Resection Of Juvenile Nasopharyngeal Angiofibroma Research Articles

Juvenile Nasopharyngeal Angiofibroma: A Series of 96 Surgical Cases

Abstract Introduction Juvenile nasopharyngeal angiofibroma (JNA) is a benign vascularized tumor that affects almost exclusively male adolescents. Surgery is the treatment of choice for JNA. Objectives The present study is a 42-year retrospective review of a series of JNA cases treated surgically without previous embolization. Methods The present is a retrospective, descriptive study based on medical records of 96 patients with JNA who underwent microscopic or endoscopic excision without previous embolization from 1978 to 2020 in a single institution. The patients were categorized according to the Andrews et al. stage, and data were collected on age, gender, tumor staging, surgical approach, affected side, and outcome. Results All patients were male, with an average age of 17 years. The predominant tumor stage consisted of type II, with 52.1%. A total of 33.3% of the patients were submitted to the microscopic technique and 66.7%, to the endonasal technique. The rate of intraoperative blood transfusion was of 17.7%. Conclusion The present study reinforces that resection of JNA in various stages is viable without previous artery embolization.

Extended Endonasal Endoscopic (EEE) Surgery with Almost No Use of Adjuvant Radiotherapy for Juvenile Nasopharyngeal Angiofibroma (JNA).

Background and Objectives: Juvenile nasopharyngeal angiofibroma (JNA) is an angiomatous hamartoma of the nasal cavity. It is a benign but locally aggressive vascular tumor of the nasopharynx affecting adolescent males. Many surgical procedures are in practice, but the extended endonasal endoscopic (EEE) approach for JNAs is a suitable and effective technique. Materials and Methods: Fifteen adolescent patients having JNA who underwent extended endonasal endoscopic (EEE) surgery from January 2010 to January 2022 were studied retrospectively. Patients having residual and recurrent JNAs and those who underwent surgery other than EEE were excluded. Results: The average age of the patients was 18.3 years of age. A total of six patients (40%) each had stage V and IV while three patients (20%) had stage III JNAs. Gross total removal was achieved in eight (53.3%) patients and seven (43.7%) had partial removal. There was no per or postoperative mortality. All the patients had at least 3 years of postoperative follow-up and during follow-ups, seven patients were found to have residual tumors, and two had recurrences. Discussion: During the last decades, the endoscopic approach for the resection of JNAs has gained increasing popularity due to its obvious advantages over transfacial approaches. The magnified and angled field of view "behind the corner" helping in a more complete inspection for the resection and shorter hospitalization time makes it a better choice than the other approaches. Conclusions: Endoscopy is an excellent approach for primary JNA. It allows well visualization and precise removal of the angiofibroma. An endoscopic multiangle, multicorridor skull base approach including Denker's anteromedial maxillotomy is suitable and preferable for the resection of extensive JNAs.

Surgical approach analysis of endoscopic resection of juvenile nasopharyngeal angiofibroma

Objective:To investigate the surgical approach for the resection of juvenile nasopharyngeal angiofibroma（JNA） under nasal endoscopy. Methods:The clinical data of 87 patients undergoing endoscopic resection of nasopharyngeal fibroangioma were retrospectively analyzed. We classified JNA according to tumor site, size, invasion scope and anatomic position relationship between tumor and midline of pupil. Three endoscopic surgical approaches were selected according to the classification, and the postoperative symptoms, complications and recurrence were investigated and analyzed. Results:The tumor resection rate of 87 cases by nasal endoscopic surgery was 100%. Thirty-five cases were approached through the middle nasal passage（small tumors located in the nasal sinuses and pterygopalatine fossa）, forty-five cases were approached through the lateral wall of the nasal cavity（tumor invaded the pterygopalatine fossa but did not exceed the midline of the pupil） , and seven cases were approached via the lateral wall of nasal cavity + ipsilateral anterior wall of maxillary sinus（tumor invaded the infratemporal fossa beyond the midline of pupil or invaded the cavernous sinus and the middle cranial fossa epidural）, Postoperative patients with nasal congestion, nasal bleeding, headache, dizziness, vision loss and other symptoms showed varying degrees of improvement. No surgical death or intracranial infection occurred. The postoperative follow-up was 6-78 months, and the recurrence rate was 3.44%. Conclusion:Endoscopic resection of nasopharyngeal fibroangioma is the main treatment method for JNA. Selecting suitable endoscopic approach to resect JNA, To maximize the advantage of nasal endoscopic equipment according to the inherent anatomical space of the human nasal cavity, In order to achieve the purpose of JNA resection, reduce intraoperative and postoperative complications, reduce the recurrence rate and improve the prognosis.

Embolization in Juvenile Nasopharyngeal Angiofibroma Surgery: A Systematic Review and Meta-Analysis.

To compare outcomes of juvenile nasopharyngeal angiofibroma (JNA) resection between embolized and non-embolized cohorts, and between transarterial embolization (TAE) and direct puncture embolization (DPE). Per PRISMA guidelines, PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched for publications prior to or in 2021. Original English manuscripts investigating the resection of JNA with and without preoperative embolization were included. Embolization type, recurrence rate, complication rates, blood loss, and transfusions were extracted. Risk of bias was assessed by the Risk of Bias in Non-randomized Studies-of Interventions method. There were 61 studies with 917 patients included. Preoperative embolization was performed in 79.3% of patients. Of those embolized, 75.8% (N=551) underwent TAE and 15.8% (N=115) underwent DPE. JNA recurrence in embolized patients was lower than in non-embolized patients (9.3% vs. 14.4%; odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.35, 1.06). DPE resulted in lower rates of disease recurrence (0% vs. 9.5%; OR: 0.066, 95% CI: 0.016, 0.272) and complications (1.8% vs. 21.9%; OR: 0.07, 95% CI: 0.02, 0.3) than TAE. A random effects Bayesian model was performed to analyze the difference in mean blood loss in 6 studies that included both embolized and non-embolized patients. This analysis showed a mean reduction in blood loss of 798 mL in the embolized group. We found embolization decreases blood loss in JNA resection. DPE led to improved recurrence and complication rates when compared to TAE, but future prospective studies are needed to further evaluate which embolization technique can optimize outcomes in JNA. NA Laryngoscope, 133:1529-1539, 2023.

A Comparision of Nitroglycerine and Dexmedetomidine for Controlled Hypotension in Endoscopic Resection of Juvenile Nasopharyngeal Angiofibroma

Background: Juvenile nasopharyngeal angiofibroma(JNA) is a locally invasive benign vascular tumor, controlled hypotension is used to facilitate endoscopic resection. Nitroglycerine and Dexmedetomidine were compared as hypotensive agents in this study. Methods : Ethics Committee has approved the study which was conducted at Government ENT hospital, Hyderabad during 2016 – 2018.Study included 40 patients divided into two groups, Group D (Dexmedetomidine) n=20,1µg/kg over 15 min followed by a maintenance infusion at 0.5µg/kg/hr,GroupN(Nitroglycerine) n=20- Nitroglycerine @ 0.5µg/kg/min and titrated in doses 0.5-5µg/kg/min for target blood pressure respectively. Results : A statistically significant difference was observed in the study in mean pulse rate between two groups Group D-66.09±2.83, Group N-86.59±4.24, p value 0.0001. Blood loss was lower in Group D-310.71±140.58 compared to Group N 482.61±141.42 , and is statistically significant (p value 0.0004). SBP, DBPand MAP were comparatively lower in Group D throughout the surgery. Conclusions: Dexmedetomidine is a better hypotensive agent with favourablehemodynamics and significantly less blood loss when compared to Nitroglycerine.

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

<p class="abstract"><strong>Background:</strong> 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.</p><p class="abstract"><strong>Methods:</strong> 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.</p><p class="abstract"><strong>Results:</strong> 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.</p><p class="abstract"><strong>Conclusions:</strong> 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.</p><p class="abstract"> </p>

Implication of embolization in residual disease in lateral extension of juvenile nasopharyngeal angiofibroma

A few studies have reported incomplete resection of juvenile nasopharyngeal angiofibroma (JNA) following embolization. The likely effects of embolization, viz. shrinkage/reduced tensile strength may have increased the fragility of tumour, leaving remnants postoperatively particularly across hour-glass constriction of sphenopalatine foramina. This paper describes the likelihood of residual disease being left following embolization and hence the importance of extended surgery for complete excision.

Cumulative sum analysis of the learning curve for endoscopic resection of juvenile nasopharyngeal angiofibroma.

To determine the learning curve with cumulative sum analysis for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and investigate whether the surgeon's expertise is a risk factor for recurrence. We reviewed the medical records of patients with JNA who underwent endoscopic or endoscopic-assisted surgery between 2006 and 2015. We used cumulative sum (Cusum) analysis to plot the learning curve for operation time versus chronological sequence, and verified the Cusum curve by risk-adjusted Cusum (RA-Cusum) analysis. We identified three phases of expertise. The recurrence rate was analyzed using the Kaplan-Meier method and log-rank tests. A multivariable Cox regression analysis was performed to identify the independent risk factors for recurrence. We included 154 JNA patients with a median age of 16years. The surgeon overcame the learning curve after case 80 with increasing surgical efficiency and competence. The learning curve plotted by Cusum analysis divided the cases into three phases: phase 1, accumulation of initial experience (cases 1-41); phase 2, further accumulation of experience (cases 42-117); and phase 3, mastering the procedure (cases 118-154). Pearson's χ2 tests showed that tumor stage (P = 0.021), blood loss (P = 0.001), operation time (P < 0.001), and phase (P < 0.001) were associated with recurrence. The log-rank test showed that time to recurrence was significantly shorter in phase 1 than in phases 2 and 3. Blood loss and phase were independently prognostic factors for time to recurrence, with P values of 0.023 and 0.009, respectively. The RA-Cusum analysis identified two inflection points of the curve at case 44 and 83, and verified the results of Cusum analysis. Surgical experience and competence with endoscopic resection affect the recurrence rate in JNA patients. 4.

Direct Puncture Embolization for Endonasal Resection of Juvenile Nasopharyngeal Angiofibroma Supplied by Internal Carotid Artery

Introduction: Juvenile nasopharyngeal angiofibromas (JNAs) have a propensity for major blood loss when approached surgically. Use of preoperative transarterial (TA) or direct tumor puncture (DTP) embolization has been shown to reduce blood loss during resection. It is critical to determine the embolization technique that best suits a specific tumor prior to resection to optimize surgical conditions by minimizing intraoperative bleeding. We present a case report that underscores the importance of this treatment approach and begs for the development of such an algorithm.

Avoiding allogenic blood transfusions in endoscopic angiofibroma surgery.

BackgroundSurgical approaches for many tumours are often limited by blood loss, exposure and risk to vital anatomical structures. Therefore, the standard of care for certain skull base tumours has become endoscopic transnasal resection. Other surgical disciplines often use cell salvage techniques, but review of the otolaryngology literature revealed very few case reports. This study investigated the value and safety of salvage-type autologous blood transfusion during the endoscopic resection of juvenile nasopharyngeal angiofibromas (JNA).MethodsJNA is a rare vascular nasal tumour and the study extended over a 3-year period to obtain adequate patient numbers. All patients undergoing endoscopic resection during this period were included in the population sample. Ten patients with JNA were identified and underwent embolization prior to the endoscopic resection. In all cases the intraoperative blood salvage apparatus was used. Close post-operative monitoring was performed.ResultsHomologous blood transfusion could be avoided in all cases. Postoperative monitoring revealed transient bacteraemia in two cases where the leukocyte filter was not used, but no evidence of septicaemia.ConclusionsPerioperative cell saver and autologous blood transfusion in endonasal JNA surgery is safe. Homologous blood transfusion can be avoided by using this technique. The use of cell salvage allows for single stage surgery without the need to abandon surgery due to excessive blood loss and its future use is promising.

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.

Endonasal Endoscopic Excision of Juvenile Nasopharyngeal Angiofibroma- The Technical Difficulties &amp; Advantages

Objective: Endoscopic excision of juvenile nasopharyngeal angiofibroma (JNA) was carried out with the objective of minimizing blood loss and attempting to complete excision of tumor under direct vision with the help of Hopkins telescope.Study design: A retrospective 12 year study of 6 cases of JNA treated by endoscopic excision is presented.Result: According to Radkowski’s classification, two patients were stage Ia, two were stage Ib and two patients were stage IIb. The mean duration of the surgery was 2 hours. The mean intra-operative blood loss was 575 ml. The mean follow –up after the primary operation was 23.3 months. All the patients but one were free of disease. One patient had a recurrence in the pterygopalatine fossa requiring a successful revision procedure 3 years after the primary surgery.Conclusion: Endoscopic resection of JNA is a difficult but effective operation in experienced hands. The endoscopic management had less intra operative blood loss, lower occurrence of complications, shorter length of hospital stays and lower rate of recurrence. So it should be considered as a first choice option.Birdem Med J 2014; 4(2): 74-78

Fully endoscopic resection of juvenile nasopharyngeal angiofibroma – Own experience and clinical outcomes

ObjectivesThe treatment of choice in juvenile nasopharyngeal angiofibroma (JNA) is surgery – nowadays endoscopic techniques. The aim of the study was to present the results of endoscopic treatment in patients diagnosed with juvenile angiofibroma. Materials and methodsIn this retrospective case series, 10 patients with a diagnosis of JNA treated at the Department of Otolaryngology of the Medical University in Poznań from 2006 to June 2013 were included. The age of patients were between 11 and 19 years old (14.6 on average). In 9 out of 10 patients the treatment was preceded by embolization. The surgery used the endoscopic approach through one nostril and the four-handed technique. ResultsTotal resection was possible in all cases. Blood loss ranged from 100 to 250ml. Post-operative hospitalization lasted from 3 to 5 days (3.3 days on average). Recurrence was reported in one patient. The observation lasted from six months to seven years (3.55 on average). ConclusionsEndoscopic resection of juvenile angiofibroma is safe for the patient. Moreover, if the evaluation of the tumour size and staging is correct, the ability of total removal of the tumour is very high. It is also connected with small blood loss, short hospital stay and good cosmetic effects.

Juvenile nasopharyngeal angiofibroma with intracranial extension – A review of 29 cases

Abstract Background: Complete resection has been the preferred treatment for extracranial juvenile nasopharyngeal angiofibromas (JNA) but resection of JNA with intracranial extension (ICE) can be quite challenging because of the associated risk of extensive haemorrhage. The aim of this study was to assess the neurological outcome of patients undergoing surgery for removal of JNA with ICE and analyse various perioperative anaesthetic factors that could possibly affect the outcome. Materials and Methods: This retrospective study was conducted including patients with JNA with ICE requiring combined otolaryngological and neurosurgical approach for tumour removal at our centre from January 2001 to December 2010. Patient's medical and anaesthesia records were reviewed and data regarding patient demography, pre-operative investigations, anaesthetic management, post-operative investigations and complications, number of days of intensive care unit (ICU) and hospital stay and Glasgow Outcome Scale (GOS) at the time of discharge from hospital were collected and reviewed. Results: A total of 29 patients were operated. The median age of presentation was 15 years. Nineteen patients (65.5%) had a good GOS of 5 at discharge, 7 (24.1%) had moderate outcome with GOS of 4 and 3 patients (10.3%) had poor outcome with GOS of ≤3. There was one mortality in our study. Perioperative factors affecting the GOS at discharge were amount of intra-operative blood loss, intra-operative infusion of packed red blood cells (RBCs) and colloid and post-operative haemoglobin. Conclusion: The outcome of patients with JNA is affected by intra-operative blood loss and transfusion.

Use of Coblation in Resection of Juvenile Nasopharyngeal Angiofibroma

We present a series of 4 patients with juvenile nasopharyngeal angiofibroma (JNA) who underwent Coblation-assisted endoscopic resection after preoperative embolization, and discuss the use and advantages of endoscopic Coblation-assisted resection of JNA. Our limited case series suggests that Coblation may be used in the resection of JNA after embolization in a relatively safe, efficient, and effective manner. Coblation allows for decreased bleeding, less need for instrumentation, and improved visualization. There are limited published data in the literature to date on the use of Coblation in endoscopic JNA resection. We describe its use in a more extensive tumor than those previously reported. Further studies are needed to fully define the safety and utility of Coblation technology for this application.

Endoscopic Graduated Multi-Angle Multi-Corridor Resection of Juvenile Nasopharyngeal Angiofibroma

Introduction: Juvenile nasopharyngeal angiofibromas (JNAs) are formidable tumors because of their hypervascularity and difficult location in the skull base. Traditional transfacial procedures do not always afford optimal visualization and illumination, resulting in significant morbidity and poor cosmesis. The advent of endoscopic procedures has allowed for resection of JNA with greater surgical freedom and decreased incidence of facial deformity and scarring.

Clinical effect of Le Fort I osteotomy approach associated with endoscope for the resection of juvenile nasopharyngeal angiofibroma

To analyze the clinical effect of Le Fort I osteotomy approach associated with endoscope for the resection of juvenile nasopharyngeal angiofibroma. Three patients with juvenile nasopharyngeal angiofibroma, stage II b, were retrospectively analyzed. All of them underwent Le Fort I osteotomy approach associated with endoscope between 2004 and 2009. All patients were followed up at first, third, sixth months and one year after surgery. Two years later, endoscopic examination and CT scan were performed, to analyze the clinical effect. All three patients had total removal of tumor and no postoperative complications. No tumor recurrence was found 2 years after operation, and no face deformity. The tooth articulation was recovered, these patients could eat hard diet, although one patient had lose a little teeth sensation. Le Fort I osteotomy had good clinical effect, if associated with endoscope, it could get a good surgical exposure, and can do well in the treatment on juvenile nasopharyngeal angiofibroma, even intruded into pterygopalatine and infratemporal fossa.

Nasopharyngeal angiofibroma: A concise classification system and appropriate treatment options

ObjectivesTo describe a clear and simplified classification system for juvenile nasopharyngeal angiofibroma (JNA), and to describe suitable management options. Study designRetrospective medical record review. MethodsThe clinical and imaging materials of 51 cases of JNA diagnosed at our hospital between 1981 and 2011 were collected and studied. Based on our experiences, we prefer to divide JNAs into three types. Type I includes JNAs fundamentally localized to the nasal cavity, paranasal sinus, nasopharynx, or pterygopalatine fossa. Type II is a JNA extending into the infratemporal fossa, cheek region, or orbital cavity, with anterior and/or minimal middle cranial fossa extension but intact dura mater. Type III is a calabash-like massive tumor lobe in the middle cranial fossa. The management and prognosis for the three types of JNA were compared and evaluated. ResultsAmong cases of type I JNA (n=16), the entire mass was removed by the initial operation in 15 cases and by a repeat operation in 1 case. Among cases of type II JNA (n=29), the entire mass was removed by the first operation in 24 cases and by repeat operation in 5 cases. In cases of type III JNA (n=6), the huge calabash-like lobe in the middle cranial fossa could not be completely excised; 4 cases underwent radiotherapy and 2 cases were lost to follow-up. Conclusions1) The transnasal cavity approach with endoscopic guidance is suitable for type I JNA resection. 2) The transantral–infratemporal fossa–nasal cavity combined approach is reliable for resection of a type II JNA, which extends into the deep anterior cranial fossa and/or minimally into the middle cranial fossa, with intact dura mater. 3) The complete removal of a type III JNA is difficult, even through a combined extracranial and intracranial approach. Radiotherapy is useful for treating the residual intracranial tumor. The successful or failed experiences of 6 typical cases prove that this revised classification system is reasonable and reliable.

Anaesthetic management of endoscopic resection of juvenile nasopharyngeal angiofibroma: our experience and a review of the literature

AbstractBackground: Juvenile nasopharyngeal angiofibroma (JNA) is a rare, benign, vascular tumour in adolescent males with potential life-threatening complications. Advances in endoscopic surgery, invasive monitoring and hypotensive anaesthesia have made JNAs amenable to endoscopic surgical resection. We present the anaesthetic management of endoscopic resection of 14 JNAs, together with a review.Method: The medical records of patients who underwent endoscopic excision of JNAs within the last seven years were reviewed retrospectively. Information was collected and analysed with regard to demographics, preoperative evaluation, intraoperative management, complications and postoperative course. Fourteen patients were included in the study. If the surgery needed to be converted to open surgery, the patients were excluded from the study.Results: The age of the patients ranged from 10–18 years. Two patients had preoperative embolisation of the feeding vessel. Standard anaesthesia induction technique, together w...

Endoscopic Surgery for Juvenile Nasopharyngeal Angiofibroma

Objective: Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign neoplasm that occurs almost exclusively in the nasopharynx of adolescent males. Surgery remains the primary treatment of choice. JNA has always presented a management challenge to surgeons because of its vascular nature, site of occurrence, and local tissue destruction. External or intraoral incisions are standard open approaches, now endonasal endoscope surgery is widely accepted for its low invasion and high success rate. The purpose of this article is to present our experience with 16 patients diagnosed with JNA who were resected with endonasal endoscope surgery. Method: Records of 16 patients aged 11 to 32 with a mean age of 19.5 years treated by endoscopic surgery in our department between 2003 and 2010 were reviewed retrospectively. All patients were male. Preoperative radiological evaluation included both high resolution computed tomography with 1-mm cuts, and magnetic resonance imaging (MRI). According to Radkowski’s classification, 4 patients were stage Ia, 5 patients were stage Ib, 4 patients were stage IIa, and 3 patients were stage IIb. The tumor stages, feeding vessels, operating time, complications, and recurrence were observed and recorded. Eight patients received preoperative angiographic embolization, and 3 patients received intraoperative external carotid artery clamping. Transnasal or transpterygoid and posterolateral wall of maxillary sinus approaches are used for tumor resection. Results: The mean duration of the surgery was 2 hours. The mean intraoperative blood loss of patients who received preoperative hyperselective embolization was 470 mL, patients who received intraoperative external carotid artery clamping was 510 mL, and patients who did not receive arterial supply blocking was 930 mL. After surgery, CT scan or MR image showed total removal of the tumor was achieved in all patients. No postoperative complications were observed. All patients were followed-up for 9 months to 3 years (mean 1.5 years), and no recurrence was founded. Conclusion: Endoscopic resection of JNA is a difficult but effective operation. The key techniques to remove tumor are bleeding control, drilling-out the bone that the tumor invaded. Endonasal surgery combined with a preoperative embolization of the arterial supply can control blood loss. For small and intermediate-sized JNA (Radkowski Ia-IIb), endoscopic surgery is an appropriate choice. If the tumor extends into lateral fossa infratemporalis or deep into the skull base,we do not recommend it.