Letter to the editor: surgical management of advanced juvenile nasopharyngeal angiofibromas

Abstract

Dear Editor We read with great interest the paper of Cherekaev et al., Advanced craniofacial juvenile nasopharyngeal angiofibroma. Description of surgical series, case report, and review of literature” published in Acta Neurochir (2011) 153:499–508 [3]. In this report the authors review their experience with 27 cases of patients with juvenile nasopharyngeal angiofibromas (JNAs) Fisch grade III and IV. Although the authors must be congratulated for their high rates of gross total resection (83%), there are some specific points in their paper that deserve special consideration. The authors rightly state that in advanced cases of JNA, “Non-radical excision of tumors may be also due to presence of blind zones and areas of limited access which cannot be visualized by operative microscope." Due to this fact most of the recent surgical literature has focused on the progressive role of either purely endoscopic or endoscopicassisted procedures, instead of the conventional microscopic techniques [1, 4, 5]. In our recently published series focusing exclusively on JNAs with intracranial extension, total resection was achieved in 85% of the cases through endoscopic-assisted and purely endoscopic techniques in up to two surgical interventions [8]. Our series seems to reflect the broad tendency of the surgical literature, especially regarding the transition from combined microscopic-endoscopic techniques (used in our institution before 2008) to purely extended endoscopic approaches alone or in combination with minor sublabial incisions [7]. Therefore, based on this experience, we cannot agree with the authors that the “endoscopic approach has its limitations: tumors Fisch grades III/V with advanced intracranial involvement including cavernous sinus, orbit, growth around optic nerves, lateral growth into infratemporal fossa, and spreading behind the pterygoid process which conflicts with endoscopic exploration. In such cases, endoscopic resection is not indicated.” In our experience of 20 patients with JNAwith intracranial extension, all patients presented involvement of the cavernous sinus, and spread into the orbit was observed in five cases. Such cases were successfully treated with endoscopic techniques with the addition of anterior maxillectomy in some selected cases (Fig. 1). All the aforementioned areas, which the authors suppose to be a contraindication for endoscopic approaches, can be successfully exposed by the addition of the extended modules of endoscopic endonasal approaches reported by the UPMC group (transpterygoid/infratemporal approach, zone 5; the cavernous sinus, zone 4) [9]. In relation to advanced tumors, the authors state that “Currently, three different opinions can be distinguished: