Juvenile Nasopharyngeal Angiofibromas: Does an External Approach Still Make Sense?

Abstract

Objective: Endoscopic removal has recently become the standard procedure in the case of small juvenile angiofibromas. However, large lesions encroaching the skull base remain a challenge. The aim of this work is to define extensions which at present cannot be addressed reasonably endoscopically. Method: Retrospective review based on cases treated from 2000 to 2010. Ratio of endoscopically treated patients has been analyzed together with staging and topographic description of these lesions. Results: Fifty-nine patients were treated from 2000 to 2010, of whom 31 were treated endoscopically. Ratio of endoscopic procedures raises from 37% (n = 10) for the 2000 to 2005 period to 84% (n = 26) for the 2006 to 2010 period. This trend, analyzed according to the staging following Radkowski, is not related to earlier diagnosis of smaller tumors, since ratio of stage IIIA is similar. Indeed, development of approaches to pterygopalatine fossa, infratemporal fossa, temporal fossa, inferior orbital fissure, orbital apex, and even cavernous sinus allowed control of deep and far-seated lesions. Conclusion: Refinement of hemostasis techniques and 4-hands surgery (Castelnuovo) allows the treatment of lateral-seated tumors, even if large. Posterior extensions may be reached through a transpterygoid approach. Only lesions which engulf the ICA or the optic nerve need further evaluation to choose between open approach or incomplete, subtotal removal.