Validation of the Index for Facial Angiofibromas: Data analysis from a randomized controlled trial of sirolimus gel treatment in patients with tuberous sclerosis complex

The Index for Facial Angiofibromas (IFA), a novel scoring system for angiofibromas, has been validated in patients with tuberous sclerosis complex (TSC). The objective of this analysis was to further validate the IFA using data from a clinical trial of topical sirolimus in patients with TSC. This was an analysis of photographs from a Phase III trial conducted in Japan (NCT02635789). Patients (n = 62) were randomized 1:1 to receive sirolimus or placebo gel for 12 weeks. Changes in angiofibromas were independently assessed using the primary composite endpoint, the Facial Angiofibroma Severity Index (FASI), and the IFA. Thresholds for a clinically meaningful change in IFA score were evaluated using receiver operating characteristic (ROC) analysis. The IFA scores had good-to-excellent inter-assessor reliability, very high intra-assessor reliability, and could be used to evaluate the distribution of disease severity at baseline. High correlations were observed between the categorized change from baseline in IFA scores and the primary composite endpoint (Kendall's coefficient of concordance, W = 0.8655, p < 0.0001), and between the change from baseline in IFA and FASI scores (Kendall's coefficient of concordance, W = 0.745, p < 0.0001). By ROC analysis, an optimal IFA cut-off point of 1.667 was determined to distinguish patients with markedly improved or improved angiofibromas from those with slightly improved or unchanged angiofibromas (area under the curve 0.937) as determined by the primary composite endpoint. The IFA score is potentially clinically useful because of its high validity and reliability. A decrease in score from baseline of ≥1.667 may be considered clinically meaningful.

A Review of Topical Sirolimus for the Treatment of Facial Angiofibromas in Tuberous Sclerosis Complex

OBJECTIVE

This article assesses the efficacy, safety, pharmacology, and clinical applications of topical sirolimus 0.2% gel for the treatment of tuberous sclerosis complex (TSC)-associated facial angiofibromas.

DATA SOURCES

A review of the literature was conducted using the Medline (PubMed) and EMBASE databases using the keywords topical sirolimus, rapamycin, Hyftor, and tuberous sclerosis.

STUDY SELECTION AND DATA EXTRACTION

Articles written in English and relevant to the topic were included.

DATA SYNTHESIS

In the phase 2 trial, the mean improvement factor, a composite measure of improved tumor size and redness, was achieved in all patient groups (P < 0.001) with significant responses among the adult and pediatric subgroups at week 12. There were no serious adverse events recorded. In the phase 3 trial, 60% of participants responded to treatment in the sirolimus group compared with 0% in the placebo group with different response rates between the adult and pediatric subgroups at week 12. Sirolimus gel had no serious adverse events, and dry skin was the most common adverse reaction. Patients who had completed the 12-week trials were then enrolled in a long-term trial; angiofibromas had response rates of 78.2% to 0.2% sirolimus gel.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS

Topical sirolimus 0.2% is a first-in-class, newly Food and Drug Administration (FDA)-approved, mammalian target of rapamycin (mTOR) inhibitor that is a promising and safe, noninvasive alternative to surgical procedures for TSC-associated angiofibromas.

CONCLUSIONS

Topical sirolimus 0.2% gel is a moderately effective treatment for TSC-associated facial angiofibromas with an adequate safety profile.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Clinicopathological Profile of Sinonasal Masses in a Tertiary Care Center in Central India: A Retrospective Study

INTRODUCTION

Diseases of the nose and paranasal sinuses have a significant impact on the patient's functional and structural aspects. They affect all age groups and both sexes. Due to its proximity to vital structures, diseases of the nose and paranasal sinuses sometimes lead to very grave prognoses.

MATERIALS AND METHODS

This was a retrospective study done in one of central India's largest tertiary care centers. We studied 227 cases of sinonasal masses in both the non-neoplastic and neoplastic categories. Clinicopathological characteristics of masses were analyzed with the help of clinical and imaging findings and subsequently confirmed by tissue diagnosis.

RESULTS

The mean age of presentation was 45.5 years, with a male-to-female ratio of 1.25:1. Most of our patients were from lower-middle socioeconomic groups with educational qualifications below the 10th standard. Nasal obstruction was the most common symptom. A computed tomography scan was the preferred radiological investigation. Sinonasal undifferentiated carcinoma was the most common variant of malignancy, with a total number of six out of 22 (27%).

CONCLUSION

The evaluation of sinonasal masses should be carried out systematically and meticulously. Since the initial presentation of most of the diseases of the nose and paranasal sinuses is the same, a proper clinical, radiological, and tissue diagnosis should be carried out to avoid causing malignant lesions.

A Rare Association of Pituitary Macroadenoma With Nasopharyngeal Angiofibroma: A Case Report

Pituitary macroadenoma and angiofibroma are two distinct and diverse types of tumors that can develop in different anatomical locations and clinical characteristics and are not typically related to each other in terms of their hormonal or developmental aspects. This case describes an adult male with pituitary macroadenoma with nasal angiofibroma. A 35-year-old male was diagnosed with pituitary macroadenoma and incidentally found to have juvenile nasopharyngeal angiofibroma (NPA). The patient underwent a diagnostic workup, including imaging studies and hormonal assays, which confirmed the concomitant presence of both tumors. The patient underwent successful endoscopic surgical excision of the NPA and transnasal transsphenoidal endoscopic pituitary macroadenoma excision as a two-stage operation. The patient was followed up postoperatively and had no evidence of tumor recurrence or hormonal imbalances. The importance of complete and comprehensive diagnostic workup and multidisciplinary management in achieving successful and optimum treatment outcomes for coexisting NPA and pituitary macroadenoma in an adult patient is highlighted in the present report.

Juvenile Nasopharyngeal Angiofibroma in Postmenopausal Females: A Potential Link With Hyperandrogenism

A 54-year-old female presented to the otolaryngology (ENT) outpatient department with an eight-month history of unilateral nasal obstruction and headache. There was no change in the sense of smell, rhinorrhoea, facial pain, or associated epistaxis. On examination, there was a large, erythematous mass in the superior aspect of the right nasal cavity, filling the space between the nasal septum, middle, and superior meatus. The rest of the ENT examination was normal. Vital signs were all within the normal range. There was no significant past medical history, and she had tried steroid nasal spray without any benefit. She had a complete resolution of symptoms from surgical intervention, and the mass was confirmed to be an angiofibroma through histopathology. This case report discusses the importance of considering nasopharyngeal angiofibroma as a differential diagnosis for patients presenting with unilateral nasal masses, including female patients, regardless of age.

Cutaneous lesions and other non-endocrine manifestations of Multiple Endocrine Neoplasia type 1 syndrome

Background

Multiple Endocrine Neoplasia type 1 is a rare genetic syndrome mainly caused by mutations of MEN1 gene and characterized by a combination of several endocrine and non-endocrine manifestations. The objective of this study was to describe cutaneous lesions and other non-endocrine manifestations of MEN1 in a cohort of patients with familial (F) and sporadic (S) MEN1, compare the prevalence of these manifestations between the two cohorts, and investigate the correlation with MEN1 mutation status.

Methods

We collected phenotypic and genotypic data of 185 patients with F-MEN1 and S-MEN1 followed from 1997 to 2022. The associations between F-MEN1 and S-MEN1 or MEN1 mutation-positive and mutation-negative patients and non-endocrine manifestations were determined using chi-square or Fisher's exact tests or multivariate exact logistic regression analyses.

Results

The prevalence of angiofibromas was significantly higher in F-MEN1 than in S-MEN1 in both the whole (p < 0.001) and index case (p = 0.003) cohorts. The prevalence of lipomas was also significantly higher in F-MEN1 than in S-MEN1 (p = 0.009) and in MEN1 mutation-positive than in MEN1 mutation-negative (p = 0.01) index cases. In the whole cohort, the prevalence of lipomas was significantly higher in MEN1 mutation-positive compared to MEN1 mutation-negative patients (OR = 2.7, p = 0.02) and in F-MEN1 than in S-MEN1 (p = 0.03), only after adjustment for age. No significant differences were observed for the other non-endocrine manifestations between the two cohorts. Hibernoma and collagenoma were each present in one patient (0.5%) and meningioma and neuroblastoma in 2.7% and 0.5%, respectively. Gastric leiomyoma was present in 1.1% of the patients and uterine leiomyoma in 14% of women. Thyroid cancer, breast cancer, lung cancer, basal cell carcinoma, melanoma, and colorectal cancer were present in 4.9%, 2.7%, 1.6%, 1.6%, 2.2%, and 0.5% of the whole series, respectively.

Conclusions

We found a significantly higher prevalence of angiofibromas and lipomas in F-MEN1 compared with S-MEN1 and in MEN1 mutation-positive compared to MEN1 mutation-negative patients. In patients with one major endocrine manifestation of MEN1 , the presence of cutaneous lesions might suggest the diagnosis of MEN1 and a possible indication for genetic screening.

The Role of Preoperative Onyx Embolization by Transnasal Direct Puncture in the Treatment of an Advanced Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) is a rare and locally aggressive tumor that commonly presents with painless nasal obstruction and severe, recurrent epistaxis. In this case report, we describe the successful management of a Radkowski stage IIIA JNA with extensive arterial supply from the internal carotid artery (ICA). Transnasal direct puncture embolization using Onyx (Medtronic, Minneapolis, Minnesota) was employed to effectively devascularize the tumor, enabling radical surgical resection in a single piece via endonasal and transmaxillary endoscopic approaches. The patient did not require blood transfusion and was discharged without neurological impairment. The effectiveness of preoperative embolization as a treatment strategy for JNA is also discussed.

Incidental finding of tuberous sclerosis complex in a woman with hematuria: A case report of renal angiomyolipoma and review of the literature

Tuberous sclerosis complex (TSC) is a rare genetic multisystem disorder that was first described by Von Recklinghausen. We describe a case of a female, who initially presented with hematuria and was later found to have multiple manifestations of the disease. The report emphasizes the value of investigations on suspected cases.

Tuberous sclerosis complex with skin lesions as the initial presentation: A case report and multidisciplinary discussion

We reported a case of tuberous sclerosis complex with facial angiofibroma as the initial presentation and conducted a multidisciplinary discussion. The patient, a young female, was admitted to the Department of Dermatology for cosmetic purpose. After the examination, she was found to have multiple system involvement, including a large renal angiomyolipoma pressing on the liver. She never had any subjective symptom. After consultation by the multidisciplinary team of tuberous sclerosis complex, the patient was treated with everolimus orally and followed up regularly. It is suggested that dermatologists should pay attention to the systemic involvement of patients with tuberous sclerosis complex. Early intervention can prolong the life of patients and improve their life quality. Multidisciplinary collaboration for lifelong disease management is the key to enhance the diagnosis and treatment for tuberous sclerosis complex and enhance the prognosis of patients.

Racial differences in the dermatological manifestations of tuberous sclerosis complex and the potential effects on diagnosis and care

Background

Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder of non-malignant tumor growths throughout major organ systems and neurological, neuropsychiatric, renal, and pulmonary co-morbidities. Skin manifestations are readily visible, often develop early in life, and are major features that contribute to TSC diagnosis. Medical photographs of such manifestations are commonly shown as examples from White individuals creating a potential barrier to accurately identifying these features in darker skinned individuals.

Objectives

The aim of this report is to raise awareness of dermatological manifestations associated with TSC, compare their appearance by race, and consider how recognition of these features could impact diagnosis and treatment of TSC.

Design and Methods

We conducted a retrospective chart review at the TSC Center of Excellence (TSCOE) at the Kennedy Krieger Institute, which included all patients in the center from 2009 (inception) through the end of the calendar year 2015 and analyzed data from the TSC Alliance Natural History Database (NHD).

Results

Among TSCOE patients, 50% of Black patients were diagnosed before the age of 1 year, compared with 70% of White patients. NHD data corroborated this trend showing a significant difference with only 38% of Blacks as compared with 50% of Whites were diagnosed at age ⩽1 year. A significant difference was observed where White participants had higher odds of having received genetic testing in both data sets. While no differences in the total number of TSC features was observed in either data set, shagreen patches and cephalic fibrous plaques were more frequently recorded in the NHD for Black individuals.

Conclusion

We highlight a disparity in the representation of Black participants within the NHD, TSCOE, and TSC trials, in addition to differences in utilization of molecular testing and topical mechanistic target of rapamycin (mTOR) inhibitor therapy between Black and White individuals. We show a trend toward later diagnosis age in Black individuals. These differences between races warrant further study across additional clinical sites and other minority groups.

Beyond the "3 Ps": A critical appraisal of the non-endocrine manifestations of multiple endocrine neoplasia type 1

Multiple endocrine neoplasia type 1 (MEN1), an autosomal-dominantly inherited tumor syndrome, is classically defined by tumors arising from the "3 Ps": Parathyroids, Pituitary, and the endocrine Pancreas. From its earliest descriptions, MEN1 has been associated with other endocrine and non-endocrine neoplastic manifestations. High quality evidence supports a direct association between pathogenic MEN1 variants and neoplasms of the skin (angiofibromas and collagenomas), adipose tissue (lipomas and hibernomas), and smooth muscle (leiomyomas). Although CNS tumors, melanoma, and, most recently, breast cancer have been reported as MEN1 clinical manifestations, the published evidence to date is not yet sufficient to establish causality. Well-designed, multicenter prospective studies will help us to understand better the relationship of these tumors to MEN1, in addition to verifying the true prevalence and penetrance of the well-documented neoplastic associations. Nevertheless, patients affected by MEN1 should be aware of these non-endocrine manifestations, and providers should be encouraged always to think beyond the "3 Ps" when treating an MEN1 patient.

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

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

Histological Patterns of Skin Lesions in Tuberous Sclerosis Complex: A Panorama

Tuberous Sclerosis Complex (TSC) is a multisystem genetic disease characterized by cutaneous and extracutaneous hamartomas. The diagnosis is based on the association of major and minor criteria, defined by a consensus conference updated in 2012. The clinical examination of the skin is crucial because seven diagnostic criteria are dermatological: four major (hypomelanotic macules, angiofibroma or fibrous cephalic plaques, ungual fibromas, shagreen patches) and three minor criteria (confetti skin lesions, dental enamel pits, intraoral fibromas). Skin biopsy is commonly performed to assert the diagnosis of TSC when the clinical aspect is atypical. Histopathology of TSC cutaneous lesions have been poorly reported until now. In this article, we review the histologic features described in the literature and share our experience of TSC skin biopsies in our pediatric hospital specialized in genetic disorders. Both hypomelanotic lesions and cutaneous hamartomas (angiofibroma/fibrous cephalic plaques, ungual fibromas, shagreen patches) are discussed, including the recent entity called folliculocystic and collagen hamartoma, with a special emphasis on helpful clues for TSC in such lesions.

Topical sirolimus: Difference between compounded preparations and commercial oral solution

Topical sirolimus has become a crucial treatment option for many dermatologic disorders. Because an FDA-approved topical formulation is not commercially available, sirolimus creams, ointments, and gels are professionally prepared by compounding pharmacies. Also, the topical use of a commercially available sirolimus solution approved for oral administration is described regularly. To better guide providers in their decision-making when topical sirolimus is being considered, this article highlights the substantial pharmaceutical and clinical differences between commercial oral solution and compounded preparations specifically designed for topical therapy.

Fibrous papules on the lips

Multiple angiofibromas are commonly found in patients with tuberous sclerosis complex. We report a rare presentation of multiple congenital fibrous papules occurring only on the lips with no syndromic associations.

Juvenile nasal angiofibroma significant locoregional involvement

Juvenile nasal angiofibroma is a benign tumor characterized by abundant vascularization and a tendency to hemorrhage. Despite its benign histology, it can present locally expensive growth that usually presents bone remodeling and the mass effect of adjacent stuctures. We present the case of a 15-year-old patient who came to the emergency department of our center for recurrent epistaxis. After physical examination, it was decided to carry out imaging tests (CT an MRI) that reveal the presence of a large hypervascular mass in the right nostril and maxillary sinus. The patient undergoes surgery after embolization of the tumor.

The "bumpy" adolescent nose: Acne associated angiofibroma-like nasal papules

BACKGROUND/OBJECTIVE

Papular scars are a recently described clinical phenotype of acne scarring characterized by papules occurring on the nose and chin. We have observed a similar presentation of nasal papules among patients seen in our clinic for acne and sought to further characterize the clinical and histopathological characteristics of this entity.

METHODS

In this single-site case series, a retrospective review of electronic medical records of patients with nasal papules in association with acne vulgaris between April 2018 and April 2019 was performed. Clinical and histopathologic findings were recorded.

RESULTS

We identified 20 patients who presented with a similar clinical phenotype of predominantly skin-colored, dome-shaped papules concentrated on the nose and chin in association with a history of more classic facial acne vulgaris. Papular lesions were seen predominately in adolescent Hispanic males. Concomitant acne on other areas of the face was identified in 18 patients at presentation while two patients had a history of adolescent acne. Biopsies were performed for five patients. Histopathologic examination demonstrated features of fibrosis and dilated thin-walled blood vessels, typical of angiofibromas.

CONCLUSION

We present a series of adolescent patients with large, flesh-colored to erythematous papules seen predominantly on the nose. These lesions are histologically indistinguishable from angiofibromas and may represent an under-recognized yet disfiguring sequela of acne that may disproportionately affect adolescents with skin of color.

68 Ga DOTANOC PET/CT Scan in Primary Juvenile Nasopharyngeal Angiofibroma - A Pilot Study

OBJECTIVES/HYPOTHESIS

Somatostatin receptors (SSTRs) are highly expressed in neuroendocrine tumors and is exploited for its imaging and treatment. SSTRs expression is also demonstrated in diverse benign and malignant tumor cell types and proliferating peri-tumoral vessels. Similarly, Juvenile Nasopharyngeal Angiofibroma (JNA) expresses different SSTRs and may be utilized for its imaging and treatment using DOTA, 1-Nal3-octreotide (DOTANOC)-PET/CT scan.

STUDY DESIGN

Prospective cohort.

METHODS

Nineteen clinico-radiologically diagnosed primary JNA patients underwent a ⁶⁸ Ga-DOTANOC PET-CT scan. Using a dedicated PET/CT scanner, a low-dose head and neck spot CT scan was performed after 45 to 60 minutes of intravenous injection of 2 to 3 mCi(74-111 MBq) of DOTANOC. The primary objective was to assess the intensity and pattern of DOTANOC uptake in these patients.

RESULTS

DOTANOC expression was noted in all cases (n = 19) of primary JNA (100%). The mean (SD) DOTANOC SUVmax ratio of tumor and background was 6.9+/-1.4(range, 3.8-9.5). Intra-cranial extension in all 13/19 patients was prominently visualized due to the absence of DOTANOC uptake in the brain. Compared to the background all stages of JNA showed significant DOTANOC uptake (P < .0001). No difference in uptake between advanced-stage tumors and early tumors was noted (P = .47). A statistically non-significant negative trend was noted for decreasing uptake with increasing age (Spearman correlation coefficient, r = -0.19).

CONCLUSIONS

This first study of ⁶⁸ Ga-DOTANOC-PET/CT scan in JNA demonstrates consistent and reliable uptake activity in all patients irrespective of age and stage. This opens up possibilities to physiological diagnostic imaging with a promise of greater specificity and sensitivity and may have applications in ambivalent diagnostic situations such as the detection of recurrence.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1509-1515, 2021.

Forehead plaque in a child with epilepsy: A clue for tuberous sclerosis

Tuberous sclerosis complex is a common neurocutaneous disorder that predominantly affects the brain, skin, eyes, heart and kidneys. The management of tuberous sclerosis complex has been revolutionised with vigabatrin for spasms and everolimus for angiomyolipomas and seizures. We describe a 10-year-old girl with generalised tonic-clonic seizures whose diagnosis of tuberous sclerosis complex was made in view of the presence of a forehead plaque. Certain clinical pointers such as ashleaf macules, café-au-lait spots, shagreen patches and forehead plaques must therefore be looked for in a child with unprovoked seizures.

[Experience of transnazal endoscopic surgery of juvenile angiofibroma of the skull base and nasopharynx without performing preoperative embolization]

Juvenile nasopharyngeal angiofibroma (JNA) is a hypervascular, blood-supplied, benign tumour affecting the sinuses, nasal cavity, nasopharynx and the base of the skull. For intraoperative hemostasis, pre-operative embolism is a common and recommended procedure, but it has serious disadvantages, such as additional radiation exposure, anesthesia, and the risk of iatrogenic complications associated with the occlusion of the central artery of the retina, orbital and middle cerebral arteries. This article presents a report on successful radical removal of the widespread SAS without resorting to preoperative embolization, but with intraoperative transnazal endoscopic clipping of the internal maxillary artery (IMA).

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Scleromyxedema histopathologically mimicking hypercellular fibrous papules (angiofibomas): Case report of an unusual histopathological presentation

Scleromyxedema (SMX) is an inflammatory condition of unknown etiology strongly associated with monoclonal gammopathy. Classical histopathology of SMX is characterized with the triad of diffuse mucin deposits, increased amount of collagen, and presence of stellate fibroblasts. Herein, we report an unusual histopathological variant of SMX in a 41-year-old female with lesions of the nose histopathologically mimicking cellular angiofibromas. The dome-shaped papules were characterized by increased collagen bundles and fascicles of spindle cells. Widened vessels were seen at the periphery of the proliferation. Cells expressed CD68. Factor XIIIa was expressed only by dendritic cells. The mucin was highlighted with colloidal iron. In sum, we draw attention to this unusual variant of SMX, which should be suspected in a setting of multiple "angiofibromas/fibrous papules" on the face with presence of mucin.

Early Sirolimus Gel Treatment May Diminish Angiofibromas and Prevent Angiofibroma Recurrence in Children With Tuberous Sclerosis Complex

Introduction: Tuberous sclerosis complex (TSC) is a multisystem neurocutaneous disorder. Angiofibromas (AF), fibrous plaques, and hypopigmented macules are the major skin findings in TSC. Topical sirolimus reduces the volume and redness of AF and other skin findings. However, the efficacy of early intervention and long-term treatment remains to be clarified. We investigated the efficacy of sirolimus gel for AF in children with TSC.

Methods: We recruited nine children (five boys; four girls) with TSC and AF. We used 0.2% sirolimus gel over 6 months. We reviewed each patient's medical records and photographs for clinical information and data related to improvements in skin lesions. We evaluated the size of AF, fibrous plaques, and color changes in AF and hypopigmented macules.

Results: Age at the initiation of treatment ranged from 3.5 to 11.0 years. The follow-up period ranged from 6 to 36 months (≥24 months in 3 children). Patients presented with papular AF (9), miliary AF (8), AF redness (9), fibrous plaques (5), and hypopigmented macules (2). After 6 months of treatment, improvement of AF size and redness was seen in all nine patients. Patients treated for ≥24 months showed significant decrease in AF size that persisted until the final follow-up. Gradual improvement in fibrous plaques was observed, and marked reduction in size was achieved by 4–18 months.

Conclusion: Early sirolimus gel intervention is effective for the treatment of AF and fibrous plaques in children with TSC. Early intervention with sirolimus gel may maintain the skin at near-normal levels in patients with TSC.

A rare form of discoid lupus erythematosus as a rosacea and angiofibroma: A case report

The rare presentation of DLE can be rosacea-/angiofibroma-like lesions which should be considered in patients with red-pink to skin-color papules with flushing and photosensitivity.

Angiofibroma of Soft Tissue: A Newly Described Entity; A Case Report and Review of Literature

Soft tissue angiofibroma is a relatively recent addition to the ever growing list of benign soft tissue tumors. It usually presents as soft tissue mass in the lower extremities in relation to joints and tendons. The tumor is composed of spindle-shaped fibroblastic cells with arborizing capillaries. We report a case of a 55-year-old female with a lump at the dorsum of left foot. Grossly the tumor was well circumscribed with yellow white cut surface. Microscopically the tumor showed typical features of angiofibroma with myxoid areas near the periphery of the lesion. Prominent vasculature is the integral part of the tumor with numerous small, branching, thin-walled blood vessels, accompanied by medium-sized ectatic vessels. Immunohistochemically the tumor cells are positive for epithelial membrane antigen (EMA). The location of the tumor, lack of cytological atypia, mitosis, and infiltrative margins help differentiate it from a sarcoma.

[Successful treatment of facial angiofibromas with local sirolimus in childhood in Bourneville-Pringle disease]

Facial angiofibroma is the characteristic symptom and also a major diagnostic criterion for Bourneville-Pringle disease. The centrofacially localized hamartomatous tumours start to appear in early childhood, and progress over time. Facial angiofibromas represent a significant cosmetological problem for the patients and a therapeutic challenge for the physician. Beside the traditional invasive treating methods, topical sirolimus is a new, promising and well-tolerated treatment modality. Several studies and case reports have been published on this new therapeutic approach, but recommendation for the optimal sirolimus concentration still does not exist. We report here two cases when children were successfully treated with topical sirolimus. Orv Hetil. 2019; 160(13): 516-520.

Long-Term Exposure and Safety of a Novel Topical Rapamycin Cream for the Treatment of Facial Angiofibromas in Tuberous Sclerosis Complex: Results From a Single-Center, Open-Label Trial

Facial angiofibromas, composed of fibrous tissue and blood vessels appearing on the face, are closely associated with tuberous sclerosis complex. Historically, oral rapamycin, a mammalian target of the rapamycin inhibitor of cell proliferation, has been used to treat visceral tuberous sclerosis–related tumors; however, the side effect profile of this medicine generally precludes its use in patients lacking significant internal involvement. The authors developed a novel topical formulation of rapamycin cream to treat the facial angiofibroma without exposing patients to possible systemic side effects. We followed 11 patients in a long-term, open-label, prospective study to evaluate the safety and effectiveness of rapamycin cream when used chronically. All of the patients showed an improvement in the appearance of their facial angiofibroma which was maintained in long-term follow-up without safety concerns or systemic absorption. The novel rapamycin cream was tolerated well by all patients and represents a way to address the cutaneous manifestation of tuberous sclerosis complex.

Phenotypic distinctions between mosaic forms of tuberous sclerosis complex

Purpose:

To determine if mosaic tuberous sclerosis complex (TSC) can be stratified into subtypes that correspond with prognosis and extent of disease.

Methods:

Next-generation sequencing of skin tumor and other samples was used to identify patients with mosaic pathogenic variants in TSC1 or TSC2. Extent of disease, onset age, and family history of TSC were determined through retrospective analysis of patient records.

Results:

The median number of disease findings and age at penetrance differed between mosaic patients with asymmetrically distributed facial angiofibromas (4 findings, 24y, n=7), mosaic patients with bilaterally symmetric facial angiofibromas (8 findings, 10y, n=12), and germline TSC patients (10 findings, 4y, n=29). Cutaneous and internal organ involvement positively correlated in mosaic (R=0.62, p=0.005), but not germline (R=−0.24, p=0.24) TSC. Variant allele fraction (VAF) in the blood (range: 0-19%) positively correlated with the number of major features (R=0.55, p=0.028). Five had a TSC2 variant identified in the skin that was below detection in the blood. One of 12 children from a mosaic parent had TSC.

Conclusion:

The phenotype of mosaic TSC ranged from mild to indistinguishable from germline disease. Patients with mosaicism and asymmetric facial angiofibromas exhibited fewer findings, later onset, and lower VAF in the blood.

Nasopharyngeal Angiofibroma Staging with a Novel Nominal Basis: An 18-Year Study in a Tertiary Center

OBJECTIVE

To develop a systematic method for anatomic mapping of juvenile nasopharyngeal angiofibroma (JNA) tumors to standardize communication, facilitate surgical planning, and convey prognosis.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

Following Institutional Review Board approval, we performed a retrospective review of radiologic and angiographic data of patients with JNA presenting to the Department of Otolaryngology-Head and Neck Surgery, Mansoura University, from 2001 to 2017. All patients underwent angiography with embolization and had >1-year follow-up. Based on frequently involved anatomic sites and factors predictive of prognosis, the NSF-COR staging system (nose/nasopharynx, sinus, fossa-cranium, orbit, residual internal carotid artery supply) was developed to explicitly convey anatomic site of involvement and presence of residual vascularity. We validated the NSF-COR staging system against other systems with Pearson chi-square test based on risk factors and clinical outcomes of blood transfusion volume, recurrence, and JNA resectability.

RESULTS

Fifty-four patients met inclusion criteria, where all primary cases (100%) demonstrated nose/nasopharynx involvement, followed by sinus (85.2%), natural fossae (85.2%), intracranial (26%), and orbital involvement (16.7%). These sites, with assessment of residual internal carotid artery vascular supply, were used to develop the NSF-COR anatomically based staging system. The components COR showed significant association with clinical outcomes of blood transfusion and recurrence. Contingency coefficients between the NSF-COR staging system and available staging systems showed significant correlations (P < .05) for prognosis.

CONCLUSION

The NSF-COR staging system conveys a communicable anatomic map of JNA tumors that integrates residual vascularity of the tumor and demonstrates strong concordance with current staging systems to assess clinical outcomes.

International consensus statement on endoscopic skull-base surgery: executive summary

BACKGROUND

Endoscopic skull-base surgery (ESBS) is a rapidly growing discipline that often combines the expertise of otolaryngology-head and neck surgeons and neurosurgeons to provide care for these challenging conditions. As the field has grown, so too has the literature evaluating this surgical approach and the challenges and complications associated with these interventions. An international, multidisciplinary effort to critically evaluate and grade the current literature on ESBS has resulted in the International Consensus Statement on Endoscopic Skull Base Surgery (ICAR:SB). This Executive Summary highlights the key findings of the ICAR:SB document.

METHODS

Following the prior methodology of the ICAR statements, the ICAR:SB document consists of 98 topics in ESBS that underwent a systematic review. When sufficient evidence exists, an evidence-based review with recommendation (EBRR) or evidence-based review (EBR) was created and then underwent an iterative review process until consensus was achieved. This Executive Summary recapitulates these findings.

RESULTS

This summary complies the EBR and EBRR from the ICAR:SB document in the management of numerous skull-base pathologies including cerebrospinal fluid rhinorrhea, intradural tumors, sinonasal malignancies, and clival tumors, as well as the key issues of reconstruction after and the complications associated with ESBS.

CONCLUSION

The ICAR:SB Executive Summary recaps the evidenced-based recommendations concerning the advantages, limitations and challenges of ESBS in the management of diverse skull-base pathologies. Although multifactorial in nature, the overall level of evidence in ESBS is modest. This represents an opportunity to address these knowledge gaps moving forward.

A case of nasopharyngeal angiofibroma removed using a minimally invasive endoscopic endonasal technique

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.

Morbidity and Volumetric Progression in Juvenile Nasopharyngeal Angiofibroma in a Long-Term Follow-Up

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.

Extranasopharyngeal Angiofibroma Arising from the Anterior Nasal Septum in a 35-Year-Old Woman

Angiofibroma is a relatively rare vascular lesion originating predominantly in the nasopharynx and occurs typically in male adolescents. Extranasopharyngeal sites of origin, such as nasal cavity, paranasal sinuses, pharynx, and larynx, are extremely rarely seen in clinical practice. In the nasal cavity, extranasopharyngeal angiofibromas (ENAs) have been reported to originate from the nasal septum, as well as from the middle and inferior turbinate. In this study, we report a case of a 35-year-old female patient with angiofibroma originating from the anterior part of the nasal septum with left-sided nasal obstruction and mild-to-moderate epistaxis as main complaints. After the radiological diagnostics and embolization of sphenopalatine artery, we performed the excision of the lesion with removal of small part of septal mucosa and perichondrium around the attachment of tumor pedicle. Histopathological examination suggested the presence of angiofibroma and diagnosis was confirmed by immunohistochemical analysis. This is the fifth reported case of septal ENA in female population in the English-language literature.

A Man with Juvenile Nasopharyngeal Angiofibroma, Vestibular Schwannoma, Cleft Lip and Cleft Palate, and Various Nevi: Case Report and Review

Juvenile nasopharyngeal angiofibroma is a vascular tumor that typically occurs in men. Vestibular schwannoma (acoustic neuroma) is a tumor affecting the vestibulocochlear nerve. A 38-year-old man with various pigmented lesions and history of juvenile nasopharyngeal angiofibroma, vestibular schwannoma, and cleft lip and cleft palate is described. Characteristics of patients with coexisting juvenile nasopharyngeal angiofibroma and vestibular schwannoma are summarized. A search, using PubMed, was performed for the following terms: acoustic, angiofibroma, blue, cleft, combined, dysplastic, juvenile, lip, nasopharyngeal, neuroma, nevus, palate, schwannoma, and vestibular. The relevant papers were obtained and their references were reviewed. Only one man with coincident juvenile nasopharyngeal angiofibroma and vestibular schwannoma has previously been described. The juvenile nasopharyngeal angiofibromas were both right-sided and diagnosed when the patients were 13 years old and 20 years old. Our patient’s vestibular schwannoma was ipsilateral with his juvenile nasopharyngeal angiofibroma and incidentally diagnosed on a magnetic resonance imaging (MRI) scan that was performed to monitor for recurrent juvenile nasopharyngeal angiofibroma when he was in his 30s. The other man’s vestibular schwannoma and juvenile nasopharyngeal angiofibroma were diagnosed concurrently, when he was 20 years old. The observation of a patient with cleft lip and cleft palate, various melanocytic nevi, juvenile nasopharyngeal angiofibroma, and vestibular schwannoma is unique. Although the appearance of juvenile nasopharyngeal angiofibroma and vestibular schwannoma may be coincidental, the occurrence of these tumors in the same individual may suggest an association with regards to their pathogenesis.

Management and Outcome in Patients with Advanced Juvenile Nasopharyngeal Angiofibroma

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

Intra-articular angiofibroma of soft tissue of the knee: A case report

Angiofibroma of soft tissue (AFST) is an extremely rare soft tissue neoplasm that typically presents as a slow-growing, painless mass in the extremities. The present study reports an unusual case of an intra-articular AFST occurring in the left knee of a 23-year-old female. Physical examination revealed a 3-cm, relatively mobile, elastic-hard, non-tender mass. Magnetic resonance imaging detected an intra-articular soft tissue mass with iso-signal intensity relative to skeletal muscle on T1-weighted sequences and heterogeneous high signal intensity on T2-weighted sequences. Contrast-enhanced fat-suppressed T1-weighted sequences demonstrated strong peripheral enhancement of the mass. An arthroscopic excision of the mass was performed. Histologically, the tumor was composed of spindle- or oval-shaped cells in a fibromyxoid stroma with a prominent vascular pattern. Immunohistochemically, the tumor cells were diffusely positive for vimentin and CD163 and focally positive for CD68, desmin and estrogen receptor. Based on these findings, the tumor was diagnosed as an AFST. The patient had no evidence of local recurrence within 9 months of follow-up. To the best of our knowledge, this is the first case of intra-articular AFST managed successfully with arthroscopic excision.

First reported case

BACKGROUND

Proteus Syndrome (PS) is a rare hamartoneoplastic disorder consisting of a disproportionate and asymmetric overgrowth of body parts, leading to severe body and face disfigurement. Individuals with PS frequently need to undergo a number of surgical procedures including Otolaryngology interventions. Their peculiar anatomy turns even the most straightforward intervention to a challenging one.

CASE DESCRIPTION

A 31-year-old adult male with PS presented with recurrent epistaxis and nasal obstruction. A nasal mass was found during the physical examination, which was surgically removed under general anesthesia. Histology revealed juvenile angiofibroma.

CONCLUSION

This is the first reported case of a patient with PS presenting with juvenile nasopharyngeal angiofibroma. Although vascular malformations may appear in these patients, juvenile nasopharyngeal angiofibroma should be taken under consideration when PS patients present with recurrent epistaxis. HIPPOKRATIA 2017, 21(3): 147-149.

[The transperygoid approach to the removal of a recurrent juvenile angiofibroma at the base of the skull without preoperative embolization]

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.

Reflectance confocal microscopy features of facial angiofibromas

Facial angiofibromas are benign tumors presenting as firm, dome-shaped, flesh-colored to pink papules, typically on the nose and adjoining central face. Clinically and dermoscopically they can mimic melanocytic nevi or basal cell carcinomas (BCC). Reflectance confocal microscopy (RCM) is a noninvasive imaging tool that is useful in diagnosing melanocytic and non-melanocytic facial lesions. To date no studies have described the RCM features of facial angiofibromas. Herein, we present two cases of facial angiofibromas that were imaged with RCM and revealed tumor island-like structures that mimicked BCC, leading to skin biopsy.

New developments in the genetics and pathogenesis of tumours in tuberous sclerosis complex

In just the past 5 years, dramatic changes have occurred in the clinical management of tuberous sclerosis complex (TSC). Detailed knowledge about the role of the TSC proteins in regulating the activity of the mammalian target of rapamycin complex 1 (mTORC1) underlies this paradigm-shifting progress. Advances continue to be made in understanding the genetic pathogenesis of the different tumours that occur in TSC, including pivotal discoveries using next-generation sequencing (NGS). For example, the pathogenesis of angiofibromas is now known to involve UV-induced mutations, and the pathogenesis of multifocal renal cell carcinoma (RCC) in TSC is now known to result from distinct second-hit mutations. In parallel, the pathological features of TSC-associated tumours, including TSC-associated renal cell carcinoma, continue to be defined, despite the fact that TSC was first described 180 years ago. Here, we review recent discoveries related to the pathological features and genetic pathogenesis of TSC-associated tumours. Copyright © 2016 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Topical Use of Mammalian Target of Rapamycin (mTOR) Inhibitors in Tuberous Sclerosis Complex-A Comprehensive Review of the Literature

BACKGROUND

Tuberous sclerosis complex is a genetically determined multisystem disorder that may affect almost any human organ. The discovery of the mammalian target of rapamycin (mTOR) pathway and its involvement in tuberous sclerosis complex-related pathology has led to the introduction of mTOR inhibitors into clinical practice. Topical administration of mTOR inhibitors for skin lesions related to tuberous sclerosis complex may represent a reasonable alternative for more invasive procedures. A growing number of patients have been described exhibiting positive therapeutic effects from the topical administration of these agents. The aim of this review was to systematically analyze available literature on the use of topical mTOR inhibitors to treat dermatologic lesions related to tuberous sclerosis complex.

RESULTS

A comprehensive review of PubMed, Medscape, and Cochrane databases between 1995 and 2015 was performed to identify available studies describing topical use of mTOR inhibitors in individuals with tuberous sclerosis complex. In most studies, topical mTOR inhibitor application proved to be effective in the treatment of skin lesions related to tuberous sclerosis complex. Facial angiofibromas were the target lesions in most instances. Few studies reported clinical improvement of hypomelanotic macules. These drugs directly address the molecular defect related to tuberous sclerosis complex manifestations.

CONCLUSIONS

Currently available clinical data suggest that topical application of mTOR inhibitors may be effective in the treatment of facial angiofibromas associated with tuberous sclerosis complex. Ongoing randomized clinical trials of topical mTOR inhibitors for TSC-related cutaneous lesions should add clarity to the role of these agents.

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

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

[Hypopharyngeal angiofibroma: a case report]

Swallowing obstruction, gradually increase, with a sore throat, no fever, no haemoptysis, no dyspnea, routine tests: blood routine, biochemical examination, blood coagulation routine, electrocardiogram, chest X-ray, did not show abnormalities.

Nasopharyngeal angiofibroma: Our experience and literature review

Introduction: Juvenile nasopharyngeal angiofibroma is a rare, highly vascular, and histologically benign tumor, generally observed in male adolescents. It shows very aggressive behavior due to local invasiveness and is associated with various symptoms. Juvenile nasopharyngeal angiofibroma originates in the sphenopalatine forame, causing epistaxes and nasal obstruction.

Objective: To retrospectively describe our experience in the diagnosis and treatment of patients with juvenile nasopharyngeal angiofibroma.

Scientific drawing: Retrospective, descriptive study conducted after approval from the Ethics Committee of the Federal University of Sergipe (protocol 0114.0.107.000 -11).

Methods: We analyzed findings in 20 patients who underwent surgery between 2004 and 2011. Factors analyzed include patient age and gender, symptoms, stages, treatment, length of surgery, intraoperatory bleeding, postoperative need for nasal tampons, hospitalization time, complications, and tumor recurrence.

Results: Patients were aged 10–29 years. All patients were treated surgically, including 17 who underwent endoscopic surgery. The mean operation time was 120 min, and the mean bleeding volume was 300 mL. Seventeen patients required clamping of the external carotids and tumor embolization.

Conclusion: Endoscopic surgery alone or with other conventional techniques was safe for the treatment of angiofibromas of different stages.