864085 DOI: 10.1016/j.ijporl.2019.109805] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/25/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVES/PURPOSE 1. Understand three different techniques for embolization of juvenile nasal angiofibroma (JNA) and assess their combined efficacy. 2. Perform successful endoscopic intralesional embolization of highly vascular sinonasal neoplasms. METHODS In this study, we present the case of a 10-year-old male patient diagnosed with juvenile nasal angiofibroma (JNA) who successfully underwent trimodal embolization and resection at a tertiary academic medical center after failed coil embolization in his home country. We examine the clinical details of the case and a review of pertinent literature. RESULTS Preoperative embolization is common in the treatment of JNA, but there is little consensus as to the proper timeframe and techniques utilized. In our case, preoperative imaging revealed a vascular tumor with intracranial extension consistent with UPMC Stage V JNA. Diagnostic angiogram revealed significant arborization from the internal and external carotid systems. A trimodal embolization technique, utilizing transarterial, percutaneous, and direct endoscopic intralesional injection of n-Butyl Cyanoacrylate (n-BCA) was performed. A two-staged endoscopic and open resection was subsequently performed one week later with minimal blood loss. In our case, combining intralesional embolization with traditional transarterial techniques resulted in an improved operative field and a successful clinical result. CONCLUSION Embolization of highly vascular sinonasal tumors with n-BCA is not limited to endovascular techniques, but can be safely combined with percutaneous and endoscopic intralesional embolization up to one week prior to surgical resection.
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Affiliation(s)
- Andrew J Maroda
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Nicholas A Beckmann
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Anthony M Sheyn
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Lucas Elijovich
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - L Madison Michael
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Julie M DiNitto
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA; Siemens Healthcare AG, Memphis, TN, USA.
| | - Sanjeet V Rangarajan
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
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8
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Llorente JL, López F. The endoscopic endonasal approach for the treatment of juvenile angiofibromas. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2019; 70:136-144. [PMID: 29764608 DOI: 10.1016/j.otorri.2018.01.004] [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: 12/31/2017] [Accepted: 01/13/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Juvenile angiofibroma (JA) is a benign tumour, for which the treatment of choice is surgery. It may be associated with significant morbidity because of its anatomical location and its locally destructive growth pattern. Severe haemorrhage constitutes a high risk in JA and its surgical management can be complex. The management of JA remains a challenge. The objective of this study was to review a series of patients with JA treated via the endonasal/endoscopic approach. MATERIAL AND METHODS Medical records of patients operated for JA were reviewed. MAIN OUTCOME MEASURES tumour stage, intraoperative blood loss, complications and persistence/recurrence rates. RESULTS A total of 30 male patients and one female were included. The mean age was 17 years. Using the Radkowski classification, one JA was classified as stage I, 5 stage IIA, 9 stage IIB, 4 stage IIC, 10 stage IIIA and 2 stage IIIB. Thirty-nine percent of the JA was classified as advanced stage JA (IIIA and IIIB). The mean blood loss was 1.156mL Except in one case, no significant complications were observed. Tumour persistence/recurrence was observed in 2 JA (6%), at the end of the follow-up. Mean postoperative follow-up time was 86 months. CONCLUSIONS This retrospective study supports the notion that endonasal endoscopic approaches for a JA are a feasible option associated with good long-term results.
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Affiliation(s)
- José Luis Llorente
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Universidad de Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, España.
| | - Fernando López
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Universidad de Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, España
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9
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The Endoscopic Endonasal Approach for the Treatment of Juvenile Angiofibromas. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2019. [DOI: 10.1016/j.otoeng.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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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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A case of nasopharyngeal angiofibroma removed using a minimally invasive endoscopic endonasal technique. Wideochir Inne Tech Maloinwazyjne 2018; 13:551-555. [PMID: 30524630 PMCID: PMC6280076 DOI: 10.5114/wiitm.2018.75862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 04/07/2018] [Indexed: 11/17/2022] Open
Abstract
Nasopharyngeal angiofibroma is a rare head and neck tumor characterized by hypervascularity. With the development of various surgical devices and hemostatic agents, endoscopic endonasal surgery for nasopharyngeal angiofibroma, which is characterized by significant intraoperative bleeding, has become possible. We describe our experiences performing an effective endoscopic endonasal removal of a nasopharyngeal angiofibroma without embolization, using advanced devices and hemostatic agents. A 21-year-old male patient presented with massive epistaxis. The characteristic findings of angiofibroma were confirmed by computed tomography scan and nasal endoscopy. Navigation-guided endoscopic endonasal surgery was performed, and complementary devices and products were used to effectively remove the mass. Development of navigation, endoscopes, tissue handling devices, and hemostatic agents has enabled effective endoscopic endonasal removal of nasopharyngeal angiofibroma without embolization.
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Epprecht L, Mosimann M, Vital D, Holzmann D. Morbidity and Volumetric Progression in Juvenile Nasopharyngeal Angiofibroma in a Long-Term Follow-Up. J Neurol Surg B Skull Base 2018; 79:533-537. [PMID: 30456021 DOI: 10.1055/s-0038-1635255] [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] [Received: 09/11/2017] [Accepted: 02/21/2018] [Indexed: 10/17/2022] Open
Abstract
Objective We compare the open and transnasal approaches for the excision of juvenile nasopharyngeal angiofibromas regarding the rate of morbidity, and residual tumor and its symptomatic recurrence over time. In addition, we present volumetric measurements of juvenile nasopharyngeal angiofibromas over time. Methods All surgically treated patients of our institution were reviewed back to 1969 for type of surgery, residual tumor by magnetic resonance imaging (MRI)-based volumetry, recurrence, and morbidity. We performed a prospective clinical and radiological follow-up on reachable patients. Results In total, 40 patients were retrievable from our records. We were able to follow up on 13 patients after a mean of 15.7 years since surgery (range: 1-47 years). Patients operated by the open approach had a higher rate of postoperative complications and thus a higher morbidity than endoscopic patients (4/4 vs 3/9; p = 0.007), although tumor sizes were equal among groups ( p = 0.12). Persisting tumor was noted in 3/4 and 4/9 ( p = 0.56) patients, respectively. The corresponding mean volumes of residual tumors were 16.2 ± 14.4 cm 3 and 10.8 ± 6.6 cm 3 ( p = 0.27). No progression could be noted in endoscopically treated patients ( p = 0.24, mean time between scans 2 years). Conclusions Our analysis shows that the endoscopic approach results in less morbidity. The open approach does not guarantee freedom from persisting tumor tissue. Age seems to be a most important risk factor for the conversion of an asymptomatic persistence into a symptomatic recurrence.
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Affiliation(s)
- Lorenz Epprecht
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Switzerland
| | - Marc Mosimann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Switzerland
| | - Domenic Vital
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Switzerland
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Rowan NR, Stapleton AL, Heft-Neal ME, Gardner PA, Snyderman CH. The Natural Growth Rate of Residual Juvenile Angiofibroma. J Neurol Surg B Skull Base 2017; 79:257-261. [PMID: 29765823 DOI: 10.1055/s-0037-1607419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/15/2017] [Indexed: 10/18/2022] Open
Abstract
Objectives Examine the postoperative growth rate of residual juvenile angiofibroma (JA) in a large series of patients relative to pediatric growth parameters and other prognostic factors. Establish an algorithm for postoperative surveillance of patients with JA. Design Retrospective case series. Setting Tertiary referral academic center. Participants Pediatric patients undergoing surgical resection of JA between September 2005 and June 2015. Main Outcome Measures Postoperative recurrence and tumor growth rates. Results Thirty-eight patients were identified with a mean follow-up of 24.1 months. Sixty-eight percent (26/34) of patients achieved gross total resection, and 32% (12/38) had persistent postoperative disease. Of those with postoperative residual tumor, all had preoperative skull base involvement and residual blood supply from the internal carotid artery following embolization. Sixty-seven percent (8/12) of patients with postoperative residual tumor demonstrated radiographic stability of disease with scans being completed approximately every 6 months. Radiographic rates of disease progression ranged from 4.1 to 9.22 mm/year. Conclusions Patients with preoperative skull base involvement and residual vascularity following preoperative embolization are more likely to have residual postoperative disease, and a longer postoperative follow-up is warranted in these patients. Progression of residual disease occurred approximately 7.5 months postoperatively. Younger patients may be more likely to need further intervention for postoperative residual disease, and postoperative imaging at 6-month intervals appears appropriate.
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Affiliation(s)
- Nicholas R Rowan
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Amanda L Stapleton
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States.,Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, United States
| | - Molly E Heft-Neal
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States.,Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Windfuhr JP, Vent J. Extranasopharyngeal angiofibroma revisited. Clin Otolaryngol 2017; 43:199-222. [PMID: 28714226 DOI: 10.1111/coa.12939] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Angiofibromas in the head and neck region usually arise in the nasopharynx, but may also occur elsewhere. This study aims at evaluating the incidence and clinical features of extranasopharyngeal angiofibroma (ENA). MATERIAL AND METHODS Systematic review of the literature (Medline® and Google™ ) up to 31 December 2015. RESULTS 174 cases of ENA were retrieved from a total of 170 publications. In contrast to former publications and previous understanding, the nasal septum was by far the most common site of the disease. Four patients had a congenital lesion, the oldest patient was 87 years old (mean: 28.7 years; median: 23 years). Male gender was predominantly affected, but the sex ratio was more balanced (2.13:1) than in previous reports in the literature until 12/2015. The majority of patients presented with nasal obstruction, either in combination with epistaxis (25.8%) or other symptoms (12.6%). Symptoms had developed within 13.1 months on average (median: 4 months). Brisk bleeding resulted in 11 of 43 biopsy procedures. Surgical resection as first-line therapy was performed in 170 patients. A tumour regrowth within 12 months was registered in four patients. CONCLUSION The increasing awareness of ENA and the willingness to publish case reports-not only in Medline-listed journals-resulted in a significant increase of published case reports lately. Although extremely rare, ENAs have to be taken into account in the differential diagnosis of unclear masses, particularly in adult patients presenting with a rapidly developing nasal obstruction resulting from a nasal septum tumour. Female gender or normal vascularity does not exclude the diagnosis. Transnasal resection is sufficient in most cases, and recurrences are rare. Pathologists as well as clinicians should consider ENA in their differential diagnosis of any mass of the upper airway.
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Affiliation(s)
- J P Windfuhr
- Department of Otorhinolaryngology, Head and Neck Surgery, Hospital of Maria Hilf, Moenchengladbach, Germany
| | - J Vent
- Department of Otorhinolaryngology, Medical Faculty, University of Cologne, Cologne/Koeln, Germany
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Janakiram TN, Sharma SB, Kasper E, Deshmukh O, Cherian I. Comprehensive preoperative staging system for endoscopic single and multicorridor approaches to juvenile nasal angiofibromas. Surg Neurol Int 2017; 8:55. [PMID: 28540121 PMCID: PMC5421208 DOI: 10.4103/sni.sni_295_16] [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: 08/03/2016] [Accepted: 01/04/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Juvenile nasal angiofibromas (JNA) is a benign lesion with high vascularity and propensity of bone erosion leading to skull base invasion and intracranial extension. It is known to involve multiple compartments, which are often surgically difficult to access. With evolution in surgical expertise and technical innovations, endoscopic and endoscopic-assisted management has become the preferred choice of surgical management. Over the last four decades, various staging systems have been proposed, which are largely based on the extent of nasal angiofibroma. However, no clear guidelines exist for the stage-appropriate surgical management. In this study, we aim to formulate a novel staging system based on the analysis of high quality preoperative imaging and propose detailed surgical guidelines related to disease stages as observed in 242 primary cases of JNA. METHODS A retrospective analysis of the case records of 242 primary JNA cases was performed at our center. Patients were staged according to various existing staging systems as well as our own new staging system, and outcome variables were compared with respect to intraoperative blood loss, multiple staged operations, and tumor recurrences. Operative records were studied and precise endoscopic surgical guidelines were formulated for each stage. RESULTS Comparing the intraoperative blood loss seen in stages of various classifications, it was found that intraoperative blood loss correlated best and statistically significantly with stages in the newly proposed Janakiram staging system when compared to the existing staging systems. Staged operations were performed in a total of 7/242 patients, and there was a significant association between the requirement of a staged operation and tumor extent (Fischer's exact test, P < 0.001). Tumor recurrence was seen in 22 cases and the pterygoid wedge was found to be the most frequent site of recurrence initially. As the extent of resection improved with better surgical technique over time, recurrences were only found in superior orbital fissure, around the internal carotid artery, and in the middle cranial fossa. CONCLUSION This new Janakiram staging system is based on preoperative imaging data from one of the largest JNA case series reported thus far. Respective guidelines reliably stratify patients into treatment groups with definite surgical approaches and predicts outcome. Improved surgical approaches in the modern endoscopic era have redefined JNA management with improved outcome. This study shows the importance of precise presurgical imaging and the choice of the most suitable surgical approach in reducing morbidity and mortality in JNA surgery.
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Affiliation(s)
- Trichy N Janakiram
- Department of Otolaryngology, Royal Pearl Hospital, Tiruchirapally, Tamil Nadu, India
| | - Shilpee B Sharma
- Department of Otolaryngology, Royal Pearl Hospital, Tiruchirapally, Tamil Nadu, India
| | - Ekkehard Kasper
- Department of Neurosurgical Oncology, BIDMC Cancer Center, Boston, Massachusetts, USA
| | - Onkar Deshmukh
- Department of Otolaryngology, Royal Pearl Hospital, Tiruchirapally, Tamil Nadu, India
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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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18
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Association between vascular supply, stage and tumour size of juvenile nasopharyngeal angiofibroma. Eur Arch Otorhinolaryngol 2016; 273:4295-4303. [DOI: 10.1007/s00405-016-4136-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/06/2016] [Indexed: 11/29/2022]
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Liu JK, Husain Q, Kanumuri V, Khan MN, Mendelson ZS, Eloy JA. Endoscopic graduated multiangle, multicorridor resection of juvenile nasopharyngeal angiofibroma: an individualized, tailored, multicorridor skull base approach. J Neurosurg 2016; 124:1328-38. [DOI: 10.3171/2014.12.jns141696] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Juvenile nasopharyngeal angiofibromas (JNAs) are formidable tumors because of their hypervascularity and difficult location in the skull base. Traditional transfacial procedures do not always afford optimal visualization and illumination, resulting in significant morbidity and poor cosmesis. The advent of endoscopic procedures has allowed for resection of JNAs with greater surgical freedom and decreased incidence of facial deformity and scarring.
METHODS
This report describes a graduated multiangle, multicorridor, endoscopic approach to JNAs that is illustrated in 4 patients, each with a different tumor location and extent. Four different surgical corridors in varying combinations were used to resect JNAs, based on tumor size and location, including an ipsilateral endonasal approach (uninostril); a contralateral, transseptal approach (binostril); a sublabial, transmaxillary Caldwell-Luc approach; and an orbitozygomatic, extradural, transcavernous, infratemporal fossa approach (transcranial). One patient underwent resection via an ipsilateral endonasal uninostril approach (Corridor 1) only. One patient underwent a binostril approach that included an additional contralateral transseptal approach (Corridors 1 and 2). One patient underwent a binostril approach with an additional sublabial Caldwell-Luc approach for lateral extension in the infratemporal fossa (Corridors 1–3). One patient underwent a combined transcranial and endoscopic endonasal/sublabial Caldwell-Luc approach (Corridors 1–4) for an extensive JNA involving both the lateral infratemporal fossa and cavernous sinus.
RESULTS
A graduated multiangle, multicorridor approach was used in a stepwise fashion to allow for maximal surgical exposure and maneuverability for resection of JNAs. Gross-total resection was achieved in all 4 patients. One patient had a postoperative CSF leak that was successfully repaired endoscopically. One patient had a delayed local recurrence that was successfully resected endoscopically. There were no vascular complications.
CONCLUSIONS
An individualized, multiangle, multicorridor approach allows for safe and effective surgical customization of access for resection of JNAs depending on the size and exact location of the tumor. Combining the endoscopic endonasal approach with a transcranial approach via an orbitozygomatic, extradural, transcavernous approach may be considered in giant extensive JNAs that have intracranial extension and intimate involvement of the cavernous sinus.
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Affiliation(s)
- James K. Liu
- Departments of 1Neurological Surgery and
- 2Otolaryngology–Head Neck Surgery, and
- 3Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | | | | | | | - Jean Anderson Eloy
- Departments of 1Neurological Surgery and
- 2Otolaryngology–Head Neck Surgery, and
- 3Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
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Wasl H, McGuire J, Lubbe D. Avoiding allogenic blood transfusions in endoscopic angiofibroma surgery. J Otolaryngol Head Neck Surg 2016; 45:25. [PMID: 27066789 PMCID: PMC4827172 DOI: 10.1186/s40463-016-0135-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 03/28/2016] [Indexed: 12/04/2022] Open
Abstract
Background Surgical approaches for many tumours are often limited by blood loss, exposure and risk to vital anatomical structures. Therefore, the standard of care for certain skull base tumours has become endoscopic transnasal resection. Other surgical disciplines often use cell salvage techniques, but review of the otolaryngology literature revealed very few case reports. This study investigated the value and safety of salvage-type autologous blood transfusion during the endoscopic resection of juvenile nasopharyngeal angiofibromas (JNA). Methods JNA is a rare vascular nasal tumour and the study extended over a 3-year period to obtain adequate patient numbers. All patients undergoing endoscopic resection during this period were included in the population sample. Ten patients with JNA were identified and underwent embolization prior to the endoscopic resection. In all cases the intraoperative blood salvage apparatus was used. Close post-operative monitoring was performed. Results Homologous blood transfusion could be avoided in all cases. Postoperative monitoring revealed transient bacteraemia in two cases where the leukocyte filter was not used, but no evidence of septicaemia. Conclusions Perioperative cell saver and autologous blood transfusion in endonasal JNA surgery is safe. Homologous blood transfusion can be avoided by using this technique. The use of cell salvage allows for single stage surgery without the need to abandon surgery due to excessive blood loss and its future use is promising.
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Affiliation(s)
- Hisham Wasl
- Division of Otolaryngology, University of Cape Town, Cape Town, South Africa.
| | - Jessica McGuire
- Division of Otolaryngology, University of Cape Town, Cape Town, South Africa
| | - Darlene Lubbe
- Division of Otolaryngology, University of Cape Town, Cape Town, South Africa
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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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Bilateral, independent juvenile nasopharyngeal angiofibroma: case report. The Journal of Laryngology & Otology 2015; 129:1032-5. [DOI: 10.1017/s0022215115001899] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Juvenile nasopharyngeal angiofibroma is a benign, vascular tumour that primarily occurs in adolescent males. Despite its benign nature, aggressive growth patterns can cause potential life-threatening complications. Juvenile nasopharyngeal angiofibroma is normally unilateral, originating from the sphenopalatine artery, but bilateral symptoms can occur if a large tumour extends to the contralateral side of the nasopharynx. This paper presents the first reported case of true bilateral extensive juvenile nasopharyngeal angiofibroma involving clinically challenging pre-surgical planning and surgical strategy.Case report:A 21-year-old male presented with increasing bilateral nasal obstruction and discharge. Examination revealed tumours bilaterally and imaging demonstrated non-contiguous tumours. Pre-operative angiography showed strictly ipsilateral vascular supplies requiring bilateral embolisation. Radical removal performed as one-step, computer-assisted functional endoscopic sinus surgery was performed. The follow-up period was uncomplicated.Conclusion:This case illustrates the importance of suspecting bilateral juvenile nasopharyngeal angiofibroma in patients presenting with bilateral symptoms. Our management, including successful pre-operative planning, enabled one-step total removal of both tumours and rapid patient recovery.
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Abstract
Oral and maxillofacial surgeons are often involved in the diagnosis and treatment of vascular neoplasms of the head and neck. An incorrect diagnosis may lead to improper or unnecessary treatment. This article reviews the diagnosis and management of vascular tumors.
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Dahl JP, Zopf DA, Parikh SR. Do open and endoscopic resection approaches to juvenile nasopharyngeal angiofibroma result in similar blood loss and recurrence rates? Laryngoscope 2015; 125:2436-7. [PMID: 26154365 DOI: 10.1002/lary.25471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/21/2015] [Accepted: 06/08/2015] [Indexed: 11/05/2022]
Affiliation(s)
- John P Dahl
- Department of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, U.S.A
| | - David A Zopf
- Department of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Department of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, U.S.A
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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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Doss GA, Miller JL, Steinberg H, Mans C. Angiofibroma in a cockatiel (Nymphicus hollandicus). J Comp Pathol 2015; 152:274-7. [PMID: 25728811 DOI: 10.1016/j.jcpa.2014.12.015] [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: 11/16/2014] [Revised: 12/19/2014] [Accepted: 12/30/2014] [Indexed: 10/23/2022]
Abstract
Human angiofibromas are rare and arise typically in the nasopharynx. In veterinary medicine they have only been described in the dog. Microscopically, angiofibromas consist of irregular groups of blood vessels within a stroma of connective tissue, with oedema and secondary inflammation often present. A cockatiel (Nymphicus hollandicus) was presented with an oral mass that consisted of aggregates of blood vessels surrounded by a connective tissue stroma, with the presence of oedema and secondary inflammation. Tumours of the oral cavity are uncommon in birds and to the authors' knowledge this is the first case of avian angiofibroma.
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Affiliation(s)
- G A Doss
- Department of Surgical Sciences, University of Wisconsin-Madison School of Veterinary Medicine, 2015 Linden Drive, Madison, WI, USA.
| | - J L Miller
- Department of Pathobiological Sciences, University of Wisconsin-Madison School of Veterinary Medicine, 2015 Linden Drive, Madison, WI, USA
| | - H Steinberg
- Department of Pathobiological Sciences, University of Wisconsin-Madison School of Veterinary Medicine, 2015 Linden Drive, Madison, WI, USA
| | - C Mans
- Department of Surgical Sciences, University of Wisconsin-Madison School of Veterinary Medicine, 2015 Linden Drive, Madison, WI, USA
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Snyderman CH, Gardner PA. Re: Khoueir N et al, Otolaryngol Head Neck Surg, 2014;150(3):350-358. Otolaryngol Head Neck Surg 2014; 151:183-4. [DOI: 10.1177/0194599814536366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Khoueir N, Abou Hamad W. Response to “Re: Khoueir N et al, Otolaryngol Head Neck Surg, 2014;150(3):350-358”. Otolaryngol Head Neck Surg 2014; 151:184. [DOI: 10.1177/0194599814536367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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