Management Of Juvenile Nasopharyngeal Angiofibroma Research Articles

Endoscopic surgical management of juvenile nasopharyngeal angiofibroma: Correlating tumour characteristics, risk of hemorrhage, and recurrence

ObjectivesJuvenile nasopharyngeal angiofibroma is an uncommon tumour primarily seen in young males. It is characterized by its vascular nature and aggressive growth pattern, presenting a significant surgical challenge. Endoscopic sinonasal surgery has become the treatment of choice, reducing both morbidity and blood loss, as well as recurrence rates. This study aims to present the clinical characteristics and surgical outcomes of patients with juvenile nasopharyngeal angiofibroma treated exclusively with endoscopic surgery at our centre. MethodsA retrospective cohort study was conducted on cases of juvenile nasopharyngeal angiofibroma treated with endoscopic surgery at a single centre between 2013 and 2023. ResultsA total of 21 patients were included in the study, with a mean age of 17.7 years. 57.14 % of the patients presented with an advanced stage (Stage ≥ IIc Radkowsky). The median volume was 79.2 cm3. Pre-surgical embolization was performed in all cases. 7 patients (33.3 %) required blood transfusion. The need for blood transfusion was associated with greater tumour volume (p = 0.0028), intracranial extension (p = 0.025), extension to the infratemporal fossa (p = 0.024), and orbital extension (p = 0.026). There were 2 cases (9.5 %) of tumour recurrence/persistence, both classified as stage IIIb. Tumour persistence/recurrence was more common in patients with intracranial extension (p = 0.045). ConclusionExclusive endoscopic resection of these tumours, regardless of volume and extension, does not increase the risk of blood loss or recurrence. Advanced-stage tumours, especially those with intracranial extension, present a higher risk of bleeding and tumour persistence. In these cases, the low morbidity of the endoscopic approach becomes more evident.

A Clinicopathological Profile and management of Juvenile Nasopharyngeal Angiofibroma in a Tertiary Care Centre in Central India

A Clinicopathological Profile and management of Juvenile Nasopharyngeal Angiofibroma in a Tertiary Care Centre in Central India

Juvenile Nasopharyngeal Angiofibroma: Outcomes Analysis Based Upon Hospital Volume.

To evaluate the management of juvenile nasopharyngeal angiofibroma (JNA) from a national perspective with outcomes comparison based on hospital volume. Ten-year Pediatric Health Information Systems (PHIS) data analysis. The PHIS database was queried for the diagnosis of JNA. Data regarding demographics, surgical approach, embolization, length of stay, charges, readmission, and revision surgery was collected and analyzed. Hospitals were classified as low volume if fewer than 10 cases and high volume if greater than or equal to 10 cases during the study period. A random effects model compared outcomes based on hospital volume. A total of 287 JNA patients were identified with a mean age of 13.8 (± 2.7) years. Nine hospitals were classified as high volume, accounting for a total of 121 patients. The mean length of hospitalization, blood transfusion rate, and 30-day readmissions did not differ significantly by hospital volume. Patients cared for at high-volume institutions were less likely to require postoperative mechanical ventilation (8.3% vs. 25.0%; adjusted RR=0.32; 95% CI 0.14-0.73; p < 0.01) or return to the operating room for residual disease than patients admitted to low-volume hospitals (7.4% vs. 20.5%; adjusted RR=0.38; 95% CI 0.18-0.79; p=0.01). The management of JNA is complex from both an operative and perioperative management standpoint. Over the past decade, nearly half (42.2%) of JNA patients have been managed at nine institutions in the United States. These centers have significantly lower rates of postoperative mechanical ventilation and the need for revision surgery. 3 Laryngoscope, 133:3216-3220, 2023.

Juvenile nasopharyngeal angiofibroma: National practice patterns and resource utilization via HCUP KID

BackgroundJuvenile nasopharyngeal angiofibroma (JNA) is a locally aggressive benign vascular tumor that typically afflicts young adolescent males. Historically removed via open approaches, these tumors are now being removed endoscopically. As the modern healthcare setting emphasizes value, efficient utilization of resources may lead to decreased cost while maintaining or improving patient outcomes. ObjectiveThe objective of this study was to investigate how perioperative management of juvenile nasopharyngeal angiofibromas (JNAs) influence overall cost. We specifically investigate the effect of approach type (open, endoscopic, or combined) with regards to cost and length of stay. We also delineated practice patterns, analyzed safety profiles, and characterize clinical outcomes. MethodsThe 2016 Healthcare Cost and Utilization Project Kids’ Inpatient Database (HCUP-KID) was queried to identify males aged <21 years with an ICD-10-CM diagnosis code of D10.6 (benign neoplasm of nasopharynx) and ICD-10-PCS codes to determine whether an open, endoscopic or combined approach was performed. Univariate statistical analysis and multivariable logistic regression were performed to examine the effects of demographics, patient characteristics, procedure type, and complications on length of stay (LOS) and cost. ResultsA total of 89 male patients were analyzed with a mean age of 14.8 years (range 8–20 years). Mean LOS was 3.4 days. Mean total charges were $128,780. Comparing open (n = 16), endoscopic (n = 65), and combined (n = 8) approaches, there was a significant difference in the need for fresh frozen plasma (p = 0.02) and packed red blood cell (pRBC) (p = 0.03) transfusion but no difference in preoperative embolization (p > 0.05) between approach types. LOS was associated with age (p = 0.02), pRBC transfusion (p = 0.04) and septal deviation (p = 0.03). Charges varied with LOS (p < 0.001) on linear regression analysis but not with other variables in this dataset. ConclusionApproach type for JNA appears to be unrelated to LOS or charges in this multi-site, population-based analysis. However, septal deviation, pRBC transfusion, and young age are associated with increased LOS in patients undergoing JNA resection.

A five-year experience in endoscopic endonasal excision of juvenile nasopharyngeal angiofibroma

Introduction: Juvenile nasopharyngeal angiofibroma (JNA) is a histological benign but locally aggressive vascular tumour which can invade the base of skull. Aim: This is a retrospective study with the aim to examine the outcome of patients with JNA and endoscopic endonasal excision of tumour at a tertiary center in Malaysia. Material and methods: 9 patients were identified from the medical record office from 2015 to 2019. We review the data on patient demographics, clinical presentations, laboratory investigations, intraoperative blood loss and duration of hospital stay. Results and discussion: 8 patients were male, 1 was female. The average age of diagnosis was 15 (range 11 to 29) years. The commonest chief complaint was recurrent epistaxis, followed by nasal obstruction and nasal discharge. Three patients were at stage I, 4 patients at stage II, 1 patient at stage III and 1 patient at stage IV based on Fisch classification. All patients underwent primary endoscopic endonasal excision of tumour with no vascular, ophthalmological or neurological complication. Seven patients had preoperative embolization done. Average operation time was 137 minutes (range 60–360 minutes). Intraoperative blood lost varied from 500 mL to 1300 mL (mean 777.7 mL). All patients were discharged well with no recurrence. Conclusions: The management of JNA can be challenging. The current shift in management favouring endoscopic endonasal excision of JNA reduces postoperative morbidity. It is possible to be applied on all stages of tumour with good success rate.

Plasma ablation-assisted endoscopic excision versus traditional technique of endoscopic excision of juvenile nasopharyngeal angiofibroma

BackgroundJuvenile nasopharyngeal angiofibroma is the vascular and locally aggressive tumor of the posterior nares and nasopharynx. Endoscopic excision is the preferred surgical modality in early Radkowski stages. The prime challenge is intraoperative bleeding. Literature is in favor of the use of plasma ablation to overcome surgical challenges. ObjectiveTo evaluate the effectiveness of plasma ablation technique in the surgical management of juvenile nasopharyngeal angiofibroma. Materials and methodsThe current study recruited 36 patients of clinico-radiologically diagnosed cases of primary JNA of stage I and II (Modified Radkowski). In prospective arm, 18 consecutive patients were recruited, who underwent plasma ablation assisted endoscopic excision. In retrospective arm, 18 consecutive patients who underwent excision by traditional endoscopic instruments in the past two years, were recruited. Both the groups were compared for baseline characteristics, intraoperative blood loss, duration of surgery, length of hospital stay, and recurrence rates. ResultsThe use of plasma ablation decreased overall blood loss by 338 ml (mean difference) which was not statistically significant (p = 0.26). On subgroup analysis, the use of plasma ablation significantly decreased mean blood loss (648 ml, p = 0.046) and duration of surgery (83 min, p < 0.001) in patients who underwent embolization. No statistically significant difference was noted between two groups in length of hospital stay (p = 0.36) and recurrence rates (p = 0.64). ConclusionPlasma ablation is an effective technique available to decrease blood loss and duration of surgery during endoscopic excision of post embolized stage I and II patients of JNA.

Current Management of Juvenile Nasopharyngeal Angiofibroma

The purpose of this article is to provide a current review of the most important management principles for evaluation and treatment of juvenile nasopharyngeal angiofibroma. Numerical staging systems have been adapted many times over the years, but a new nominal staging system based on specific anatomical site involvement and residual internal carotid artery vascularization helps to provide a more comprehensive alternative for evaluation. An expanding body of evidence supports the use of an endoscopic surgical approach to reduce risk of tumor recurrence and reduce intraoperative blood loss. With minimally invasive, endoscopic techniques available, the primary treatment modality for JNA remains surgery. However, gamma knife radiosurgery can be useful in a multimodality approach to more advanced cases of JNA and to address recurrence in the immediate postoperative period. This review focuses on the evaluation and surgical management of juvenile nasopharyngeal angiofibroma with emphasis placed on the most current staging systems, the necessity for preoperative embolization, the endoscopic approach to resection, and the adjuvant therapies that are available.

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

Objective 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. Study 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.

Evaluation of the Anaesthetic Management of Juvenile Nasopharyngeal Angiofibroma in a Tertiary Cancer Care Hospital: A Five Year, Prospective Observational Study

Evaluation of the Anaesthetic Management of Juvenile Nasopharyngeal Angiofibroma in a Tertiary Cancer Care Hospital: A Five Year, Prospective Observational Study

Massive juvenile nasopharyngeal angiofibroma: ode to the open surgical approach

The management of juvenile nasopharyngeal angiofibroma has undergone a significant evolution, with more surgeons moving towards the minimal invasive endoscopic approaches. Although considered the standard of care by most, an...

Benign Primary Neoplasms

The goal of this paper is to present a detailed up-to-date overview of sinonasal benign neoplasms by reviewing their clinical and pathological characteristics, their diagnosis and their treatment. Traditionally, excision of larger benign neoplasms required invasive open approaches; however, due to advances in endoscopic surgery, there has been a shift towards their complete removal without employing any visible scars. The use of the chemotherapeutic agent 5-fluorouracil in the management of inverted papilloma in the frontal sinus has aided with disease control, where complete excision via the endoscopic route is difficult and challenging. The management of nasal papilloma by surgery, consensus opinion advocates removal of all diseased mucosa including subperiosteal excision of the sclerotic bone at the primary setting to maximize the likelihood of disease free outcome. In the management of juvenile nasopharyngeal angiofibromas, recent advances include the use of pre-surgical treatment with anti-androgen therapy which results in tumour shrinkage and devascularisation of the tumour by embolization prior to undertaking surgery. Benign sinonasal neoplasms are uncommon and have a number of aetiologies; however, they share common presenting symptoms. Despite being termed ‘benign’, some of these lesions are locally invasive involving the bone of the skull base and the orbit. An awareness of these uncommon lesions, their diagnostic characteristics and their specific management is fundamental to undertaking surgical treatment.

Complications of Midface Swing for Management of Juvenile Nasopharyngeal Angiofibroma.

Access osteotomies provide direct exposure to inaccessible areas of the deep part of craniofacial skeleton for treating pathologies involving vital structures. The use of maxillary swing approach for gaining wide access to the nasopharynx, infratemporal fossa, parapharyngeal space, middle fossa of skull base. Though the maxillary swing requires transfacial incision for wide exposure but with careful handling the scar is minimum and this approach can be used in young people. Surgical resection is carried out following preoperative embolization of the involved feeder vessels. Total 16 cases were considered for this study. This article highlights cases successfully treated in our institution, the mention of complications associated with the cases along with management. Maxillary swing is a good approach for getting access to the deep pathologies like JNA.

The Natural Growth Rate of Residual Juvenile Nasopharyngeal Angiofibroma

Introduction: The surgical management of juvenile nasopharyngeal angiofibromas (JNA) is well described; however, the exact role and time course of postoperative surveillance and imaging remains unknown. With reported recurrence rates of upwards of 50% in some cases, the need for post-operative imaging following surgical resection of JNA is relevant. It has been hypothesized in the literature that a surge in hormones during puberty may induce growth of residual tumor. However, the natural growth rate of this rare tumor in the postoperative setting remains unknown. The goal of this study is to examine the postoperative growth rate of residual disease in a large series of patients relative to pediatric growth parameters and other prognostic factors, and to establish an algorithm for postoperative surveillance.

Endoscopic versus Traditional Craniofacial Approaches in Management of Juvenile Nasopharyngeal Angiofibromas

Background: Surgical management of juvenile nasopharyngeal angiofibromas (JNA) has traditionally been through craniofacial techniques. Endoscopic approaches to sinonasal tumors are now commonly performed in a safe and efficacious manner. For JNAs, in combination with pre-operative embolization, complete resection with recurrence rates similar to traditional approaches is possible.

English

BACKGROUND:Juvenile nasopharyngeal angiofibroma (JNA) is an uncommon lesion which exclusively occurs in an adolescent male. They comprise about 0.05% to 0.5% of all head and neck tumors. The surgical management of this lesion is challenging. This tumor being highly vascular has the potential to bleed torrentially during surgery. The advent of endoscopic sinus surgery has significantly modified the way in which the tumors of the nose and paranasal sinus have been managed.AIM AND OBJECTIVES OF THE STUDY:Audit the clinical and operative data, to ascertain the role of preoperative embolization and autologous blood transfusion.STUDY DESIGN: Retrospective study.SUBJECTS AND METHODS:Clinical and operative data of all patients of JNA during the period 2008 to 2011were included in this study.RESULTS: Complete tumor removal was obtained in all the eight cases. Seven of these cases had Stage II b and 1 had stage III b (Radkowski classification). Six cases were managed by endonasal endoscopic approach. Two cases were treated by external approach. All patients underwent super selective embolisation preoperatively 24 hour prior to surgery. The average blood loss during surgery was 362ml+/-176.2ml. All but one had received autologous blood transfusion during surgery. CONCLUSION: Pre-operativeembolization minimizes the intra operative blood loss. Autologous blood transfusion needs to be planned in advance and reduces the morbidity associated with transfusion. Endonasal endoscopic surgery has tremendously reduced the morbidity and facial morphological deformity in surgical management of Juvenile nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibroma: Timisoara ENT Department's experience

Juvenile nasopharyngeal angiofibroma is a histologically benign, but very aggressive and destructive tumor found exclusively in young males. The management of juvenile nasopharyngeal angiofibroma has changed in recent years, but it still continues to be a challenge for the multidisciplinary head and neck surgical team. ObjectiveThe purpose of this study was to review a series of 30 patients describing the treatment approach used and studying the outcome of juvenile nasopharyngeal angiofibroma in the ENT Department Timisoara, Romania for a period of 30 years. MethodsThe patients were diagnosed and treated during the years 1981–2011. All patients were male. Tumors were classified using Radkowski's staging system. Computed tomography and magnetic resonance imaging allowed for accurate diagnosis and staging of the tumors. Biopsies were not performed. Surgery represented the gold standard for treatment of juvenine nasopharyngeal angiofibroma. All patients had the tumor removed by an external approach, endoscopic surgical approach not being employed in this series of patients. ResultsAll patients were treated surgically. Surgical techniques performed were: Denker–Rouge technique in 13 cases (43.33%), paralateronasal technique in 7 cases (23.33%), retropalatine technique in 5 cases (16.66%) and transpalatine technique in 5 cases (16.66%). No preoperative tumor embolization was performed. The recurrence rate was 16.66%. The follow-up period ranged from 1 year to 12 years. ConclusionsManagement of juvenile nasopharyngeal angiofibroma remains a surgical challenge. Clinical evaluation and surgical experience are very important in selecting the proper approach. A multidisciplinary team, with an experienced surgeon and good collaboration with the anesthesiologist are needed for successful surgical treatment.

Bilateral Non-Superselective Embolization With Particles Under Transient Occlusion of the Internal Carotid Artery in the Management of Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) is a rare histologically benign tumor, highly vascularized, with usually aggressive behavior, and can extend from the nasal cavity to neighboring structures. We present the case of a 14-year-old male harboring a JNA, presenting with an active severe and persistent epistaxis. Two previous surgical attempts of removal were unsuccessful, because of profuse intraoperative bleeding. Angiography showed a highly vascularized neoplasm with multiple branches arising from both internal carotid arteries, with absence of branches from the external carotid due to previous surgical ligation. Direct puncture tumor embolization was not possible because removal of nasal packing triggered major hemorrhage. The only option for embolization was a technique of non-superselective embolization with particles under transient occlusion of the internal carotid artery. The procedure was performed uneventfully from either side, the tumor was subsequently removed, and the patient had no recurrence 2 years after the initial treatment.

Juvenile Angiofibroma: The “Anchorage” Concept

Objective: To present the Anchorage Concept, a set of characteristics shown by juvenile nasopharyngeal angiofibroma (JNA) that hinder the surgical resection and contribute to intraoperative complications and incomplete excisions. Method: Case series consisting of 46 JNAs in the past 10 years (2001-2011) and including tumors I to IIIb in Radowski staging classification. Surgical technique varied according to tumor stage and included exclusive endoscopic surgery, external access and combined, with or without preoperative embolization. Results: Multiplicity of vascular pedicles: The maxillary artery, JNA’s principal irrigation source, commonly presents as an extension of the lesion, laterally positioned. This characteristic makes vascular clipping difficult and demands a careful surgical dissection next to the external carotid vascular trunk. Besides its main vascular trunk, JNA has many other vascular pedicles which become an anchoring factor and provoke intraoperative bleeding. Vector and growth angles: During its growth, JNA may dispose vectors that form angles in relation to nasal cavity. Sometimes, these angles are 90° shaped. From its origin at the upper margin of the sphenopalatine foramen, JNA grows forward and backward into the nasal cavity and maxillary sinus, upward into the sphenoid, laterally toward the pterygopalatine fossa, and inferiorly toward the infratemporal fossa, via the pterygomaxillary fissure. Conclusion: The Anchorage Concept must be taken into account in the management of JNA. Knowledge of these points is of great value to facilitate the removal of the tumor, which persists being a surgical challenge in most cases.

Juvenile Nasopharyngeal Angiofibroma

The aim of this study was to review recent management of juvenile nasopharyngeal angiofibroma (JNA) in our institution during the past 10 years and to analyze the shift in surgical paradigm based on the rate of endoscopic approach and Radkowski staging. Case series with chart review. The study was conducted from April 2000 to August 2010 in a tertiary care university hospital (Lariboisière, Paris, France). All patients referred for a JNA were included in the study. Medical files and imaging data were retrospectively analyzed. Surgical management was then evaluated for 2 different periods (group 1, n = 31, consecutive patients operated on from April 2000 to June 2005, and group 2, n = 41, from July 2005 to August 2010). Seventy-two patients were operated on, with a mean age of 16.25 years (range, 9-33 years). The rate of the endoscopic approach was significantly higher in group 2 than in group 1 (82.9% vs 45%). Rates of recurrence and complications were similar. Recurrences (ie, residual disease growing and treated by redo) were noted in 6 cases or 8.3% (group 1, n = 3; group 2, n = 3; P > .05). Progress in skull base anatomy, instrumentation, cameras, and surgical strategy allows for expansion of the indications for endoscopic removal of JNA. This approach may have a better outcome in terms of blood loss, hospital stay, and local sequelae. Still, an external approach should be considered only for selected cases due to massive intracranial extension or optic nerve or internal carotid artery entrapment by the tumor.

An Outcome Review of the Surgical Management of Juvenile Nasopharyngeal Angiofibroma (JNA)

Objective: To review endoscopic and open approaches in the surgical treatment of juvenile nasopharyngeal angiofibromas (JNA).