Juvenile Nasopharyngeal Angiofibroma are rare vasoformative neoplasms of the Nasopharynx. Due to the innocuous nature of their presenting symptoms, the tumor frequently has extra nasopharyngeal extensions at the time of initial diagnosis. The advances in radiographic CT techniques and pre–operative emobilization have reduced the mortality and morbidity to a great extent. We analyzed nine cases of angiofibroma with and without emobilization and concluded that preoperative emobilization reduces intra operative blood loss considerably, giving excellent surgical clearance of the tumor mass with minimal risk of recurrence.
Materials and methods
Nine cases of proved nasopharyngeal angiofibroma after clinical evaluation, imaging and angiography, were subjected for the surgical resection. First 14 cases of Stage I and II were approached by the Tran palatal route and whole tumor mass with pedicle attached at the nasapharynx was excised. These cases which did not undergo emobilization and the total blood loss of 10–12 units was quite significant intra–operatively.(because of unavailability of embolization facilities)
The second group of 24 cases of stage II B and C were subjected for surgical clearance by lateral rhinotomy and Tran–palatal approach. The whole mass could be removed. The preoperative emobilization reduced intra–operative blood loss considerably,and required only two units of blood. The post–operative recovery was uneventful. The third group of another 12 cases of Stage III (a) was approached by lateral rhinotomy and Medical Maxillectomy. The preoperative emobilization reduced intra–operative blood loss significantly requiring only one unit of blood giving precise surgical excision in the tumor mass clearance. All cases treated at this hospital did not show any recurrence so far.
Table 1
| Surgical approach | No. of cases | |
| 1 | Trans–palatal. | 14 |
| 2 | Trans–palatal with lateral rhinotomy. | 24 |
| 3 | Lateral rhinotomy with medial maxillectomy. | 12 |
| 4 | Endoscopic | 15 |
| Total Cases | 65 | |
In all the 65 cases there was no morbidity or mortality and no other significant complications were encountered.
Discussions
Juvenile nasapharyngeal angiofibroma though benign in nature are aggressive and locally invasive – always extending to extra nasopharyngeal spaces. They are always found in male adolescents and are associated with significant morbidity and mortality after surgical excision. The recurrence rate is seen between 20%–30%. The origin of these tumors is at the superior margin of the sphenopalatine foramen and extends to the least resistance area, pterygo–maxillary fossa, intratemporal fossa and intracranium. The symptoms are nearly always nasal obstruction and recurrent epistaxis. As the tumor stage (2,4) increases, the associated symptoms like disordered speech, proptosis, and conductive deafness are seen.
Table II
| Revised staging for INA | |
| Stage IA | Limited to nose and nasopharynx. |
| Stage IB | Extension into more than one sinus. |
| Stage IIA | Minimal extension into PMF. |
| Stage SIB | Full occupation of PMF with or without erosion of orbital bone. |
| Stage IIC | Intra temporal fossa with or without cheek. |
| Stage IIIA | Erosion of skull base and minimal intra cranial extension. |
| Stage IIIB | Erosion of skull base with extensive intra cranial extension. |
Table III
| Age distribution | ||
| Age | Sex | Cases |
| 12–15 | M | 14 |
| 15–18 | M | 24 |
| 18–20 | M | 12 |
| 20-24 | 15 | |
| Total | 65 | |
The Ideal treatment modality5 is always surgical excision for resectable lesions and chemo radiotherapy for non–resectable lesions.
The common surgical approaches recommended are Trans palatal,Ttransantral, LateralRrhinotomy with medial maxillectomy andMidfacial degloving.,and Endoscopic surgical excision The surgical approach is planned according to the staging of the tumor. We prefer endoscopic approach for small lesions of Stage I, Transpalatal and lateral rhinotomy with medial maxillectomy and endoscopic approach for stage IIB and IIIA. The Pre–operative carotid angiography with gelfoam emobilization is must which will reduce intra–operative blood loss considerably with excellent and precise tumor mass clearance.
Transfemoral route of catheterization under LA was used in all cases. The emobilization with small gelfoam is effective in reducing blood loss at surgery and contributed to improved long term outcome without significant morbidity and mortality. Complications like accidental embolism of the brain, and ophthalmic artery, facial nerve palsy and necrosis of skin and soft tissue may occur.
It is recommended that surgical procedure should be undertaken within 24 to 28 hours after pre–operative emobilization. In our 65 cases, the follow up was more than five years for 14 cases, one year and six months for 12 cases and six months for the last few cases. Wich failed for followups All cases so far showed excellent recovery with no recurrence.
Conclusions
Selective pre–operative emobilisation of ECA, ICA and IMA play an important role in reducing intra–operative blood loss during the surgical clearance of the nasopharyngeal angiofibroma. It gives excellent surgical clearance and precise working during surgery. It reduces the recurrence rate because of total removal of tumor mass. It reduces the morbidity mortality. We recommend the lateral rhinotomy and medial maxillectomy and endoscopic approach for better clearance of Stage IIA and Stage IIIA lesions. Inacceable growth involving skull base extension must be subjected for post op radiation. The cosmetic result of lateral rhinotomy is acceptable at the cost of potentially lethal and invasive tumors. Now with recent advances in imaging for skull base lesions Endoscopic surgery is gaining excellent platform.
Contributed by Dr. K. K. Desarda
