Juvenile Nasopharyngeal Angiofibroma: Correlating Histology, Surgical Approach and Blood Loss

ABSTRACT Juvenile nasopharyngeal angiofibroma (JNA) is locally destructive benign vascular tumor for which surgical excision has always been the treatment of choice, in spite of the availability of various other treatment modalities. Complete removal at the maiden attempt has always been the key to a successful outcome. Recurrences (or rather residuals) discourage both the surgeon and patient. This prospective study was carried out in the Department of Otorhinolaryngology, Sir Sayajirao General Hospital, Vadodara, Gujarat, between August 2002 and 2015. We have studied 28 patients with JNA for growth patterns, histological characteristics and to compare various surgical modalities. Besides other investigations a detailed histological examination of the tumor was performed which suggested that as the tumor ages, the stroma predominates and the vessels are compressed into slits. In actively growing tumor the vascular component predominates. The percentage of open vascular channels is directly proportional to the bleeding while the intervascular fibrosis is inversely related. Surgical excision of JNA is the preferred modality of treatment. Surgical approach is sometimes the most tricky decision. Choosing the right approach is akin to walking on the thin rope with adequate exposure on one side and postoperative scar on the other. How to cite this article Thapar T, Gupta RR, Jagtap PJ, Aiyer RG. Juvenile Nasopharyngeal Angiofibroma: Correlating Histology, Surgical Approach and Blood Loss. Clin Rhinol An Int J 2015;8(2):47-52.

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Transnasal microscopic approach for juvenile nasopharyngeal angiofibroma

Otolaryngologia Polska ◽

10.5604/01.3001.0012.2303 ◽

2018 ◽

Vol 72 (5) ◽

pp. 31-36 ◽

Cited By ~ 1

Author(s):

Wiesław Gołąbek ◽

Anna Szymańska ◽

Kamal Morshed

Keyword(s):

Infratemporal Fossa ◽

Surgical Excision ◽

Vascular Tumor ◽

Stage I ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Preoperative Embolization ◽

Stage Iiia ◽

Nasopharyngeal Angiofibroma ◽

Feeding Vessels

Introduction: Juvenile nasopharyngeal angiofibroma (JNA) is a rare, benign, vascular tumor originating in the nasopharynx. The treatment of choice for JNA is surgical excision. In recent years, surgical management has been greatly influenced by the use of the transnasal endoscopic technique. The aim: The aim of the study was to present our experience with the transnasal microscopic removal of JNA. Material and methods: Ten patients with JNA aged 12-17 underwent diagnostics imaging and transnasal microscopic tumor excision. Medical records of patients were retrospectively reviewed. The main outcome measures were complications and recurrences. Preoperative embolization of feeding vessels was performed in 7 patients. Results: According to Andrews’ classification, the group included 2 stage I patients, 6 stage II patients and 2 stage IIIA patients with the extensive occupation of the infratemporal fossa. 9 patients had no recurrence in 6-11 years follow up. One stage IIIA patient had a recurrence posteriorly to the pterygopalatine process and it was completely removed. No complications during or after surgery occurred. Conclusion: Transnasal microscopic excision is an effective approach to resect stage I-IIIA JNA

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Management of Pterygoid Venous Plexus Hemorrhage during Resection of a Large Juvenile Nasopharyngeal Angiofibroma: A Review of 27 Cases

Ear Nose & Throat Journal ◽

10.1177/014556131309200513 ◽

2013 ◽

Vol 92 (5) ◽

pp. 204-208

Author(s):

Lin Chang ◽

Yi Zixiang ◽

Fang Zheming ◽

Lin Gongbiao ◽

Li Zhichun ◽

...

Keyword(s):

Blood Loss ◽

Surgical Approach ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Imaging Data ◽

Venous Plexus ◽

Nasopharyngeal Angiofibroma ◽

Intraoperative Bleeding ◽

Type Iii ◽

Type Iv ◽

Facial Vein

We retrospectively reviewed the cases of 27 patients who experienced intraoperative bleeding during resection of a large (Fisch type III or IV) juvenile nasopharyngeal angiofibroma (JNA). Of this group, 16 patients had a type III JNA and 11 had a type IV tumor. The degree of hemorrhaging during excision of these JNAs varied greatly among individual patients. The amount of blood lost ranged from 200 to 5,000 ml (mean: 1,800) in the type III cases and from 700 to 8,000 ml (mean: 2,850) in the type IV cases. In 5 of these cases, both intraoperative observations and imaging data suggested that an important factor in the blood loss was damage to the pterygoid venous plexus (PVP). The PVP communicates with the cavernous sinus, ophthalmic vein, maxillary vein, and facial vein; no valve exists between these veins. In patients with a large JNA, the PVP is usually compressed by or adherent to the tumor. When a PVP is seriously damaged during removal of a JNA, hemorrhaging can be very profuse. Therefore, a suitable surgical approach and appropriate hemostatic procedures should be used to prevent or manage PVP hemorrhage as effectively as possible. We also describe in greater detail 5 typical cases of JNA excision that did (n = 3) and did not (n = 2) involve PVP damage.

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Juvenile Nasopharyngeal Angiofibroma: Changing Paradigms in Management

Bengal Journal of Otolaryngology and Head Neck Surgery ◽

10.47210/bjohns.2018.v26i1.154 ◽

2018 ◽

Vol 26 (1) ◽

pp. 35-42

Author(s):

Vijay Bhalla ◽

Ramakrishnan Narayanaswamy

Keyword(s):

Blood Loss ◽

Staging System ◽

Vascular Tumor ◽

Demographic Variables ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Military Hospital ◽

Endoscopic Endonasal ◽

Nasopharyngeal Angiofibroma ◽

Camera Systems ◽

Endoscopic Methods

Introduction Juvenile Nasopharyngeal Angiofibroma (JNA) is a tumor of young and adolescent males. It is a benign vascular tumor arising from the spheno-palatine foramen. It is best managed surgically at present by endoscopic methods with or without pre-operative embolization. Tumor attributes like intracranial extent and residual vascularity after embolization need to be assessed pre-operatively before undertaking endoscopic surgery, in order to reduce surgical blood loss and morbidity. Materials and Methods Twenty-three cases of JNA (n=23) were operated endoscopically at a tertiary level military hospital. They were staged with the Snyderman staging system. Demographic variables including stage wise management were brought out with intraoperative time and blood loss recorded for different stages. Results The intraoperative surgical time, intra-operative blood loss and recurrence/residual rates were compared with similar studies in existing literature and correlated well. Conclusion Endoscopic Endonasal approach to JNA is now a well-established technique. With improvements in embolization techniques and better instrumentation like HD camera systems, endo-bipolar cautery, Coblation and endo-liga clips and neuro-navigation, better visualization and better haemostatis can be achieved, resulting in significant reduction in the morbidity and improvement in surgical results.

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Trend analysis in management of juvenile nasopheryngeal angiofibroma: our institutional experience

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20195696 ◽

2019 ◽

Vol 6 (1) ◽

pp. 94

Author(s):

Heli H. Vasani ◽

Chinmayee P. Joshi ◽

Kalpesh B. Patel

Keyword(s):

Surgical Excision ◽

Vascular Tumor ◽

Endoscopic Approach ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Surgical Approaches ◽

Open Approach ◽

Nasopharyngeal Angiofibroma ◽

Endoscopic Method ◽

Group A ◽

Group B

Background: Juvenile nasopharyngeal angiofibroma is a vascular malformation rather than true neoplasm. It accounts for 0.5% of all head and neck tumors and its general incidence is 1:150,000. It is uncommon, benign, extremely vascular tumor that arises from tissues in the sphenopalatine foramen, the pterygoid base causing Early spread submucosally towards nasopharynx. Surgical excision is mainstay of treatment.Methods: This is a retrospective observational study carried out from March 2002 to March 2019, 130 patients underwent surgical resection of juvenile nasopharyngeal angiofibroma at Civil Hospital, Ahmedabad. Patients were divided in two groups with Group-A having patients from 2002-2010 and Group B having patients from 2011-2019.Results: A total 130 cases of juvenile nasopharyngeal angiofibroma with a mean age of 16.25 years (range 9-33) were treated by surgical excision from March 2002 to March 2019. In Group A patients open approach was used most often with endoscopic approach used only till stage II-A. In Group B patients the preferred surgical approach was trans-nasal endoscopic approach cases up to stage IV-A and open approach including the midfacial degloving approach and infratemporal approach was used cases with extensive intracranial, lateral infratemporal fossa, orbit, optic nerve, cavernous sinus involvement.Conclusions: Our study shows that over the years there has been shift in surgical approaches used in treating angiofibroma with the advent of newer endoscopic method and addition of various technology such as coblation, navigation has made the procedure for a highly vascular tumor simpler.

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Management of Juvenile Nasopharyngeal Angiofibroma: A Three Years Retrospective Study

Bangladesh Journal of Otorhinolaryngology ◽

10.3329/bjo.v21i1.24294 ◽

2015 ◽

Vol 21 (1) ◽

pp. 33-37

Author(s):

Sharfuddin Mahmud ◽

Dipali Biswas ◽

Manilal Aich ◽

Md Abdur Rouf Sardar

Keyword(s):

Retrospective Study ◽

Surgical Approach ◽

Preoperative Evaluation ◽

Preoperative Staging ◽

Vascular Tumor ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Common Symptom ◽

Nasopharyngeal Angiofibroma ◽

Factors Affecting ◽

Male Adolescents

Introduction: Juvenile nasopharyngeal angiofibroma is a pathologically benign yet locally aggressive and destructive vascular tumor. It comprises 0.5% of neoplasms in the head and neck typically affecting adolescent boys.Material & Method: A retrospective study of surgically treated patients of juvenile nasopharyngeal angiofibroma was performed over a period of 3 years. The study discusses about most common presenting complaints, correlation of preoperative radiological and intraoperative staging and factors affecting recurrence of juvenile nasopharyngeal angiofibroma.Result: 20 surgically treated patients were included in the study; all were male with average age of 15.7yrs having epistaxis and nasal obstruction as the most common symptom. Preoperative staging was almost similar with intraoperative staging except one case which needed upstaging. Suitable surgical approach was adopted considering site of lesion. Two recurrent cases were also managd successfully.Conclusion: Juvenile nasopharyngeal angiofibroma is a benign disease of male adolescents with bone eroding capacity. The planning of surgical approach for its excision has utmost importance which is based on extent of the lesion or staging done pre-operatively. Early preoperative evaluation not only helps in better management but also prevents recurrence of JNA.Bangladesh J Otorhinolaryngol; April 2015; 21(1): 33-37

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Successful Repair of Large Skull Base Defect Following JNA Excision

Clinical Rhinology An International Journal ◽

10.5005/jp-journals-10013-1028 ◽

2010 ◽

Vol 3 (1) ◽

pp. 49-52

Author(s):

Alok Thakar ◽

Gaurav Gupta ◽

Mohnish Grover

Keyword(s):

Skull Base ◽

Free Flap ◽

Surgical Excision ◽

Vascular Tumor ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Intracranial Extension ◽

Nasopharyngeal Angiofibroma ◽

Young Males ◽

Skull Base Defect ◽

Successful Repair

Abstract Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular tumor of young males. Surgical excision remains the principal modality of treatment. Tumors with intracranial extension may require major surgical resections which are not devoid of complications. We here present a case of JNA with massive intracranial extension with postsurgery huge skull base defect with resultant encephalocele which was repaired successfully using rectus abdominis free flap.

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Juvenile Nasopharyngeal Angiofibroma - Excision Through Lateral Rhinotomy and Sublabial Approach - A Case Report

Journal of Dhaka Medical College ◽

10.3329/jdmc.v20i1.8587 ◽

1970 ◽

Vol 20 (1) ◽

pp. 78-81

Author(s):

NK Sinha ◽

MH Rashid ◽

MM Shaheen ◽

DC Talukder ◽

MAY Fakir ◽

...

Keyword(s):

Surgical Excision ◽

Complete Removal ◽

Definitive Treatment ◽

Surgical Approaches ◽

Complete Excision ◽

Nasopharyngeal Angiofibroma ◽

Male Adolescents ◽

Large Size ◽

Complete Surgical Excision ◽

Sublabial Approach

Juvenile angiofibroma is a rare hypervascular, locally aggressive benign tumour which is exclusively found in the nose and paranasal sinuses of male adolescents. The definitive treatment for this tumour is complete surgical excision. Different surgical approaches are used for complete excision. Most recent development is excision of the tumour using endoscopes. But in certain cases with large size and different extensions, open transfacial approaches are the choice for complete removal and for less operative bleeding, which are the main challenges for surgical excision of this tumour. DOI: http://dx.doi.org/10.3329/jdmc.v20i1.8587 J Dhaka Med Coll. 2011; 20(1) :78-81

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Bilateral, independent juvenile nasopharyngeal angiofibroma: case report

The Journal of Laryngology & Otology ◽

10.1017/s0022215115001899 ◽

2015 ◽

Vol 129 (10) ◽

pp. 1032-1035 ◽

Cited By ~ 2

Author(s):

M-L Mørkenborg ◽

M Frendø ◽

T Stavngaard ◽

C Von Buchwald

Keyword(s):

Case Report ◽

Contralateral Side ◽

Growth Patterns ◽

Sinus Surgery ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Computer Assisted ◽

Nasopharyngeal Angiofibroma ◽

Operative Planning ◽

Life Threatening ◽

One Step

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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Massive juvenile nasopharyngeal angiofibroma: ode to the open surgical approach

BMJ Case Reports ◽

10.1136/bcr-2016-218731 ◽

2017 ◽

pp. bcr-2016-218731

Author(s):

Ravi Meher ◽

Nikhil Arora ◽

Eishaan Kamta Bhargava ◽

Ruchika Juneja

Keyword(s):

Surgical Approach ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Nasopharyngeal Angiofibroma ◽

Open Surgical Approach

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Role of Transarterial Angiography with Embolization in Deciding Surgical Approach to Juvenile Nasopharyngeal Angiofibroma: A Step-Ladder Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1715594 ◽

2020 ◽

Author(s):

Ravi S. Manogaran ◽

Arulalan Mathialagan ◽

Vivek Singh ◽

Prabhaker Mishra ◽

Rajat Jain ◽

...

Keyword(s):

Surgical Approach ◽

Tertiary Care ◽

Three Dimensional ◽

Vascular Supply ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Vascular Pattern ◽

Nasopharyngeal Angiofibroma ◽

Intraoperative Bleeding ◽

Angiography And Embolization

Abstract Objectives This study was aimed to understand the usefulness of transarterial angiography and embolization in management of juvenile nasopharyngeal angiofibroma (JNA) and to apply the information obtained to stage the disease, select appropriate surgical approach, predict intraoperative bleeding, and prognosticate the disease. Design This study represents a retrospective review of the patients of JNA with major focus on transarterial angiography and embolization findings and its clinical and surgical implications. Setting The study conducted at a tertiary-care super-specialty referral center. Participants Forty-two patients who had undergone transarterial angiography and embolization followed by surgery over the period of 5 years from July 2015 till February 2019 were participated in this study. Main Outcome Measures Tumor vascular pattern based on transarterial angiography, staging of the disease based on extent and vascular supply, surgical approach selected, and prognosticating the disease were determined from this study. Conclusion Transarterial angiography with embolization becomes a prudent preoperative investigation for management of JNA. It provides a complete three-dimensional map of the tumor with stage-specific vascular pattern, reduces vascularity of the tumor, and predicts the sites from where bleeding can occur intra operatively. Thus, it helps in choosing the appropriate surgical approach aiding in complete tumor removal with minimal bleeding.

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